Cognitive Effects of Videogames on Older People

Abstract

Background: The use of video games has shown benefits for the ageing population. This paper studies the cognitive effects of video games on the elderly, as well as these effects on self-concept and quality of life. The mediator effect of self-concept is also evaluated. The instruments used are the Cognitive Subscale of Alzheimer's Disease Assessment Scale (ADAS-Cog), the Clinical Inventory of Self-Concept (ICAC) and the World Health Organisation Quality of Life Questionnaire (WHOQOL-bref). Methods: The study involved the participation of 43 elderly people distributed between three experimental conditions (15 used video games, 17 relaxation and 11 had no intervention). There were two periods of assessment, before the intervention and after 8 weeks. Results: It was found that the participants who used video games showed a decline in cognitive deterioration, unlike the control groups. The self-concept measure deteriorated signifi-cantly under relaxation condition and on the passive control group. The quality of life test did not show any differences. Nor were any correlations found between the time of use of video games and larger effects. The mediator effect of self-concept on differences obtained in the ADAS-Cog (r =0.57, p = 0.014) and in the ICAC (r =-0.47, p= 0.039) was confirmed. Conclusions: In summary, the results show that the use of video games leads to the improvement of cognitive functioning in the elderly and to the maintenance of self-concept and quality of life. The results also suggest that the higher the self-concept, the better the cognitive effects achieved.

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ICDVRAT with ArtAbilitation, Maia, Portugal, 2008
©2008 ICDVRAT/University of Reading, UK; ISBN 07 049 15 00 6
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Cognitive effects of videogames on older people
A Torres
Faculty of Medicine, University of Porto, 4200-319 Porto, PORTUGAL
Department of Communication and Art, University of Aveiro,
3810-193 Aveiro, PORTUGAL
anatorres@ua.pt
ABSTRACT
In these days the percentage of older people in the population is growing worldwide. It is
therefore urgent to decrease the morbidity resulting from biopsychosocial losses associated
with old age. The preservation and recovery of cognitive functions and of physical,
psychological and social autonomy are provided through new mental and physical activities.
As have other activities, the use of video games has shown benefits for this ageing population,
in particular at the cognitive level. Although there are only few studies which studied this
videogames’ application. In this study we studied the cognitive effects of videogames on the
elderly people. And we also studied these effects on self-concept and on the quality of life. The
instruments used are the Cognitive Sub-scale of Alzheimer’s Disease Assessment Scale, the
Clinical Inventory of Self-Concept and the WHOQOL-Bref. The study involved the
participation of 43 elderly people distributed between 3 experimental conditions (n = 15 used
videogames, n = 17 relaxation and n =11 had no intervention). There were two moments of
assessment, before the intervention (Pre-test) and after eight weeks of it (Post-Test). Old
people shows to be able to use videogames as well as to like to use it. Although they faced
some difficulties using key board and mousse. They show to prefer games without time
challenge and without fast and exact movements. They also show to prefer videogames with a
real story behind the play activity. It was found that the videogames participants showed a
decline in cognitive deterioration from the pre to post intervention tests (t (14) = 3,505, p =.
003, r = .68), unlike the control groups. The self-concept deteriorated up significantly under
relaxation condition (t (16) = 2.29, p = .036, r = .50) and on passive control group (t(10) =
3.44, p = .006, r = .74). The quality of life did not show any differences from the start to the
end of the study. Nor were any correlations found between the time of use of videogames and
larger effects. The mediator effect of self-concept on differences obtained in the ADAS-Cog
(rS = .57, p = .014) and in the ICAC (rS = -.47, p = .039) was confirmed. In sum, the results
show that the use of videogames leads to the improvement of cognitive functioning and to the
maintenance of the self-concept and the quality of life of elderly people. They also suggest that
the higher the self-concept, the better are the cognitive effects achieved.
1. INTRODUCTION
The improvements of hygienic conditions and medical knowledge led to the individual aging enlarge. The
twenty-first century are even called of the aging century, because it is characterized by the abrupt increase in
the proportion of elderly population.
United Nations (2001) expects that in 2050 the elderly population will represent 15.6% of the world
population against 21% of young adults.
It is consensual that elderly population is more vulnerable to bio psychosocial losses, despite the fact that
the aging process is very heterogeneous. At a physiological point of view, every system can reflect their
organs aging. There are several changes in the nervous system: neurotransmitters levels changes, the brain
atrophy, neuronal cells modifications, oxygen and blood flood decrease (Kaplan and Grebb, 1997). There is
even evidence that the brain atrophy is linked to age-related cognitive decline (Albert and Killianny, 2001).
And the age-related cognitive decline (especially the moderate decline) is related to psychological symptoms
as clinical depression (e.g., Forsell, Jorm and Winblad, 1994), low self-concept and quality of life. The rest of
the related aging losses also contribute to these psychological symptoms. These losses are especially social

