XR for aging adults with intellectual disabilities: exploratory case study

1 Introduction

Intellectual Disability (ID) has been treated differently over the years and across cultures. According to the American Association on American Association on Intellectual and Developmental Disabilities, 2021, ID is characterized by significant limitations in both intellectual functioning and adaptive behavior as expressed in conceptual, social, and practical adaptive skills. According to the World Report on Disability, ID affects approximately 1% of the global population, representing tens of millions of individuals worldwide (World Health Organization and World Bank, 2011). Despite 20th-century progress, some improvements have clearly impacted this population but efforts persist to ensure equity. Paradoxically, the improvement in life expectancy over recent decades of people with ID, while representing a positive development, has also generated new challenges that span social, health, and economic domains (Ginis, 2025).

The World Health Organization defines Active Aging as the process of maximizing opportunities for physical, social, and mental wellbeing throughout one’s life to improve Quality of Life (QoL) as individuals grow older. Following the model of QoL developed by Schalock et al. (2002), it comprises eight dimensions: Self-Determination (SD), Rights (R), Emotional Wellbeing (EW), Social Inclusion (SI), Personal Development (PD), Interpersonal Relationships (IR), Material Wellbeing (MW), and Physical Wellbeing (PW). Emotional wellbeing refers to feeling safe, valued, and satisfied with life; interpersonal relationships concern meaningful connections with others; personal development involves opportunities for learning and growth; self-determination refers to autonomy and choice; social inclusion reflects participation in the community; rights concern the respect and protection of human dignity and freedom; while physical and material wellbeing refer to health, access to services, and the resources needed to support a dignified life. Together, these dimensions provide a comprehensive framework for evaluating QoL beyond health-related indicators associated with longevity (Wolters-Leermakers et al., 2025; Pérez-Curiel et al., 2023).

One of the factors widely recognized as having a major impact on the QoL of aging population with ID is when their parents or close relatives are no longer present and alter their routines (Mailick Seltzer and Wyngaarden Krauss, 2001; Innes et al., 2012). While it is a natural part of life that parents die before their children, most of this population has lived closely with them and many of their experiences have been mediated through them (Barratt et al., 2025). In fact, Innes et al. (2012) emphasized the importance of considering the different life markers—often fewer in number—defined as key events in life that shape an individual’s trajectory, among people with ID compared to the general population. This is particularly relevant when examining their experiences in childhood, education, relationships, employment, and retirement. For example, many of them are not the ones who got married, it was their siblings; many have not been employed and therefore have not retired, yet they have celebrated their parents’ retirements. Their lives have been strongly shaped by the life markers of those around them rather than by their own. These differences in life markers become even more pronounced when considering that the current generation of aging adults with ID grew up during a period in which educational opportunities were more limited and societal efforts toward the integration and inclusion of people with ID were far less established. This lack of opportunities, together with their distinct life markers, suggests that providing firsthand experiences and personalized activities can positively impact their QoL.

XR technology enables users to engage in experiences that might otherwise be inaccessible to them due to financial limitations, mobility challenges, or other barriers. At the same time, thanks to the Head Mounted Displays (HMD), the experiences can be directly perceived firsthand, making them even more meaningful for users. This is possible because HMDs allow individuals to view an area of the 180/360-degree scene, known as the viewport, that changes with head rotation if working with three Degrees of Freedom (3 DoF). The scene surrounding the viewer and the 3 DoF enhances spatial presence, defined as the sense of being there, called spatial presence (Riva and Mantovani, 2012), and social presence, understood as the feeling of being with others. It can even impact socioemotional aspects such as empathy (Davis, 1983) or attitude (Holden and Karsh, 2010). The adaptation of XR technologies to people with ID may vary depending on the type and severity of the disability, particularly according to the level of interaction required by the application. Previous work has explored the use of natural and intuitive interaction paradigms (Jiménez-Moreno et al., 2025; Cortés et al., 2026), as well as the use of handheld controllers when appropriate (Caravella and Shivener, 2026; Goyena et al., 2025b), showing that both approaches can be effective depending on users’ capabilities and the goals of the activity. Likewise, evaluation procedures should also be adapted to users’ comprehension and communication abilities (Gibson et al., 2020; Bircanin et al., 2021).

Considering that XR technologies have the potential to create immersive experiences that support individuals facing barriers, such as mobility limitations, and that the use of HMDs enables the creation and elicitation of first-person experiences with high levels of spatial presence and other socio-emotional dimensions, this project proposes the use of immersive video (180-degree or 360-degree video) to recreate experiences of interest to participants (aging adults with ID), that may have a positive impact on their wellbeing. In the present work, interaction with the technology is intentionally kept to a minimum, as the three proposed XR experiences are primarily based on content visualization. Therefore, the main novelty of this work is the long-term co-design, deployment, and evaluation of XR experiences with aging adults with ID in a real-world setting. The specific contributions of this work are as follows.

• We provide preliminary evidence suggesting that XR-mediated immersive experiences may be associated with improvements in some of the dimensions of QoL.
• We explore the potential value of the participatory intervention in which aging adults with ID actively contribute to shaping activities, enhancing engagement and perceived wellbeing.
• We explore the feasibility of evaluating key XR aspects, such as spatial and social presence, in aging adults with ID, offering methodological insights for inclusive XR research.
• By integrating XR experiences into the routine activities of a day center over an academic year, we provide insights into the practical application of immersive technologies in real-world settings.

In fact, the immersive video sessions have been scheduled into the center’s calendar for the next academic course, with the primary outcome being the successful acceptance of the technology and the benefits it has for the aging population with ID.

