Improving Everyday Task Performance Through Repeated Practice in Virtual Reality.
Improving Everyday Task Performance Through Repeated Practice in Virtual Reality.
There are very few effective interventions that promote functional independence in people
 with Alzheimer's disease (AD) and related dementias. This R21 project is the first step in
 the long-term goal of developing an effective, enjoyable, portable, and inexpensive
 non-immersive virtual reality (VR) training intervention for improving the performance of
 everyday tasks. The investigators' VR training approach is built upon the results of past
 studies that show 1) when people with AD repeatedly practice daily tasks they subsequently
 perform them more completely and without error; and 2) healthy people are able to transfer
 skills learned in VR-contexts to tasks in the real world. This R21 study will obtain
 preliminary data to inform a future randomized clinical trial through three aims: Aim 1) To
 test the hypothesis that individuals with mild-moderate AD will show improved performance on
 an everyday task after repeatedly practicing the task in a non-immersive VR setting; Aim 2)
 To explore usability and acceptability of the VR training as well as associations between
 individual differences variables (e.g., cognitive abilities, demographics) and training
 effects. To test Aim 1, 40 participants with mild to moderate AD will be recruited to
 complete daily VR Training sessions for one week. VR Training will include repeated practice
 of a single, everyday task in a non-immersive VR-context (VR Breakfast or VR Lunch;
 counterbalanced across participants). The primary outcome measure is performance of the
 real-life version of the trained task, which will be collected before and at two time points
 after training, compared to performance of an untrained, control task of comparable
 difficulty, and scored from video by coders blinded to training task/condition. To evaluate
 Aim 2, all participants and an informant will complete interviews and questionnaires and
 participants will complete tests of cognitive abilities. Usability and acceptability of the
 VR training will be evaluated and associations between participant variables and VR Training
 results will be explored. If the proposed hypothesis is supported and results show that
 training effects generalize from virtual to real tasks in the study sample, then VR training
 of custom and individualized tasks will be investigated in a future randomized, controlled
 clinical trial for maintaining and improving functional abilities in people with mild to
 moderate AD.
Functional disability, the loss of independence in everyday tasks like meal preparation, is a
 core diagnostic criterion for clinical dementia/Alzheimer's disease (AD) and contributes to
 the disease's exorbitant costs and caregiver burden. There is currently no cure for AD and
 available interventions have had limited success at reducing functional disability. Cognitive
 training leads to reliable improvements on the specific task(s) that are repeatedly
 practiced, but transfer to untrained, functional tasks is limited. Because of both limited
 transfer and rigid (procedural) learning in AD, novel language-based interventions for
 dementia have focused on repeated practice with a circumscribed and highly personalized
 vocabulary to maintain functional communication. Repeated practice of everyday tasks
 (leveraging intact procedural memory also has been shown to improve performance of trained
 tasks in people with AD but is not a feasible intervention, because the effort required to
 set up tasks, monitor performance, and provide feedback/supervision is far greater than
 having a caregiver simply complete the task for the patient. However, if repeated practice of
 specific everyday tasks could be implemented in a more cost-effective, efficient manner, then
 this straightforward intervention strategy could reduce functional disability and associated
 costs of care and caregiver burden.

 This R21 proposal will investigate the efficacy of a low-cost and portable computer training
 program that uses non-immersive virtual reality (VR) to enable participants with AD to
 independently practice meaningful everyday activities (e.g., meal preparation). The goal of
 this R21 study is to evaluate the extent to which training in a virtual context will
 generalize to real life tasks. If training effects generalize from virtual to real settings,
 then training of customized tasks for maintaining and improving functional abilities in older
 adults with AD will be investigated in a future randomized, controlled clinical trial.

 This proposal was informed by a cognitive activation model on which everyday activities are
 represented as schema hierarchies. Activation within the schema hierarchy may spread
 automatically from higher level schema (e.g., make lunch) to lower level schema (e.g., spread
 peanut butter) as well as from objects or environments that may "trigger" associated schema
 (e.g., a coffee mug may activate coffee-making schema). Deliberate cognitive control is
 essential to modulate activations, enable smooth transitions between schema subtasks, and
 inhibit inappropriate activation from objects in the environment. Without control mechanisms,
 interference from competing schema or objects in the environment may derail performance and
 lead to inefficiency and disorganization of task steps (i.e., commission errors like
 mis-sequencing, incorrect object selection, etc.). Another mechanism for performance
 difficulties involves premature decay of schema activation or degraded task schema/knowledge
 (i.e., omission errors). On this model, repeated practice serves to strengthen associations
 within a schema hierarchy and between task schema and target objects in the environment,
 reducing the burden on control mechanisms and the likelihood of premature decay.