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losses. During the aging process elderly people lost significant others. These losses are related to deaths, to
the end of professional relationships and to the distance of others (which is more difficult to overcome)
(Giddens, 1997). Consequently, older people are submitted to a loss of social support. And these losses are
intensified by ageism (the word Ageism was created by Butler (2005) based on words to designated
discrimination against black people (racism) and against women (sexism). It is related to prejudices against
older people).
Regarding cognitive decline, many studies have demonstrated that certain cognitive functions diminish
with increasing age. Information processing speed is compromised, as is memory, verbal fluency, efficient
consolidation on newly learned information and executive functions such planning and behavioural
organization (Hooren et al, 2007).
At the same time, several studies argue that Information and Communication Technologies (ICT) have
benefits to the older people. It is argued that TIC can improve social support (e.g. Wright, 2000; White et al,
1999), cognitive functioning (e.g. Bond, et al, 2001), quality of life (e.g., Leung and Lee, 2005; McConatha,
McConatha and Drmigny, 1994) and diminish depressive symptoms (e.g. Whyte and Marlow, 1999). There
are also studies that refer the benefits of videogames, which are specific ICT instruments. Visual
improvement (Green and Bavelier, 2006, 2007; Risenhuber, 2004), spatial visualization (Subrahmanyam and
Greenfield, 1994), reaction time (Bialystok, 2006), visuo-motor coordination (Griffith et al, 1983) and quality
of life (Leung and Lee, 2005) are some of the benefits verified. The videogames’ studies with older people
verified several benefits too, although there is only few studies until now. The benefits achieved with
videogames by older people are: reaction time(e.g., Dustman et al, 1992; Clark, Lanphear and Riddick, 1987;
Goldstein, 1997); cognitive functioning (Farris et al,1994), intelligence (Drew and Waters, 1986), visuo-
motor coordination (Drew and Waters, 1986), attention and concentration (Weisman, 1983), self-esteem and
quality of life (McGuire, 1984; Goldstein, 1997). Green and Bavelier (2006) adverts that a massive increase
in the amount of dopamine released in the brain was indeed observed during video game play, in particular in
areas thought to control reward and learning. They also adverts that the role of this surge in dopamine and its
implications are not currently well known, but work in rats suggests that dopamine may be important in the
modification of the brain following perceptual training.
The aim of this work is to test the acceptance of videogames of older people and their ability to use it.
Our purpose is also to identify the factors which contribute to their acceptance level. Simultaneously we will
evaluate the cognitive effects of the videogames use on older people, as well as, the effects on their self-
concept and quality of life. We also evaluate the mediator effect of self-concept on cognitive results
achieved. We believe that older people are able to use videogames and that instruments have beneficial
effects to them. We expect that higher the self-concept higher will be the beneficial effects.
2. METHOD
2.1 Sample
Participants were 43 people (10 man and 33 woman). They are all Portuguese and belongs to a residential
homes to older people (26 are resident, 8 are daily frequent and 9 are activities frequenters). Mean age of
78.33 (SD= 8.002, min=65, max=93).
Participants presented the following inclusion criteria: 65 years old or more, inexistence of aphasia,
hearing and visual severe deficits or behavioural and perceptual disorders. They maintained the
psychopharmacological therapy during the experiment period and before two months of its beginning. All of
them gave their informed consent. The study followed the ethical standards of the American Psychological
Association (APA, 2001).
On the beginning of the study we randomised the participants for 2 groups: experimental group (with
videogames) and control group (with relaxation sessions). Although, some of them could not participate in
the 2 kinds of activities, so we opted for to have 3 groups: experimental group (videogames – n=15), active
control group (relaxation sessions, n=17) and passive control group (without experimental treatment, n=11).
There is not significant statistical differences between the 3 sample groups regarding the age (F=.340,
p=.714), the sexual genre (χ2(2)=4.38, p>.50), the education level (χ2(6)=5.5, p>.50), the previous
occupational area (χ2(12)=20.74, p>.50) and the marital status (χ2(8)=4.47, p>.50).
2.2 Instruments
2.2.1 Measures. There are 2 evaluation stages: pre and post-tests. Each stage encloses different instruments
full-fill. The instruments used are: a demographic questionnaire (age, occupational area, educational level,