2 Related work

2.1 Aging in the intellectual disability population

Life expectancy in individuals with ID has increased in recent years and is now approaching that of the general population (Coppus, 2013). As in general population, the health and physical maintenance habits they have adopted throughout their lives become particularly important (Havercamp and Scott, 2015). Likewise, many age-related issues are common to the general population, such as behavioral issues, depression, or tendencies towards social isolation. However, recent research indicates that some issues manifest at earlier ages in individuals with ID (Sandberg et al., 2016; Latteck and Bruland, 2020). For example, individuals with Down syndrome have a predisposition to develop Alzheimer’s-type dementia (O’Caoimh et al., 2013; Strydom et al., 2018). Other issues may manifest with different prevalence or severity in individuals with specific ID compared to the general population. For example, a study conducted in Spain revealed that chronic constipation, urinary incontinence, thyroid disorders, and obesity were the most common chronic conditions among individuals with ID and were more prevalent than among age-matched individuals without ID (García-Domínguez et al., 2020). Similarly, a study conducted in the UK found that people with ID had a higher prevalence of epilepsy, severe mental illness, dementia, hypothyroidism, urinary incontinence, and constipation compared with the general population (Carey et al., 2016). Along the same lines, a US study reported that adults with IDs experienced poorer overall health and higher levels of physical inactivity compared with the general population (Havercamp and Scott, 2015).

Something important to note is that not all challenges faced by individuals with ID are health-related. Lifestyle, education, and the opportunities available to individuals with ID play a crucial role in impacting their aging. While these factors also influence the general population, people with ID are often exposed to more limited access, which can further affect their later life stage. It is not only that the population with ID can face premature aging, but the challenges they encounter may also differ, and there is currently a lack of studies considering this part of the population (Simões and Santos, 2017; Innes et al., 2012) which is expected to grow the next decades. In fact, there are concerns related to life markers that worry both the individuals and their co-resident family members and/or legal guardians (Barratt et al., 2025). Specifically, some of these challenges are connected to their future plans (accommodation, economy, etc.), the access to services and the presence of unmet needs, which is a key insight across all user-focused themes (Innes et al., 2012).

2.2 Quality of life in aging adults with ID

The literature widely adopts the QoL model proposed by Schalock et al. (2002) to evaluate the wellbeing of people with intellectual disabilities, as it provides a comprehensive framework to understand it across different dimensions (Wolters-Leermakers et al., 2025; Pérez-Curiel et al., 2023). Premature aging can negatively impact the QoL of individuals with ID as well as a lack of resources and research projects focused specifically on population with ID (García-Domínguez et al., 2020; McCallion et al., 2013).

We found studies that have evaluated the use of technology in the lives of aging adults from different perspectives (Pang et al., 2021; Gustafson et al., 2015). What’s important is that the adoption of technology does not automatically lead to a positive impact on QoL (Bong et al., 2019). This is why it is crucial to involve the participants from the project’s design phase to develop applications that are both personalized to their interests (Sitbon et al., 2020; Wilson et al., 2019; Roomkham et al., 2022) and meaningful, as the applications helps them continue doing activities that are important to them (Zhao et al., 2024; Tauseef et al., 2025).

In this regard, Ullal et al. (2024) presented a participatory design approach to develop augmented reality-based telepresence activities for older adults, adapting the technology by simplifying interactions and tailoring the experience to older adults’ interests, thereby facilitating accessibility and engagement.

A significant number of studies have demonstrated the benefits of immersive technologies in training and rehabilitation settings in the aging population due to their potential to enhance physical, cognitive, and emotional functions (Baragash et al., 2022; Goyena et al., 2025a). The choice of technology depends on the objectives and can range from medical applications for prevention and monitoring (Park and Jayaraman, 2003; Hirose et al., 2012) to musical applications as crucial component for multisensory stimulation in people with dementia or cognitive issues (Wesselink et al., 2025; Pérez et al., 2024; Yu et al., 2026). Assistive telepresence robots, voice assistants or smart home technologies can help alleviate feelings of loneliness, a very common emotion among the aging population (Koceski and Koceska, 2016; Chen et al., 2021; Pal et al., 2017). This feeling is also reported by aging adults with ID; however, not all have achieved independence, and their needs for using this technology may differ from those addressed in existing studies.

The fundamental problem is that the life markers of aging adults with ID can be very different from those of the general population. Consequently, the QoL we aim to enhance, along with its influencing factors, may vary and necessitate studies that both include this population in the participant sample and incorporate their input into the project design.

2.3 Challenges working with people with ID in research

The literature shows a significant effort to apply Participatory Design (PD) techniques with people with ID, applying them in different areas and contexts, such as evaluating Artificial Intelligence (AI) algorithms (Jiménez-Moreno et al., 2025) or designing therapeutic (Goyena et al., 2025a) or educational settings (Caravella and Shivener, 2026). Previous work has shown that participatory approaches can be seen as an empowerment tool not only for design but also to improve participation, relationships, and a sense of belonging (van Dijk et al., 2016; Acton et al., 2024). Collaborative and diverse environments are essential to advancing technology design and ensuring the inclusion of people with ID, preventing them from being left behind in the development and adoption of emerging technologies (van Dijk et al., 2016; Dudley et al., 2023). Creed et al. (2024) present a research agenda highlighting the remaining challenges of working with people with ID and XR technologies. The study emphasizes physical constraints of devices, unintuitive software interfaces, and ad-hoc solutions that lack the flexibility to meet diverse user needs. Some examples of the lack of flexibility in technology that create barriers include issues with eye-tracking calibration (Dal Magro et al., 2025), with the handheld controllers (Caravella and Shivener, 2026), or even in mainstream commercial applications (Anderton et al., 2025).

In relation to user inclusion in co-design and PD techniques, there are cases with a clear limitation: communication (Wolters-Leermakers et al., 2025). In fact, the participation of individuals with ID in the design and evaluation of the technology remains a significant challenge. Wilson et al. (2019) explored the question, “How does one have a voice in design if one is not verbal?” since many individuals with ID face limitations in verbal communication (Porter et al., 2001), challenging the qualitative data collection. The study emphasized the critical role of the research team and its capacity to extract insights and interpret interactions that extend beyond verbal language. Bircanin et al. (2021) conducted short sessions between designers and adults with severe disabilities, and they presented four principles of active support: every moment has potential, graded assistance, little and often, and maximizing choice, and control. A good practice for gathering as much information as possible is to collect evaluations through the caregivers or professionals who regularly work with the individuals (Wesselink et al., 2025).

Another important pillar highlighted by Dudley et al. (2023) is that conducting empirical work in real-world settings with individuals with ID in long-term projects presents significant challenges due to ethical and logistical constraints. This challenge is not unique to older adults with IDs; rather, it is a recurring issue in XR research that limits the availability of practical, reliable tools and evidence-based guidelines for developers Zhou and Globa (2026).

