Helping patients with Alzheimer’s.
“This blog is part of a series of stories that helps commemorate all the efforts made by our small but powerful team @Dreamplaycr. Special thanks to my cherished friend Brian Kerven who pushes me to be my best everyday.
In one of our many visits to the National Psychiatric Hospital (HNP), Alexis told us the story of a patient that was hospitalized because his daughter couldn’t tolerate how rude he had become. When serving him food he would push all the dishes off the table. As an Alzheimer’s patient, he was no longer able to talk, but his daughter explained that he would act out violently, and she would yell back at him saying he was rude and insolent. It was getting frequent, making her seek out help. The answer was simple: As an Alzheimer’s patient you can easily forget how to pick up a fork: extend your hand (left or right), open your hand, put your hand down, close your thumb and index (maybe middle finger?), apply pressure (but just enough to grip), flex your elbow so the fork gets close to your mouth, open your mouth... well… you get it. Even the simplest task is just a list of commands that our brain automatically executes out of memory because we’ve been practicing since we were little babies. But what happens when the memory is gone? You can forget how to speak, and how to slowly move your forearm above a plate to pick up a fork, instead of…pushing the dishes from the table.
So who is Alexis?
He is an Occupational Therapist Master in Social and Sanitary Gerontology, at the time of this story, a supervisor at the HNP, and also one of our heroes. When he asked to meet for the first time, I was thrilled about the possible solutions we could implement to help using virtual reality. When we started DreamPlay, one of our main goals was to impact Costa Rica’s overall healthcare, and this was our first opportunity. This is where everything matched for the first time in my head. The technology is “delivered” or “consumed” in a way that you stop seeing the world as soon as you put the headset on. You don’t know what’s happening outside, you cannot be distracted by your surroundings, and you can only see the display. The headset provided a perfect scenario for a healthcare professional looking to get the attention of a person with dementia. In the case of Doña Marta, we saw how she could extend her attention span exponentially when using VR, but I’ll introduce you to her in a bit.
According to the World Health Organization, around 50 million people worldwide have dementia. It is the 5th leading cause of death and costs USD$818 billion a year. Most of the time healthcare efforts are focused on prevention, but what can be done to help people already diagnosed?
At the HNP, there are permanent daily workshops where planned program activities are given to people suffering from some type of dementia. The professional setting is designed for patients who require supervised care during the day. The HNP provides the means for patients to enjoy social activities in a group setting, while still receiving needed health services, like physical or cognitive therapy. The plan was simple, for those families interested we would try different exercises with technology, with the goal of improving specific daily challenges. Doña Marta was one of the patients attending the morning workshops and with whom (thanks to her family), we had more opportunities than normal to use VR. We were part of an interdisciplinary team, formed by doctors, therapists, pharmacists, and us, as the experts in technology.
Although an NDA might restrict me from giving more detail about the project, I can at least share some details about our part. Based on the patients ICAP’s rating (explained in the picture above), we would be able to apply alternative therapy (any technology that would enhance the patient’s experience to achieve the therapy goal). Since most of the patients suffered from some type of dementia, VR was, for 90% of the cases, the best technology to avoid distractions, showing improvement in the attention span, and thus ushering the end of the exercise. This was a major game-changer since it gave us the opportunity to track results. Back in 2017, the headsets we used at the hospital were Facebook’s first line of VR headsets, Oculus Rift, and the Chinese leader at the time, HTC’s Vive. Obviously, each had its pros and cons. Oculus could easily win with its portability and curated content, but HTC was our winner for accuracy and flexibility to create content (since it uses Steam). That’s not to say that we had a favorite, nor a definitive solution headset, but we used one or the other, depending on the goal of the therapy. I was glad to see that after we started going to the hospital, more technology was introduced, such as robots for the patients to practice orientation exercises, or even something simple such as an Xbox One Kinect Sensor for eye-body coordination exercises. Oculus’ “experiences” had the best quality graphics and sound effects, making it more attractive to patients with low attention span, but we had a major pain point in which for example, Oculus Studios Stories like “Henry,” (which, by the way, is an Emmy Award-winning production and is beautifully created content) is in English, and is therefore impossible to understand for the patients. If only Oculus knew how we were using their content and how having the option for content in Spanish was key. Sadly, some products and services are made available to Latin America with a great delay, if ever at all, which I resent a lot for cases like this. We would use this type of content to check how much of the story the patient remembered at the end of it. What was the story about? Who was in it? How did the story start? I still remember how some patients would have this specific look in their faces that I can almost say I recognize, they would get angry at the fact that they just watched something amazing, but didn’t remember what it was. I imagine this feeling to be like waking up from a dream, in which you remembered you interacted a lot, but without a clue of what was it.