 To evaluate the efficacy of VR Training the investigators will recruit 40 participants with
 AD to complete daily training sessions for one week. VR Training will include repeated
 practice of a single, everyday task in a non-immersive VR context (e.g., VR Breakfast) using
 a laptop with a touch-screen interface. Performance of a real-life version of the trained
 task (e.g., Real Breakfast) and a matched, untrained/control, real task (e.g., Real Lunch)
 before and at two time points post-VR Training will serve as the primary outcome measures.
 All procedures are designed to achieve the following aims:

 Aim 1: To test the hypothesis that individuals with mild-moderate AD will show improved
 performance on an everyday task after repeatedly practicing the task in VR. When people with
 AD repeatedly practice tasks in real life, they show improved performance of those tasks.
 Transfer from VR training to real life outcomes has not been systematically studied in AD,
 but healthy adults, a case report of a woman with moderate AD, and pilot data from the
 investigators' laboratory support transfer from VR to real tasks. Thus, the investigators
 predict that participants will show significantly higher task accomplishment, fewer errors
 and faster completion times from Baseline to Post-Testing on real trained tasks versus real
 untrained tasks.

 Aim 2 (Exploratory): To explore usability and acceptability of the VR Training and
 associations between individual differences variables (e.g., cognitive abilities) and
 training effects. These analyses will elucidate mechanisms and identify individuals most
 likely to benefit from VR Training.

 Results will demonstrate the efficacy and feasibility of VR Training and identify the patient
 characteristics most strongly associated with training benefits on real life tasks. Data will
 be used to inform a future randomized clinical trial using VR tasks that are customized to
 participants' daily routines.
Inclusion/Exclusion Criteria:

 1. 65 years or older;

 2. fluency in the English language;

 3. availability of an informant reporter who has knowledge of the participant's daily
 functioning;

 4. no lifetime history of severe psychiatric disorder (e.g., schizophrenia, bipolar
 disorder), nervous system infections or disorders (e.g., epilepsy, brain tumor,
 large-vessel stroke, major head trauma) other than Alzheimer's disease;

 5. no current metabolic or systemic disorders (e.g., B12 deficiency, renal failure,
 cancer);

 6. no current major depression or moderate-severe depression symptoms;

 7. no current moderate - severe, uncontrolled anxiety symptoms;

 8. no severe sensory deficits that would preclude visual detection or identification of
 common everyday objects used in the study or the inability to hear the task directions
 (e.g., blindness, total hearing loss);

 9. no severe motor weakness that would preclude the use of everyday objects or the VR
 Training computer touch screen (e.g., severe deformities or paralysis of both upper
 extremities) ;

 10. intact estimated general intellectual functioning (i.e., no history of intellectual
 disability);

 11. available to participate in the one-month follow-up session after the VR Training
 (i.e., no surgery, travel, etc. scheduled over the next month);

 12. diagnosis of mild to moderate Alzheimer's disease within the past year, including
 confirmation of mild to moderate dementia on Mini Mental Status Exam (score
 approximately 25 or lower), significant functional difficulties reported by informant
 report, and cognitive impairment on demographically adjusted (age, education, sex, and
 race) cognitive test scores at baseline.

 An informant (N = 40) also will be recruited for each participant with dementia. Informants
 are people who know the participant well and interact with the participant on a daily
 basis. Informants will be asked to report on the participants' daily functioning and the
 extent to which the informant is burdened by the participants. Informants also will be
 asked to report on changes in medical or mental status during the study period. Informant
 eligibility criteria is listed below:

 1. 18 years of age or older

 2. fluency in the English language

 3. available and willing to complete study questionnaires in person or by phone

 4. has daily contact with the participant

 5. reports that he/she is knowledgeable of the participant's daily functioning