People suffering from dementia often are not able to spend time outside in the natural environment, because travelling even short distances from where they live can be impossible. Being stuck indoors can deepen depression and anxiety in some dementia patients. Furthermore, recent research has shown that time spent outside in nature can help reduce depression and anxiety, even within the general population.

Knowledge of this research, and her own passion for the outdoors, inspired Lora Appel, Ph.D. ‘16, to wonder whether dementia patients would benefit from experiencing a “virtual” environment as much as the “real” experience of being outside in the natural world.

Appel’s curiosity led to the birth of a research study, known as Prescribing Virtual Reality (VRx), which began in July, 2017 and is based out of OpenLab at the Toronto General Hospital in Toronto, Canada, where Appel is a Post-doctoral Research Fellow.

Appel’s project was funded by the Spark grant from the Centre for Aging and Brain Health Innovation (CABHI), and also from the Donald J. Matthews Foundation.

In the Q&A below, Appel explains the Prescribing Virtual Reality (VRx) project. Appel said, “While experiencing natural environments and being in social settings may greatly benefit people with dementia and improve their mental health and quality of life, they are increasingly restricted from spending time immersed in these beneficial ambiances. As a way of relaxing patients and diminishing their propensity to wander, VR provides a novel therapeutic approach that hasn’t been used yet as standard of care, but may successfully replace or significantly decrease the need for current approaches.”

Through this project, patients with dementia are shown films of the natural world. “With the help of a VR filmmaker, we created a library of naturalistic 360-footage, with lengths of 3 to 10 minutes, from a variety of natural settings (quiet lake, green forest, calming beach, etc.) from local Canadian forests, to the beaches of Iceland,” Appel said. “These represent a series of vignettes that we are currently using for the VR prototype library, which is being evaluated and will be further refined throughout the current study.

“Currently 40 out of our target 50 participants, have completed the study; and unfortunately I am unable to share preliminary results until they are published… however I can reveal that people tend to prefer atmospheres that remind them of their personal experiences, their memories, for example the nature close to their childhood homes. It appears as an unintended outcome that VR tends to elicit participant’s discussion of memories – which is of significance with this patient population. We set out to evaluate symptoms such as depression, anxiety, aggression, and wandering; memory is an entirely different, yet exciting area of research.

We will have results about other characteristics of the experiences, like light, sound exposure, multimodal stimuli, interactivity … but I encourage you to follow up and read our findings when they are published, hopefully soon.”

While at SC&I as a doctoral student, Appel’s Ph.D. advisor was Associate Dean for Research and Professor of Communication Mark Aakhus. Her dissertation was titled, “Applying Design Science to Address Health System Problems: A Case of Designing Communication to Manage Clinician Anonymity in an Academic Hospital.” According to Appel, her dissertation was an “relatively applied research project that developed an evidence-based health information technology (HIT) promoting effective inter-professional communication between hospital-based clinicians by encouraging teamwork and the sharing of relevant patient information. The study employed a rigorous user-centered design methodology that guided iterative development of a powerful digital communication application that fit the unique needs of the hospital and health care providers who represent multiple professional areas.”

In addition to her exciting research at the OpenLab, Appel was recently chosen by the National Communication Association (NCA) as a winner of the Gerald R. Miller Outstanding Doctoral Dissertation Awards. She received the award in November, 2017.

Q&A with Lora Appel Ph.D. ‘16

How did you originally become inspired to use virtual reality to assist patients with dementia and Alzheimer's disease?

I had been working on a number of projects at OpenLab, a research and innovation centre at Toronto General Hospital after my dissertation. About 15% of our time is dedicated to our own research ideas and initiatives: thinking of ways to address problems we’ve noticed in the hospital, or issues that were raised while conducting other studies. We get to present our ideas to the team, and if the lab agrees that the project falls within our objectives, as individual researchers we are encouraged to apply for funding opportunities. “Prescribing Virtual Reality (VRx)” was once such project.

I was inspired by my personal enjoyment of the outdoors (and the lack of opportunity during Canadian winters), and an increasing number of research papers demonstrating that exposure to natural environments delivers health benefits. Studies show that patient rooms with windows with a view of greenery, and even patient rooms with synthetic plants, can have an impact on patient outcomes. I thought, what about patients with physical constraints that can’t sit up, or those lacking social support that can’t go outside, or those with cognitive impairments, that are often confined indoors for their own safety. People living with dementia often lack all three.

To this I thought that emerging technologies, like Virtual Reality (VR), might be able to help. VR has the power to transport people outside the confines of a room, or medical condition.

More abstractly, I was also curious to what extend “real” natural environments have an impact on health and wellbeing, versus the mere perception of being in nature.