Here’s where a fine line is drawn by specialists and professionals: when treating people with some type of dementia, applying VR can make them feel like there’s no difference between a virtual world and the real one. For that reason, this therapy, though it showed incredible effects in the patients using it, the amount of, or how often is received should be well revised. If you are interested in knowing more about the Neuroscientific part of applying VR in the healthcare field, I would like to refer you to one of my personal heroes: Dr. Walter Greenleaf. Dr. Greenleaf is a neuroscientist and a medical technology developer at Stanford University. With over three decades of research and development experience, Dr. Greenleaf is considered a leading authority in the field of digital medicine and medical virtual reality technology. We happened to meet him at a conference at San Francisco, and then we were lucky enough to have him come to Costa Rica as a speaker for a Neuroscience conference some time later. I highly recommend the site: medvr.io/online-talks for conferences about his work and other professionals in the field.
Another challenge we faced was practicing motor skills with VR controllers. Mimicking natural hand movements is a challenge while holding the controllers, so we started using Ultraleap’s Leap Motion for a “non-controls experience”. However, the lack of haptic feedback interfered in the process for some patients. Although VR has improved over the years, the previous scenario and many others like it, show some of the limitations we faced at the time. The challenges didn’t necessarily lessen the provable improvement for the patients that participated in the program here in Costa Rica and around the world, that said, I would like to see the VR businesses, rather than focusing on the gaming industry, give credence to some less revenue generating, business where, the technology really shines, like healthcare. Scenarios like not being able to find headsets in the market for kids to wear comfortably is something that shouldn’t still be complicated. The Hospital Nacional de Niños, (National Children’s Hospital) has a special unit for burn survivor kids. They were applying VR as a pain management tool for kids enduring wound debridement. If you happen to not know what that is, burn wound debridement is a procedure for treating a wound in the skin. It involves thoroughly cleaning the wound and removing all “hyperkeratotic” (thickened skin or callus), infected, and nonviable (necrotic or dead) tissue, foreign debris, and residual material from dressings. Even the experience of cleaning a burn with gauze is something that I found very painful, and I’m extremely shocked at how brave kids sometimes are. Immersive VR showed the potential to decrease suffering during cleaning, not to mention the positive psychological effects in the patient and the patient’s family. Dr. Carlos Siri, head of the department, is empathic on how highly sterile the room where the debridement is done must be, since burning more than 60% in skin’s surface implicates risk of infection, and having a whole rig (highly reliably computer and headset) was something reserved for the more critical uses, since there is no way to surgically disinfect the equipment. Currently, most major VR companies create headsets only for young adults 13+ years old. Researchers have warned that virtual reality headsets could pose risks to some children. Some believe that continued use of VR could trigger eyesight and balance problems in young people. The profile of the patient needs to be cleared by many professionals since the refresh rate of the screen (as with computers, cellphones, and television) might be problematic for patients suffering from epilepsy, or photosensitive people in general.
Another interesting approach, secondary to the one we used for the practice and track of “Adaptive Behavior Domains”, is the method used by the team of The way Back. The wayback is a virtual reality film series designed for those living with dementia and their carers. Using VR they recreated key positive moments from the past, taking viewers back in time, triggering memories and stimulating conversations about them. The feelings of uncertainty a patient with dementia can face: not being able to recognize your face in the mirror or the people who surround you, where you are, or what just happened, can leave a patient with high levels of anxiety, and this is a non-drug alternative way to relieve stress for the patient. I will explain about this app and others on my next blog about a Conference I was invited to talk at Guatemala for the use of VR for people with mild cognitive impairment (MCI) or dementia.
Thinking outside the box is one of the most overused sentences I’ve heard during my time working in the technology field…that is, until I started this project. Today Doña Marta is able to walk (with assistance) but she started going to the HNP in a wheelchair and without being able to hold her head weight. I’m not attributing all the results to VR but I’m definitely sure it helped in the process. Let’s never get stuck with technology’s intended/marketed use.