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marital status, physical and emotional disorders, medication and time of use); the cognitive part of the
Alzheimer Disease Assessment Scale – ADAS-Cog (Rosen and Mohs, 1984; Portuguese version: Guerreiro,
2003); The clinical self-concept inventory – ICAC(Vaz-Serra, 1986); The World Health Organization
Quality of Life Questionnaire – WHOQOL (WHOQOL Group, Portuguese Version: Vaz-Serra et al, 2006).
In the first assessment the participants also full-filled the consent form and in the final assessment they
answered to questions about the sessions satisfaction and about the occurrence of life parallel major
problems. The instruments used showed good psychometric characteristics in our sample. The most
important psicometric characteristic in our study (a pre and post test design) is the test-retest correlation,
which is high in ADAS-Cog (r=.83, p=.000), in ICAC (r=.75, p=.000) and lower in the WHOQOL-Bref
(rS=.55, p=.000).
2.2.2 Intervention Sets.
2.2.2.1 Videogames. The videogames was selected based on their cognitive stimulation capacities. We opted
to use causal games because they involve very simple rules and play techniques, making them easy to learn
and play (IGDA, 2006). Participants of the experimental group are submitted to 8 videogames sessions (one
weekly). It was selected 7 videogames after we use several videogames with a pilot-participant: QBeez,
Supper Granny 3, ZooKeeper, PenguinPush, Bricks, Pingyn and memory games. The QBeez game was
referred by Nicole Lazaro (2006) as being a game with emotional capacities and subsequently with capacity
to develop a high interest level on users. In our opinion this games can improve the attention-concentration,
the processing speed, the procedural tasks, the work memory and gnosis. The Supper Granny 3 game
involves the resolution of problems and consenquently the attention-concentration, processing speed, the
executive functions, the work memory and the spatial orientation. The Zookeeper seems to be able to
stimulate attention-concentration, processing speed, the procedural tasks, the work memory, gnosia, and
temproral orientation (because it has time challenging). PeguinPush seems able to stimulate attention-
concentration, processing speed, spatial orientation and executive functions. Bricks were widely referred for
being an exercise of knowledge of physic. We believe that it can exercise the attention-concentration, the
processing speed, the procedural tasks and the work memory. Pingyin can improve attention-concentration,
process speed, working memory, the procedural tasks and temporal orientation. The memory games can
improve memory functions and also attention-concentration, process speed, gnosia and temporal orientation
(in which there is time challenge).
2.2.2.2 Relaxation Session. The active control group was submitted to 8 relaxation sessions (one per week).
The relaxation method used was the Jacobson’s progression muscular relaxation training.
2.2 Procedures
After the videogames selection we try them in a pilot-participant, who selected the definitive 7 videogames
which are the most adequate to his use. The participant-pilot was similar characteristics to the 43 study
participants (the inclusion criterions). We also take advantage of his participant-pilot pre-study to test all the
procedures to comply with during the assessment and intervention session. Then we selected the study
participants through the clinical files analysis to confirm the inclusion criteria. After this selection we did a
first interview in which the general aim of the study was introduced (to study the older people in two
activities – we opted for being very general in the purposes presentation in order to avoid induce a bias of
participants’ behaviour (Hawthorne Effect))
and was full-filled the measures (Pre-Test). Then we randomised
the participants by the experimental conditions.
During 8 consecutive weeks the participants was submitted
to the experimental conditions (videogames or relaxation sessions). And finally, we did a last interview to
fulfill the second assessment of the measures (Post-Test) and to evaluate how the participants feel about the
experiment and also to know if there are some life events relevant during the experiment period.
It is important to remark that as the participants did not have computer literacy, we had to do training on
the beginning of the first session. The training consists on an introduction of the mouse and keyboard
functioning and it was a duration of approximated 5 minutes (depend on the participant acquisition
satisfaction).
In the first videogame session it was also presented all games to the participants, who can choose which
they would which to play. In the following sessions we asked if they want to see all the games again or if
they know which they wish to play already.
In all videogames’ sessions the participants didn’t have a period limited to use the games, they can use it
how long they wish. During the sessions we give them reinforcements (“Well done”) and prompts (“Ok, lets
see what you have to do now, you will find out.”).