3 Research context

The research is conducted at an Occupational Center for Training, Opportunities, and Labor Insertion of Fundación Juan XXIII that supports individuals with ID. Specifically, it focuses on the oldest individuals of the center. Participants attend the center daily, where professionals work to meet their needs as aging adults with ID, enhance their opportunities for stimulation and services, and improve their QoL. It is worth noting that the center was originally for males only and some participants of this project have been attending the center for nearly 50 years. Although the center is now for all genders and more balanced in terms of gender among other age groups, this balance has not yet been achieved in the oldest age group.

The design of this project seamlessly integrates with the existing activities and evaluation methods that the center’s professionals have been using with their individuals with ID. From a research perspective, this decision presents a challenge as the technology is tested in a completely real use case, outside of a controlled laboratory setting. The technology must smoothly integrate into these routines, allowing us to explore its impact on their day-to-day experiences and deeply analyze the potential of the technology we are developing. Professionals at the center come from diverse backgrounds, including education and psychology. While multiple professional profiles contributed to the design and experiences of the phases (i.e., the guided tours included both psychologists and care service professionals, given that the participants required ongoing assistance), the content viewing sessions were conducted by the lead psychologist.

3.1 Ethics

Since the phases and activities were incorporated into the center’s program, they were reviewed and approved by the Ethics Committee of Fundación Juan XXIII, and the procedures established by the committee were followed. Before the project began, an information sheet was provided to the co-resident family member or legal guardian outlining the phases, objectives, schedule for the course, and the study methodology. It was ensured that these activities would not interfere with participation in other important activities, such as gerontogymnastic sessions. Additionally, a meeting was held with the co-resident family members or legal guardians, during which any questions were addressed. Finally, the co-resident family members or legal guardians signed the consent form. Moreover, participants whose co-resident family members or legal guardians did not consent to the use of images but were interested in benefiting from the project were also included.

4 Methods

This participatory intervention aims to create a win-win situation: providing personalized experiences through technology that aim to enhance the wellbeing and QoL of individuals, while researchers explore the potential of technology as a supportive tool for aging adults with ID during an academic year. As activities are integrated into the Fundación Juan XXIII program, the technology is evaluated in a real-world setting, obtaining reliable insights presented in this document.

As a starting point, experiences that Fundación Juan XXIII considers meaningful and positively impactful for aging adults in its center are translated into technology-mediated formats. These experiences include music concerts, guided tours of the participants’ hometowns—where participants themselves act as guides—and meetings with a former educator from the center. Participants were actively involved in shaping specific aspects of each activity according to their interests and preferences. Moreover, the experiences were implemented using real-world immersive media, including 180-degree videos, 360-degree videos, and real-time 360-degree videocalls, rather than computer-generated virtual environments. The rationale for adapting these activities to XR lies in the fact that they are known to be effective, yet they cannot always be implemented due to limitations in resources (e.g., staffing, financial constraints, and/or time), or because not all aging adults are able to participate, for instance due to health-related issues. Additionally, the use of technology enables a higher frequency of sessions, increasing accessibility and continuity.

The fundamental goal of the experiences, both with and without technology, is to enhance some dimensions of the QoL while placing each individual at the center, enabling them to take an active and leading role. This principle has been preserved throughout the present approach. Accordingly, participants are actively involved during the design process, contributing their perspectives and sharing their interests.

Table 1 maps the main design decisions of the participatory intervention to the eight QoL dimensions proposed by Schalock and Verdugo, namely, Self-Determination (SD), Rights (R), Emotional Wellbeing (EW), Social Inclusion (SI), Personal Development (PD), Interpersonal Relationships (IR), Material Wellbeing (MW), and Physical Wellbeing (PW). These are categorized according to the experiences, while some, the generic ones, were included to enhance the connection between participants and researchers.

TABLE 1. Summary of key decisions categorized into generic and phase types, along with their impact on QoL influencing factors. Specifically, Self-Determination (SD), Rights (R), Emotional Wellbeing (EW), Social Inclusion (SI), Personal Development (PD), Interpersonal Relationships (IR), Material Wellbeing (MW), Physical Wellbeing (PW).

As the participants involved in this study have no prior experience with XR technologies, and given our aim to facilitate their adaptation to and acceptance of such technologies, we adopted a methodology that progressively evolves in terms of both technology and interaction. Three phases were designed. In the first phase, participants viewed pre-recorded 180-degree videos to assess their adaptation to the use HMDs and to an immersive environment that requires less mobility than full 360-degree content. In the second phase, we introduced pre-recorded 360-degree videos. Finally, in the third phase, a real-time 360-degree videocall was introduced, enabling interactive experiences. In summary.

• In Phase 1, participants visualize music concerts in 180-degree videos.
• In Phase 2, participants visualize tours guided by some of their colleagues in 360-degree videos.
• In Phase 3, participants interact in a real-time 360-degree videocall, immersive videocall, with a former educator from the center.

Within each phase, Figure 1 presents the procedure and the factors considered when selecting participants for each of the experiences, presented in detail in Section 4.1. For Phases 1 and 2, it also summarizes the experiences that participants lived in person during the video recordings. In the case of the music concerts, participants took on an observer role, as the events took place at the Fundación Juan XXIII. In contrast, during the guided tours, they assumed a more active role, as some participants were able to travel to their villages and present them to peers they had personally invited. Subsequently, the figure outlines how the content viewing sessions were conducted and the total of the participants of the phase. In Phase 3, given that it consisted of a real-time immersive videocall, the session was scheduled prior to an in-person encounter with the educator.

4.1 Participants

The activities selected were based on participants’ interests, and they actively contributed to their design. For this reason, the ones involved in each phase are different. The distribution can be seen in Table 2. The age inclusion criteria used in this study were aligned with those applied at Fundación Juan XXIII. As all interventions at the foundation are guided by a preventive approach, participants aged 45 years and older were included following a commonly adopted operational criterion in ID services and aging programs aimed at the early identification of aging-related changes and cognitive decline. Following previous aging and dementia research in individuals with Down syndrome, a lower age threshold, 35 years, was applied to this subgroup due to the earlier onset of age-related cognitive changes reported in the literature (Hon et al., 1999; Hithersay et al., 2019; O’Caoimh et al., 2013).