Explain the ways this treatment could lead to a possible reduction in wandering and reduced medication? Is it because the patients become happier as a result of their virtual travels or does increased brain activity or anything else play a role?

Depression, anxiety, and feelings of loneliness are the most common mental health problems for older adults, but are particularly prevalent in those with dementia. There is a negative cycle in which feelings of isolation and loneliness trigger depression and cognitive decline in older adults, which further exacerbates the problems faced by those living with dementia (Cloutier-Fisher, 2011; Nicholson, 2009).

This is especially true for residents already living in health care institutions where there is ample evidence showing elevated levels of depression and feelings of isolation that result in faster rates of cognitive decline and increased mortality. Unfortunately, for the majority of individuals with dementia, institutionalization is often necessary at the later stages of the disease due to unmanageable caregiver burden and the need to keep patients safe. Over 60% of people with dementia will wander (becoming disoriented and lost, even in their own neighborhood or familiar places), both in community-dwellings and institutionalized settings (Robinson et al., 2006) and as a result, to keep them safe, they are often confined inside their homes or other care facilities for long periods, with limited access to the external environment including natural and social spaces.

At the same time, exposure to natural environments (seeing greenery, hearing outside natural sounds) has been shown to reduce depression, anxiety, aggression, and bio-physiological distress. Likewise, social interaction is consistently identified as key aspect to improving seniors’ quality of life (Adams, Leibbrandt, & Moon, 2011; Heylin, 2010; Reichstadt et al., 2010; Theurer & Wister, 2010). So while experiencing natural environments and being in social settings may greatly benefit people with dementia and improve their mental health and quality of life, they are increasingly restricted from spending time immersed in these beneficial ambiances.

As a way of relaxing patients and diminishing their propensity to wander, VR provides a novel therapeutic approach that hasn’t been used yet as standard of care, but may successfully replace or significantly decrease the need for current approaches.

Current means to reduce depression, anxiety and aggression include medications that are associated with potentially harmful consequences (negative side effects, the hastening of cognitive decline). Moreover, for preventing wandering to keep dementia people safe, there is often the use of barrier/restraint methods, potentially causing pressure sores and infection, psychological problems such as anxiety and distress, and physical violence. Finally, there are ethical and acceptability issues associated with, and human resources required for monitoring and/or responding to electronic tracking devices used with dementia people to prevent wandering. Virtual Reality therapy may prove to provide a less expensive, ethically acceptable means of relaxing, engaging, and distracting dementia patients, without the negative side effects

When did you begin using this type of therapy?

The research protocol was finalized last December 2016, however by the time funding was obtained and ethics approved (which can be frustratingly cumbersome when done within medical institutions – and across 4 study sites), we finally began the research July, 2017.

Why does this kind of treatment seem to be so effective and are you the only researcher exploring this new treatment?

As the price of commercially available AR/ VR units drops, the more this technology will be explored and tested for medical purposes. There are a number of clinical researchers already looking at VR as therapy. In fact, VR has been proven as an effective treatment for anxiety, phobias, and PTSD. However, to date, I am unaware of any research studies rigorously evaluating the impacts of VR exposure on cognitively impaired patients (like those with Dementia and Alzheimer’s).

Anecdotally (based on YouTube videos) some long-term care institutions in Australia and the UK have bought VR setups for their clients, however they are not systematically, or otherwise, evaluating the effects. I am currently conducting a systematic literature review on the topic of VR and dementia.

In order for other health care institutions to agree that this technology can serve as an effective therapy, and furthermore invest in the technology, we will need to provide scientific evidence.

The cognitively impaired are an especially difficult yet important population to target in clinical research because they may be unaware, or unable to consent to their treatment. I like to think of it like the line is from a song, made famous by Frank Sinatra: “New York: if you can make it here, you can make it anywhere.” In other words, if we can prove that this group of patients can tolerate VR headsets and VR experiences; that they don’t become more disoriented, that they suffer some adverse effects, that they are not uncomfortable or unsafe for any reason– then we can more confidently expose other patients as well. This type of designing is also known as “design by exception” whereby you create an intervention for the most extreme use-case, in the hope that it will be appropriate, for those less extreme cases. Still, we will need to conduct research for every different condition, like stroke, traumatic brain injury, Parkinson’s, ALS, etc. since each condition is unique in symptoms and needs, as well as the impact and treatment we want to achieve in each case.

Then there is the importance in targeting conditions of the elderly specifically, because as we all know, the baby boomer generation is aging (Worldwide, the total number of people with dementia is projected to near 75 million in 2030; World Health Organization), and with it will be an increased burden on the healthcare system. Coupled with the increasing numbers of children that live in different cities from their parents and families, more and more of our parents and grandparents will have to be taken care of in health care facilities.