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3. RESULTS
3.1 Quantitative Results
In the experimental condition (videogames condition), participants presented greater cognitive deterioration
at the pre-test assessment (M=17.60, SD=7.68) than at the post-test assessment (M=14.20, SD=5.98). This
difference was a statistical significant decrease at ADAS-Cog
1 (t(14)=3.505, p=.003, r=.68). And this effect
is high, because it explains 46% of the total variance. In opposition, participants at the control conditions
presented a non significant increment (see table below).
Table 1. Pre and Post-Tests ADAS-Cog Results at each condition.
Videogames Group Active Control Group Passive Control Group
Mean D.F.. St. D.
Mean D.F.. St. D.
Mean D.F.. St. D.
ADAS
17,60
14
7,68
18,24
16
7,96
17,18
10
7,73
ADAS_pos
14,20
14
5,98
19,94
16
9,22
19,82
10
13,26
t-test
3,505(*)
-1,69
-1,28
p
.003
,109
,230
* significant at the 0.05 level
Table 2. Pre and Post-Tests ICAC Results at each condition.
Videogames Group Active Control Group Passive Control Group
Mean
D.F.
St. D.
Mean
D.F.
St. D.
Mean
D.F.
St. D.
ICAC
71,93
14
6,16
72
16
6,48
73,45
10
4,91
ICAC_pos
71,47
14
5,97
69,29
16
6,82
69
10
7,5
t-test
,49
2,29(*)
3,44(*)
P
,64
,036
,006
* significant at the 0.05 level
Table 3. Pre and Post-Tests WHOQOL-Bref Results at each condition.
Videogames Group Active Control Group Passive Control Group
N
Mean
Rank
Sum of
Ranks N
Mean
Rank
Sum of
Ranks N
Mean
Rank
Sum of
Ranks
Negative
Ranks
5ª
6,00
30,00
11ª
7,45
82,00
2ª
3,00
6,00
Positive
Ranks
5
b
5,00
25,00
3
b
7,67
23,00
3
b
3,00
9,00
Ties
5
c
3
c
6
c
Quality of Life G post -
Quality of Life G pre
Total
15
17
11
Z
Wilcoxon Signed Ranks Test
-,262
d
-1,934
d
-,447
d
Asymp. Sig. (2-tailed)
,794
,053
,655
a. Quality of Life G post < Quality of Life G pre
b. Quality of Life G post > Quality of Life G pre
c. Quality of Life G post = Quality of Life G pre
d. Based on positive ranks.
1
At the ADAS-Cog, lower the total result, lower the cognitive deterioration level.

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Regarding the results achieved with ICAC, it was verified a decrease of self-concept in all the conditions,
although the videogames conditions was not a significant decrease. In respect to quality of life, there wasn’t
any significant statistical differences (See Table 3). Differences between pre and post tests of the measures
used in our study didn’t showed to be significantly correlated to the time of use of videogames as we can see
in the Table 4 below.
Table 4. Correlation between time of use of videogames and differences achieved in dependent variables.
Dif. ADAS Dif. ICAC
Dif. WHOQOL
Time of Use
Correlation
-.130
a
.071
a
,334
b
Sig. (1-tailed)
,257
,362
,112
N
15
15
15
a. Spearman Correlation
b. Pearson Correlation
The results obtained in our study confirm that there is a positive correlation between the initial ICAC overall
result and the differences achieved at ADAS and ICAC. There is not however a significant correlation with
the results of the WHOQOL.
Table 5. Correlation between Initial Self-concept and differences achieved at the Dependent Variables
Dif. ADAS Dif. ICAC
Dif. WHOQOL
ICAC_Total
Correlação
,566(*)
a
-,469(*)
a
,234
b
Sig. (1-tailed)
,014 ,039 ,201
N
15 15 15
a. Spearman Correlation
b. Pearson Correlation
The statistical tests also allow us to assure that the demographic variables didn’t interfere in the differences
achieved. Sex genre do not influence the differences achieved at ADAS-Cog (U=148, p>.05), at ICAC
(U=165, p>.05) and at WHOQOL (U=155, p>.05). The educational level also didn’t influence the results
achieved at ADAS-Cog (H(3)=.62, p>.05), at ICAC (H(3)=3.45, p>.05) and at WHOQOL-Bref (H(3)=2.5,
p>.05). Neither did the previous occupational area: ADAS-Cog (H(6)=5.78, p>.05), ICAC (H(6)=1.64,
p>.05) and WHOQOL-Bref (H(6)=4, p>.05). As well as, the marital status didn’t influence the results:
ADAS-Cog (H(4)=4.37, p>.05), ICAC (H(4)=3.14, p>.05) and WHOQOL-Bref (H(4)=8.28, p>.05). Age
didn’t show any influence on the differences achieved at ADAS-Cog (rs=-.2, p>.05), at ICAC (rs=.04, p>.05)
and at WHOQOL-Bref (r=-.1, p>.05).
3.1 Qualitative Results
During the experiment we registered also qualitative observations data.
The answers obtained to the final questionnaire, regarding participants satisfaction with sessions, show us
that only one participant thinks that a part of the session are not very adequate to his cognitive skills (ADAS-
cog tasks). He thinks that it is to people with worse cognitive difficulties. It was explained that the tasks have
to be the same for all participants despite the cognitive skills (because it is a scientific study). The other
participants think that the sessions was adequate.
We also observed that 2 women didn’t want to participate in videogames sessions even before to see it.
One did not want because she never had liked games, even traditional ones. The other women never had liked
any kind of machines.
We observed that all of the videogames participants are able to use the computer after a brief introduction
of use (5 minutes). Despite that their majority feels initially anxious about the computer use. Before the
computer use they said that they are not able to do it and similar sentences. During the videogames use,
participants expressed them self with sentences as “It is very funny!”, “Can you give me this to put in my
grandchild computer to allow me to play more?” and “This is really a good entertainment!” During the use it
was also observed another kind of contentment expressions as laughter, especially when they achieve the