TABLE 2. Participant demographics: gender, age, technology adoption, and disability. Additionally, the table shows the phases of the project in which the participants were involved: music concerts (1), guided tours (2), and the immersive videocall (3). In the technology adoption column the Smartphone (SP) and/or tablet denote participants who have one.

In terms of technology adoption, all participants have previously used 2D videocalls, as the center continued to support its users through this platform during the pandemic. Before each content viewing session and afterwards during the evaluation, the lead psychologist explains to the users what the XR technology consists of to help them stay connected to reality and the experience delivered through the technology.

To select participants of the first phase and the songs to be recorded, all aging individuals of the center participated in a collaborative session. They were asked about their favorite songs, why they liked those songs, and the music was played while they danced. Consequently, those who participated the most and showed the highest motivation towards the music were chosen to be part of the first phase of the project. Specifically, 12 participants were involved, each attending 5 content viewing sessions.

For the guided tour phase, the second one, an initial analysis was conducted by asking the aging individuals of the center about their hometowns. For logistical reasons, the nearest villages were chosen, and families were gathered to plan the locations for the guided tours. Participants from these villages were selected, and each of them chose two colleagues to whom they would like to show their hometowns. 18 people participated in these content viewing sessions: 11 individuals completed two sessions, four individuals completed three sessions, and three individuals completed one session. These differences are explained by the fact that individuals from the villages attended all the visualization sessions in their respective villages, while the others had the option to choose which sessions to attend.

In the third phase, the 12 participants who knew the two retired teachers invited to take part in the encounter were selected.

4.2 Research questions (RQs)

Cromby et al. (1996) presented several key principles for the effective use of virtual environments in learning contexts. While the present paper does not focus specifically on educational outcomes, it draws upon the following principles that are in line with the ones presented by them: user-centered design approach, friendly interfaces for end-users, the professionals of the center are involved in the whole process, and the lead psychologist carries out the viewing content sessions. In terms of the research, the motivation behind designing the project based on activities that are not new in the Fundación Juan XXIII and transitioning these activities to a technology-mediated format allows us to: first, ensure that the activities are significant and beneficial for the participants; second, guarantee that our study design focuses specifically on the variable of technology. Based on these decisions, we can investigate the following Research Questions (RQs).

• RQ1: Can the immersive experiences have a positive impact on life satisfaction, emotional affect, and cognitive functioning among aging adults with ID?
• RQ2: To what extend does engaging aging adults with ID as active collaborators, rather than passive participants, in tailoring project activities relate to their QoL?
• RQ3: Is it feasible to evaluate key influencing factors commonly studied in XR, such as spatial and social presence, in aging adults with ID?

4.3 Phases

4.3.1 Phase 1: music concerts

In phase 1, sessions involve visualizing music concerts in 180-degree videos. The concerts were recorded with musicians looking and speaking directly to the 180-degree camera to enhance the social presence of individuals viewing the videos with the HMD, the spectators, and evoking the concert in a first person perspective (Orduna et al., 2023). These music concerts were held at the center, allowing all the center’s individuals to enjoy them in person.

There were 10 music concerts with six songs, around 3 minutes each, creating 15 playlists of four songs each in 180-degree videos, resulting in 12 min. Two recordings were made for each group: one without audience to ensure high audio quality, and one with audience to provide a live experience for all aging population of the center. Artists granted rights for use in this project’s research. The songs and the musical genre were taken from the exploratory session to assure the interest for the individuals of this phase. The fact that all the participants of the centre could attend the live concerts was a unique opportunity, but it also facilitated the project participants to interact with the artists before the content viewing sessions.

The content viewing sessions, with one playlist per session, were conducted once a week during 5 weeks, resulting in a total of 60 min of content viewing. The experience was conducted in groups of four people to encourage the adoption of the routine and activity as a shared experience. This way, participants knew that despite wearing the headsets, they were all together.

4.3.2 Phase 2: guided tours

In the second phase, participants became the tour guides of their hometowns in the recordings. Participants provide information about several locations around their hometowns and explain the significance to them. While all participants of the project attend the music concerts in person before the viewing content sessions, only six participants attend each guided tour.

There were four hometowns of four participants recorded, allowing them to explain cultural aspects, general points of interest, and personal memories associated with special locations. These recordings were of a duration between two and 5 minutes. These recordings took place during one-day trips in which two villages were recorded each. The trips involved the two participants from the hometowns, two colleagues selected by each one, two professionals of the center, a researcher, and a recording technician.

The content viewing sessions, with one village per session, were conducted in groups of four: the one from the hometown and three colleagues. It took place once a week during 4 weeks. In this phase, it was especially important that the one from the hometown participated in the session, fostering a feeling of ownership, empowerment and as a motivation for the group to attend the session. Two types of viewings were considered: one where the colleagues who went on the trip watched and relived the experience together, and another where participants viewed it with colleagues who were seeing the village for the first time.

4.3.3 Phase 3: immersive videocall

The third phase features a 360-degree videocall, called immersive videocall, where participants engage in a one-to-one conversation using the HMD. They interact with the other person, who is positioned in the same location as the 360-degree camera, that captures and transmits the 360-degree video that the participant visualizes in the HMD. In this phase, each participant engages in an immersive call with two former teachers whom participants have not seen in person for a long time.

The audio and 360-degree video were captured and streamed from a location within the facility (a room decorated to resemble a living room) where the former educator was. This setup ensured that participants were unaware of the teacher’s presence within the center. The teacher visualized the participant as a cartoon avatar, as presented in Figure 2, with synchronized movements of the head and lips that matched those of the participant attending the conversation with the HMD. Additionally, the audio was streamed from the HMD to the teacher’s location. At the end of the videocall, the professor surprised each participant by reuniting with them individually. The immersive communication sessions, involving one educator and one participant per session, took place in two different days.

4.4 Technical specifications

The 180 and 360-degree videos were recorded using the Vuze XR camera in 4 K (3840x2160) resolution. The videos were encoded with H.264/Advanced Video Coding (AVC) and streamed in HTTP Live Streaming (HLS). Although the full bitrate ladder was generated, only the highest quality, 20 Mbps was used in the content viewing sessions. The HMDs employed in the three phases of the project were the Oculus Quest 2.