In order to improve quality of life, and decrease caregiver burden as well as economic burden on the health system as a whole, it is critical that we come up with ways in which we can support “Aging in place.” Many social innovators are looking at new and old ways in which the elderly can continue living at home independently with aids for as long as is safe, and I hope that VR will prove to be one of these initiatives.

What has been one of the most rewarding times you've used VR?

A particularly rewarding experience I had was with a moderately cognitively impaired patient who would not leave our research session without sharing the VR experience with his wife. He was so amazed and he insisted we invite her to try it also. They both really enjoyed the experience and later spoke together about their shared memories.

At a later clinic visit his wife sought me out to tell me that when he had been referred to a specialty sleep apnea consultation at another hospital he understood that he was going for another VR session for which is was overly enthusiastic and excited. When he finally realized the sleep apnea mask was not a VR headset he refused to participate. He was only willing if he could try VR again.

How do you determine which patients might benefit the most from this treatment?

One important aspect of this feasibility study is to first determine which patients can tolerate the VR headset, and exposure to these virtual environments. We did not limit our inclusion/ exclusion criteria to mild, moderate, or severe cognitive impairment, so we will have some preliminary findings but when it comes to treatment benefits, we will need to run additional studies on larger populations. We are in the planning phases of conducting a larger randomized controlled trial (RCT), with strict bio-physiological measures in order to answer this question. Still, I presume that the outcomes and benefits will be different for each group (e.g. VR may be better at reducing depression in mild cognitive impairments, whereas it is more effective as reducing the propensity to wander in those with moderate cognitive impairments).

How did your Rutgers education help prepare you for your career, and did you study virtual reality at Rutgers?

I did not study VR at Rutgers, but my work was focused on technological interventions in healthcare. For my dissertation I studied rapidly changing inter-professional teams in research hospitals and how breakdowns in communication, specifically between different professions, can have negative side effects on patient care and provider satisfaction. I designed a number of interventions, including a smartphone application, to try to decrease a phenomenon we named, “clinician anonymity.” What was unique about the research was the use of design science, and iterative design technique in order to study and develop a solution.

Rutgers without a doubt prepared me for my work in hospital/ healthcare related research. Naturally the research methods you learn is school differs from the way research practically takes place outside the walls of the university, however the basics of quantitative and qualitative techniques taught at Rutgers are what I use today. It is the appreciation for rigorous, empirical, replicable research that gives my current research such strength.

Are there professors at SC&I you remember were particularly helpful and inspiring, and if so, why?

There are four professors in particular, all of which I was lucky enough to have on my committee at one point or another.

It goes without saying that Dr. Mark Aakhus, my advisor, had an invaluable impact on my life at SC&I, and more broadly as a researcher. I was always drawn to implementation and creating practical change but he always pushed me to think beyond my dissertation, to really think about what I could contribute to the field of communication as a whole. He truly forced me think at a higher theoretical level. Dr. Aakhus was my first proper introduction to philosophy and to this day I use philosophy of science arguments to guide how I think about designing experiments in order to be able to produce results that convince a wide variety of thinkers from medical professionals, to policy makers, patients and caregivers. It is crucial to understand that different people are convinced in different ways, and in order to affect change in the real world, you have to cater to how your audience makes sense of the world around them.

Dr. Keith Hampton, who is now at Michigan State University, really inspired me to be a good teacher. His classes were my favorite, always fun, challenging, and encouraging of debate. I also had to opportunity to be his TA, and I was impressed at how his coursework always reflected current events in order to stay relevant for his students. He made sure to treat his students fairly and to emotionally support his TAs when students were being rude. I want to be that kind of teacher.

Assistant Professor Lisa Mikesell’s work most closely resembles the research I do now at the hospital. Without her advice I’m not sure I would have finished writing my dissertation. I strive to have her dedication and thoroughness, and her work serves as a gold standard that has made me a better researcher today.

Finally, I want to thank Dr. James Katz, who is now at Boston University, as he was the reason I pursued a PhD in the first place. I was completing a Masters at SC&I with no real intent to stay in academia and he convinced me that I was well suited for a life in research. He has continued to provide me with advice and support throughout my career and for that I will always be grateful.

What award did you win at NCA?

I’m so thankful, it has been a very good year. With the encouragement of my advisor, Dr. Mark Aakhus, I submitted my dissertation to NCA and just heard that I as awarded the “Gerald R. Miller: Outstanding Dissertation Award.” I am very excited to attend NCA this November and reunite with all my friends and colleagues from SC&I.

In the Media

August 8, 2017 a story about Appel’s research was on Canadian National television. This clip aired on CBC's National News.