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videogames purposes. Although we observed that they faced some limitations on computer use. They do not
feel very confident in mouse and keyboard use, so they use it low and sometimes it is hard to them see the
cursor.
It was interesting to observe that some videogames are more chosen than other. In Table 6 below we
present a decreasing list of videogames preferences. The last three was equally chosen by the participants.
Table 6. Videogames Used by decreasing order
QBeez
Super Granny 3
Memória
Pingyin
Zoo Keeper Bricks Penguin Push
Regarding this observation the first two games are played without time challenge. The memory games chosen
by participants are all without time challenge too. They demonstrated very interest for the Pingyin, because it
is a videogame about the climate current world problems, but they give up to use it because they could not
handle with the time challenge. Zookeeper has the time challenge difficult too and does not elicit as much
interest as Pingyin did. Participants shows difficult to handle with the precision and fast of the movements.
Despite they can manipulate the Penguin Push, they feel a little boring during its use.
It was also observed that some participants complained about excessive tears in the eyes during the game
playing.
4. CONCLUSIONS
The results achieved in this study supports that older people are able to use computers and that the
videogames use can improve their cognitive skills. The results also supports that the videogames use
maintain the self-concept and the quality of life of older people. Although it does not support that if older
people play it during more time they can achieve better results. It seems, however, that when they have
higher self-concept, they can achieve more cognitive improvements.
Our results are according the previous studies regarding cognitive effects of videogame playing by older
people. We believe that if the intervention period was extended (longer than 8 weeks), the improvements
would also have higher influence on the self-concept and quality of life.
We also observed that women show fewer predispositions for videogames playing than men as it is
widely found. Any man refused to try videogames, in opposite to two women.
Despite the ability of older people to computer use, they have some anxiety about it and there is some
interface limitations to this population too. We believe that it is necessary to demystify the prejudices about
aging and about the use of computers by older people, in order to reduce the anxiety verified. At the same
time it is necessary to improve ICT design to adequate it to this population. We think they would benefit with
tangible interfaces as touch screens or Wii equivalents. We also think that they avoid videogames with very
fast and precise movements and with time challenge. We think that our qualitative results also let us to
conclude that they prefer videogames with a real and meaning story behind it.
We can not retire any conclusion about the tears effect observed, because we do not have how to know if
it is related to the therapeutic visual effects referred (e.g. Green and Bavelier, 2007) or, in the other hand, if it
is just related to a visual effort to see the videogames interfaces. This would be object of future research.
Our study would be better if we have a bigger sample, although it has already more than the previous
ones. We hope that this study can have practical implications in older people daily living and in future
research.
Acknowledgements: We want to acknowledge to all the volunteer participants and to their institutions.

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