In the recordings of the music concerts, audio was captured from the microphone mix of the recording. The camera was placed on the stage in front of the musicians at a height of 1.5 m, corresponding to the average eye level of a person (Keskinen et al., 2019).

During the recordings of the guided tours, the camera was set at the same height as in the music concert recordings, but the participants of the trip were located in a circle around it to encourage those watching the video aposteriori to rotate and view the full 360-degree scene. In this case, audio was captured by a professional stereoscopic recorder to avoid ambient noise. During content viewing sessions, participants wore headphones to facilitate immersion (Tse et al., 2017).

A control application was developed for the psychologist in charge to manage the content viewing sessions. The interface of the application is presented in Figure 4. It enables the selection of videos to be viewed, organized into playlists containing multiple songs or places of the guided tour. Additionally, as can be seen in Figure 5, the icons in the interface—displayed in green—indicate the status of each HMD, represented with an ID: red if the application is not launched, yellow if the application is running but displaying the waiting room, and green if the application is running. While waiting in the waiting room, the time used by the psychologist to fit the entire group with HMDs, participants watched a video of a musical duo. The interface features “Play” and “Stop” buttons, which are used to start and stop video playback, respectively. This system ensures synchronized content viewing among participants and provides the psychologist with precise information regarding the completion status. Initially, researchers assisted the psychologist to supervise the use of the control application and provided an instruction manual to manage the content viewing sessions.

In the final phase, the camera was positioned in front of the teacher at 1.5 m. The audio was captured and transmitted through the Jabra speaker that is part of the prototype that provides the real-time 360-degree video communication. During the immersive videocalls, participants could see their hands represented as avatar hands, as shown in Figure 3.

4.5 Data collection

4.5.1 Pre-project questionnaires

The month before starting each phase, the following questionnaires were collected. The purpose of these questionnaires was to conduct an initial assessment at the beginning of the course, in order to understand the baseline status of the center’s aging adults and enable follow-up over time. These questionnaires are routinely used each academic year at the center, ensuring their effectiveness and suitability for the participating individuals. Note that all the questions in this subsection and in the following ones were asked in the mother tongue of the individuals, Spanish, and have been translated in this paper.

• The Satisfaction With Life Scale (SWLS) (Diener et al., 1985) consists of five items to evaluate the personal perception of wellbeing in a five-level likert scale (where 1 = “totally disagree” and 5 = “totally agree”). This scale sums all the evaluations obtained from the items to produce an overall score ranging from 5 to 25. Note that the original SWLS uses a seven-point Likert scale for each item, yielding a total score ranging from 5 to 35. In the present study, the scale was adapted to a five-point response format (range 5–25) to improve accessibility and facilitate comprehension among participants.
• The SWLS is complemented by the SWLS with faces (Avia and Valverde, 1998) that is a single item, with responses represented by emoticons of faces (five-level scale).
• The Positive and Negative Affect Schedule (PANAS) (Watson et al., 1988) was used for the early detection of symptoms associated with mood disorders, such as depression, or anxiety disorders. It consists of 20 items evaluated in a five-level scale (where 1 = “nothing or almost nothing” and 5 = “very much”). Note that subscale scores (positive and negative) are the sums of the respective items (range 10–50 each), and the final score is computed as the positive subscale total minus the negative subscale total (range −40 to 40).
• The Cambridge Cognition Examination (CAMCOG) (Hon et al., 1999) scale is a tool to assess dementia and other mental and physical disorders considering the following aspects: orientation, language (comprehension and expression), memory (remote, recent, and new learning), attention, praxis, abstract thinking, and perception. The version specifically designed for individuals with Down Syndrome, known as the CAMCOG-DS (Ball et al., 2006), was the one used in this evaluation. Although not all participants had Down syndrome, the CAMCOG-DS was used because standard cognitive questionnaires are often difficult to apply to individuals with ID, whereas the CAMCOG-DS provides a more accessible assessment format suitable for the participants of this case study.
• The Autobiographical Memory Test (AMT) (Van Vreeswijk and De Wilde, 2004) was applied following the version presented in (Latorre et al., 2013) for Spanish population based on 14 items related to words with positive, neutral, and negative valence. Participants were instructed to share a specific memory related to each of the words.

4.5.2 Post-session questionnaires

At the end of each session, questions focused on cybersickness, as well as social and spatial presence were asked. The questionnaires were presented on a touchscreen laptop, allowing participants who were able to do so to select the chosen evaluation (Gibson et al., 2020). Two basic principles were followed: using dichotomous yes/no questions and questions with three-level responses represented by words (where 1 = “little”, 2 = “moderate”, and 3 = “a lot”) and emoticons of faces, the same ones used by the Fundación Juan XXIII’s professionals for evaluations. The touchscreen allows participants who were able to read the questions to do so independently and select the emoticon that best matched their response by touching the screen.

• For cybersickness, the Vertigo Score Rating (VSR) defined by Pérez et al. (Pérez et al., 2018) was used as a basis and was divided into two questions to facilitate understanding. The first question was, Did you feel dizzy? and only if the participant answered “yes” individuals answered between the three levels.
• For spatial presence (PPQ) and social presence (SPQ), the adapted questionnaires from (Orduna et al., 2023) were used. The rationale behind this choice is that these questions have been previously tested in similar scenarios, allowing us to assess whether the observed trends are consistent and meaningful.
• Interaction during the sessions was essential, especially in cases where there is a communication barrier. Therefore, the sessions in the phases 1 and 2 were recorded and documented according to the active interpersonal subscale of the social presence Temple Presence Inventory (TPI) questionnaire (Lombard et al., 2009) in a seven-level likert-type scale.

4.5.3 End-of-academic-year questionnaires

At the end of the project, the SWLS, SWLS with faces, PANAS, CAMCOG-DS, and AMT were collected to see the evolution in their wellbeing, taking into account that these evaluations were previously collected at the beginning of the academic year.

Additionally, the lead psychologist conducted in-person semi-structured interviews (N = 22). The interviews focused on participants’ experiences using XR technology, its impact on their daily life at the center, and on their overall wellbeing. For example, the lead psychologist asked which aspects of participating in these activities had contributed to positive emotions and which had led to negative ones.

5 Results

Table 3 presents the collected measurements using the questionnaires. The Pearson and D’Agostino normality test was computed to validate the normal distribution of the collected evaluations. If the data were normally distributed, a paired t-test was conducted. In cases where the data did not follow a normal distribution, the Wilcoxon signed-rank test was employed. Given that seven related outcome measures were evaluated using the same participant sample, we applied the Holm-Bonferroni correction. The Holm procedure was selected because it controls the family-wise error rate while preserving more statistical power than the traditional Bonferroni adjustment, which is particularly important in exploratory studies with relatively small samples. Statistical significance at α = 0.05 was evaluated using Holm-adjusted p-values; outcomes that remain significant only without correction are described as suggestive. Effect sizes were computed as Cohen’s d z (mean difference divided by the standard deviation of the differences) for paired t-tests, and as rank-biserial r for Wilcoxon signed-rank tests. Positive effect sizes indicate improvement (i.e., higher post-project scores, except for PANAS negative affect, where lower scores indicate improvement).

TABLE 3. The Mean (M) and Standard Deviations (SD) of the items assessed in the pre and post project evaluations: SWLS, SWLS with faces, PANAS negative and positive, and PANAS affect balance (Pos − Neg), CAMCOG-DS, and AMT. The Significance column presents the statistical analysis between pre and post evaluations per questionnaire item, including the test statistic, uncorrected p, Holm-adjusted p (step-down correction across the seven pre–post comparisons), and effect size (d z or r). The effective sample size differs slightly across outcomes because some participants did not complete all pre and post measurements.

Table 4 shows the data collected after the content viewing sessions and immersive videocalls. Note that the results have not been analyzed by subgroups based on the phases of the project each individual participated in due to an insufficient sample size. This limitation arises from the personalized nature of the project and its implementation within the specific constraints of the center’s environment. Figures 6, 7 shows the collected measurements of the active interpersonal subscale of the social presence TPI questionnaire—Sound Response, Smiling, and Talking—across three phases. Additionally, it is important to take into account the design decisions presented in Table 1.

TABLE 4. The mean (M) and standard deviations (SD) of the items assessed in the post-session evaluations divided into the phases of the project. Specifically: Spatial Presence (PPQ), Social Presence (SPQ), and Vertigo Score Rating (VSR).

To support the quantitative analysis and better understand the observed effects, we conducted a qualitative thematic analysis of the semi-structured interviews following an inductive approach (Braun and Clarke, 2006). Additionally, this analysis contributed to the findings and insights for practice (Section 6). Table 5 presents the resulting qualitative codebook, including the themes, codes and its definitions derived from the data.

TABLE 5. Qualitative codebook resulting from the inductive thematic analysis of the interviews, presenting themes, codes, and definitions.

5.1 Effects of immersive experiences on life satisfaction, affect, and cognition in aging adults with intellectual disabilities

Regarding RQ1, we investigated the first hypothesis (H1): participants attending XR sessions may show changes upon completion in terms of life satisfaction, cognitive impairment, and other factors measured by the evaluated questionnaires before and after the participatory interventions (Table 3): SWLS, SWLS with faces, PANAS positive affect, PANAS negative affect, and PANAS affect balance (positive minus negative subscale scores), CAMCOG-DS, and AMT.

It can be observed that there are changes in the mean scores across SWLS, SWLS with faces, PANAS positive affect, PANAS affect balance, and AMT evaluations, with medium to large effect sizes (d z ranging from 0.48 to 1.10; r = 0.78 for SWLS and AMT). The result of CAMCOG-DS does not present a significant difference, although a small positive effect was observed (r = 0.45). In terms of the positive PANAS result, it showed a statistically significant change: positive affect increased (medium effect; uncorrected p < 0.01, p Holm = 0.020). In terms of the negative PANAS result, it decreased in the expected direction (uncorrected p = 0.044, small effect), but this comparison did not remain significant after Holm correction (p Holm = 0.087) and is therefore reported as suggestive. PANAS affect balance improved significantly after Holm correction (uncorrected p < 0.001 , p Holm < 0.01; large effect). In future evaluations, we might consider discussing pleasant/unpleasant emotions if we further develop the emotional component.

These findings suggest a potential positive association between the case study and the observed outcomes; however, causal conclusions cannot be drawn, as participants were involved in activities beyond this project that may also have contributed to the observed improvements. Nevertheless, this participatory intervention has been the most novel and distinctive activity introduced at the center during the academic year. Furthermore, its benefits extended beyond the direct participants of the intervention. For example, activities such as attending live music concerts may have had a positive impact on the broader aging population at the center. Last year, these questionnaires detected a decline in 23 individuals of the aging population of the center, whereas this year that number has decreased to just three individuals.

Considering the thematic analysis, the main theme that emerges is emotional impact, both in terms of wellbeing and happiness, as well as the elicitation of positive emotions. Several participants mentioned that the content viewing sessions had positively influenced their mood, leading to an increased sense of happiness (P3, P6, P10, P15, P19), joy (P5, P11), emotion (P20), or surprise (P1). The presence of positive emotions has the effect of reducing negative ones, and in some cases, such as with participant P13, this is highly relevant to his wellbeing, as he revealed that he felt better during the content viewing sessions because it was like watching a movie and even helped him forget about body pains.

5.2 Impact on quality of life through collaborative research between individuals with ID and researchers

Regarding RQ2, we investigated the second hypothesis (H2): design decisions made in collaboration with participants will be associated with QoL domains outlined in Schalock’s model. Relating each decision of the design with the impact on the QoL (Table 1), no matter how insignificant it may seem, helps researchers and the community to understand the impact that our way of designing the activities and involving participants can have on them. The impact of these design decisions is reflected in the qualitative findings, as identified through the thematic analysis.

Decisions that have an impact on self-determination have been selected based on their alignment with participants’ preferences, interests, desires, and personal histories, as well as their ability to promote choices, increase options, and create opportunities. One of the themes identified in the analysis is experiential content, referring to music—chosen by the participants themselves—as a stimulus for enjoyment and memory activation, as well as autobiographical memories shaped by each participant’s personal experiences. In this regard, P15 and P19 shared during the interview that they felt proud of themselves for doing well. P14 explicitly reported, “people have seen my hometown”. “Even participant P11 felt that he was contributing to enabling this experience to be enjoyed by others in the future. Specifically, he stated: “to help other people have the same experience in the future.”

The key decisions regarding rights are based on prioritizing the development of XR technology for older individuals with ID, who are often socially overlooked, while taking into account their personal interests and making decisions accordingly. In this regard, one of the themes identified is accessibility. HMDs provided participants with the opportunity to “travel” to different places without the need for physical displacement, which for some of them represents a significant challenge. P18 mentioned “To enjoy a trip without travelling” or P7 said “I was able to see concerts without leaving the centre and it made me feel very good”.

Decisions that influence emotional wellbeing are those that have a direct impact on life satisfaction scales, particularly those related to what participants enjoy. As mentioned before, the thematic analysis revealed experiential content as a central theme. Phase 1, focused on music, played a key role as a stimulus for eliciting joy, while the content across all three phases facilitated the activation of autobiographical memories, allowing participants to reconnect with meaningful life experiences. For example, P2 noted “I felt very good. They sang songs from my good old days”.

There are two key factors in decisions that impact social inclusion: participants being the central focus in a technological experience, and those that involve increasing their participation in a variety of activities in their daily lives. In fact, P15 highlighted that during the guided tours, he felt respected and appreciated, stating that: “It was good for me, because I was enthusiastic. The people in the village respect me, and most of them said good morning to me. And my heart was happy.”

Decisions considered beneficial for the personal development include those that connect participants with new technologies, enhance their personal and digital competencies, and allow for greater personal expression. In this context, P10 highlighted that she has learned about music and the villages of her colleagues. In relation to the XR technology theme, P1 stated “With the HMD I was very happy. I liked it”, P4 noted “I liked the concerts and I did not get dizzy with the HMD”, or P13 “I did not even know what an HMD was”.

The decisions that had the greatest impact on interpersonal relationships include the social contact with music groups during the first phase, village neighbors and the involvement of participants’ families in the second phase, and former teachers in the third one. For example, P13 highlighted that what he enjoyed the most was taking a photo with a singer and his colleague. P15, P16, P17, P20 emphasized that they had greatly missed one of the teachers and that receiving an immersive videocall had brought them significant joy. Undoubtedly, the bond established with the researchers stands out, as P2, P4 cited it as one of the most significant aspects of the project in the semi-structured interviews.

Physical and material wellbeing has been promoted through decisions that allowed participants to travel and dance, such as visiting new villages, thus changing their usual environment. It is also important to emphasize that experiences based on their interests have helped them connect with memories and people they miss. P13 mentioned that the content viewing sessions brought back memories of his mother, while P2, P3, P4, P6, P7, P9, P16, P17, P19, P20 recalled their childhood or youth, for example, reminiscing about the lessons with the teacher who participated in the immersive videocall.

5.3 Exploratory steps in using technology-related questions with older adults with intellectual disabilities

Regarding RQ3, we investigated the third hypothesis (H3): social and spatial presence can be assessed using questionnaires based on clear, concise, and simple items on 3-level scales, complemented by the evaluation of observable signs collected by the lead psychologist. Table 4 presents the evaluations of the PPQ and SPQ, aggregated as the arithmetic mean of the items and participants for each phase. As observed in the literature studies upon which the items of PPQ and SPQ are based, the scores obtained in this type of technologies are very high.

In terms of spatial presence, although there is a slight increase from 180-degree videos (music concerts) to 360-degree videos (guided tours) and in the final phase involving 360-degree video with real-time communication (immersive videocall), the PPQ score remains the same. However, in terms of social presence, it is observed that the sense of presence is slightly higher during concerts compared to guided tours. This observation is consistent with the fact that, although the camera was located in the center of the group (researchers, participants, and the professionals of the center) during the guided tours recordings, the musicians displayed greater enthusiasm in looking at the camera compared to the participants who were describing locations during the guided tour. Although a statistically significant difference cannot be demonstrated, it is observed that all individuals who participated in the final phase rated social presence at its maximum value. In this phase, participants were engaged in an immersive videocall using the HMD to view both the former teacher and their surroundings, allowing for real-time interaction. The maximum evaluation of social presence could indicate that participants comprehended the questions.

Social presence was supported by evaluations documented by the lead psychologist. Figures 6, 7 show that participants’ reactions varied depending on the phase of the project. In phase 1, the music concerts, participants were more likely to emit sounds (e.g., laugh or speak) or smile, rather than talking directly to the people in the video, in this case, the musicians. This behavior is likely due to the fact that most participants sang during the sessions, as they were familiar with the selected songs. In phase 2, the guided tours, participants mostly smiled, as P10, P20 reported greatly enjoying watching the beautiful hometowns of their colleagues. Talking to their colleagues in the 360-degree videos was less common. As previously noted, the participants did not speak directly to the camera during the recordings as the musicians did.

In phase 3, the immersive videocall, participants increased their reactions, including making sounds, smiling, and speaking with their former instructor. These observations suggest that aging adults with ID may be able to adapt to the immersive environment and use it to participate in a videocall. Familiarity with the technology may have played a role, as the gradual increase in complexity (pre-recorded 180-degree video - pre-recorded 360-degree video - real-time 360-degree video) was one of the principles considered in the design. One participant only took part in the videocall due to exceptional circumstances that prevented him from participating in the earlier phases, but the lead psychologist believed that reuniting with his former instructor would be encouraging for him. This outcome suggests that older adults with ID may not be excluded if this technology becomes a communication platform in the coming decades and opens up new avenues for research into applications that facilitate interaction with people in remote environments through immersive videocalls.

Although high levels of discomfort were not found using the VSR scale according to the data shown in Table 4, nine participants answered “yes” to the question about dizziness in Phase 1, one participant in Phase 2, and three participants in Phase 3. However, the thematic analysis highlighted that issues related to the HMD ergonomics and user discomfort emerged as a recurrent issue, constituting a key barrier to effective use. Specifically, participants (P7, P11, P15) reported that the HMD was uncomfortable because it felt too tight, while others (i.e., P12 or P6) stated that the HMD did not fit them well.

6 Findings and insights for practice

6.1 XR experiences as a trigger for emotion and memory

Some participants recognized the setting and the music concerts they were visualizing during the first phase. P10 stated I had a great time, singing and dancing, and [professional’s name] laughed when I sang and danced, especially with “La chica yeyé”. The interaction with the musicians on the concert days increased social presence for some, making them feel as though the musicians were performing live for them. Therefore, it is crucial to keep participants informed about the technology they are using and ensure they are aware of the immersive experience that XR creates around them.

However, the activation of memories extended beyond the music concerts in the Fundación’s center; interviews revealed that songs emerged as a key element in triggering memories. For example, P2 stated “They sang songs from my good old days.” and P7 commented “I had a very good time and it made me remember when I used to listen to that music.”

As expected, for the people whose villages were visited, there was a strong impact on their memories. P4 mentioned “I loved visiting the village where I used to live, seeing the Tormes River and the Roman bridge.” However, it also had an effect on some of those who only watched the videos, as they referred during the interviews to specific details mentioned by their peers in the recordings. For instance, “I remember the very beautiful villages, the fountain of the four spouts, I would like to go and see it.” said P10.

6.2 Social connection is as important as technology

In the first phase, participants experienced the concerts in person, with the opportunity to see and interact with the musicians. As a result, when they later watched the videos, they recognized them, and P13 even mentioned “I liked everything, but I think I liked the concert by the singer I took a photo with, together with my friend [colleague’s name]”.

During the day-trips of the second phase, the traditional roles between participants, center professionals, and researchers disappeared, beyond basic assistance and technical aspects of recording. This led to strengthened bonds between researchers and participants. This has been one of the most significant factors in promoting full inclusion, and its impact has been documented in their surveys. Specifically, P2, P4, and P9 highlighted the researchers as one of the best outcomes of the project. Additionally, the involvement of the families to organize visits to participants’ hometowns expanded the boundaries of the project beyond the participants, enhancing their wellbeing.

In the third phase, the opportunity to interact with the former teacher was highly meaningful for the participants and facilitated the recall of shared past experiences. P11 highlighted during the interview “seeing [former teacher’s name] was very emotional.” and P22 said “What I enjoyed the most was the opportunity to talk to [former teacher’s name] and then see him.”

It is important to highlight the connection that was established among the participants of this participatory intervention. Allowing participants from the villages to choose with whom to visit their hometowns, as well as organizing viewing sessions with the person from the village and three additional participants or four participants significantly strengthened this connection. Recording the sessions allowed the lead psychologist to assess observable signs with greater accuracy. In fact, they revealed interactions between participants, such as handshakes during the viewing of music concerts or some were even observed holding hands during the guided tour viewing sessions. It indicated that despite the high sense of social and spatial presence enjoyed during the experience, participants remained aware that they were in a classroom with their colleagues.

6.3 Participant desire to repeat as a marker of acceptance of the XR technology

Despite the initial barrier posed by the unfamiliarity of the professionals of the center with XR technology, the technology has been accepted by professionals of the center and participants. In terms of technology, participants have adapted to viewing 180-degree and 360-degree content, as well as using the technology for real-time immersive videocalls. In this regard, participants expressed their willingness to continue using the technology, as they stated during the interviews. P4 wanted additional viewing sessions per week or P10 wanted to repeat the experiences.

The application developed by the researchers has been tailored to meet the needs of the lead psychologist, allowing him to independently manage and oversee the content viewing sessions. As Bayor et al. (2019) presented, the personalization of the case study based on the preferences of Fundación Juan XXIII participants has been a mutual learning experience in which we have better understood how people with ID understand this technology, which can help us explain it to a general public.

6.4 Headsets are both enablers and barriers

Headsets were frequently mentioned during the interviews as a tangible element that helped participants reflect on the experience they had undergone. Notably, several users described them as an enabling tool that allowed them to access experiences they would not otherwise have been able to live. On the contrary, out of the 22 participants, only 6 expressed dissatisfaction with something related to the experience during the interviews at the end. Specifically, participants that noted discomfort with the HMD, as previously mentioned. One of the challenges encountered by the lead psychologist was ensuring that the HMD was correctly adjusted and that participants were able to see clearly through it.

7 Conclusion

This participatory intervention allowed aging individuals with ID to interact with new technologies and researchers that are usually beyond their reach. People with disabilities often participate in the same types of activities and interact with familiar technologies. However, having a disability should not prevent them from working with innovative technologies. Therefore, it is crucial for tech companies, research centers, and universities to approach disabilities with an open mind and a willingness to test and adapt technologies to diverse circumstances.

The implemented approach involved a progressive XR protocol, incorporating 180-degree video, 360-degree video, and real-time 360-degree video. Designed to align with the interests and preferences of aging individuals with intellectual disabilities in an occupational center, the project adapted their most beneficial activities to XR technology. This adaptation may have facilitated more frequent and accessible engagement with these activities, such as visits to villages through HMDs. The future steps would aim to address activities proposed by participants that they currently cannot perform without technology, such as driving.

A total of 22 aging participants with ID engaged in the three phases, with the findings suggesting a positive association between participation in the participatory intervention and improvements in wellbeing and QoL-related outcomes. As a result, the content viewing sessions will be included in the center’s activity calendar for the next academic course. However, a limitation of the study was that, due to the personalized design of the project and the small sample size, it was not possible to assess the impact of each phase individually. Future studies including larger samples, control conditions, and phase-specific analyses would be helpful to better understand the contribution of individual XR activities to the observed outcomes.

This work presents an initial approach to questionnaires based on clear, precise, and simple items that can be used with aging individuals with ID to assess the technology. Additionally, the vertigo score rating has been divided into two parts: a dichotomous question (which is easier for participants to answer) and a 3-level scale using words and emoticons. The remaining questions, social and spatial presence, can be evaluated on the same 3-level scale. Future work should also continue refining accessible evaluation methods for aging adults with ID and further explore how XR technologies can support meaningful activities, social participation, and quality of life in this population. In this sense, the lessons learned presented in this paper aim to inspire further development of accessible technology, ensuring that individuals with disabilities, particularly aging adults, are included in user-centered research.

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Footnotes

Edited by: Omar Niamut, Netherlands Organisation for Applied Scientific Research, Netherlands

Reviewed by: Akshith Ullal, Vanderbilt University, United States

Kelly Kearney, Florida Atlantic University, United States