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Serious Games for Dementia

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Serious Games for Dementia

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With the current phenomenon of aging populations in most parts of the world, there are corresponding increases in age-related conditions associated with impaired cognitive status, such as dementia and delirium. Cognitive status is a key component in carrying out activities of daily living such as walking and bathing, and departures from normal cognitive status may be indicators of acute (e.g., delirium) or chronic (e.g., dementia) conditions. Individuals with cognitive impairments may benefit from playing serious games, which are games designed for a primary purpose other than entertainment. Serious games can potentially assess a variety of factors associated with cognitive decline in dementia, while keeping individuals active and stimulated, thereby potentially slowing down or furthering cognitive decline. In this workshop paper, we discuss the development and use of serious games focusing on cognitive functions that are affected by the progression of dementia.
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Serious Games for Dementia
Tiffany Tong
University of Toronto
5 King’s College Road
Toronto, Ontario, Canada
1-416-978-7581
tiffany.tong@mail.utoronto.ca
Jonathan H. Chan
King Mongkut’s University of
Technology Thonburi
Bangkok, Thailand
66-2-470-9819
jonathan@sit.kmutt.ac.th
Mark Chignell
University of Toronto
5 King’s College Road
Toronto, Ontario, Canada
1-416-978-8951
chignel@mie.utoronto.ca
ABSTRACT
With the current phenomenon of aging populations in most parts
of the world, there are corresponding increases in age-related
conditions associated with impaired cognitive status, such as
dementia and delirium. Cognitive status is a key component in
carrying out activities of daily living such as walking and bathing,
and departures from normal cognitive status may be indicators of
acute (e.g., delirium) or chronic (e.g., dementia) conditions.
Individuals with cognitive impairments may benefit from playing
serious games, which are games designed for a primary purpose
other than entertainment. Serious games can potentially assess a
variety of factors associated with cognitive decline in dementia,
while keeping individuals active and stimulated, thereby
potentially slowing down or furthering cognitive decline. In this
workshop paper, we discuss the development and use of serious
games focusing on cognitive functions that are affected by the
progression of dementia.
Categories and Subject Descriptors
D.2.10 Design: Human Factors
General Terms
Design, Human Factors
Keywords
Activities of daily living; Alzheimer’s disease; cognitive
assessments; cognitive screening; dementia; executive function;
games; gamification; human factors; instrumental activities of
daily living; serious games.
1. INTRODUCTION
The rapid aging in many societies is leading to an increasing
prevalence of age-related conditions associated with abnormal
cognitive status, such as delirium, and dementia [1]. Other aging-
related issues that affect quality of life, and the ability to live
independently, include frailty and loss of functional status. In
Canada alone, 20% of people over the age of 65 are estimated to
be frail [22]. Cognitive impairment is an important component of
the cumulative deficits that contribute to frailty, and cognitive
abilities such as memory and executive functioning are necessary
for performing activities of daily living.
According to the Alzheimer’s Association (2015), 32% of
Americans aged 85 or older have Alzheimer’s Dementia (AD),
and AD is currently the sixth leading cause of death in the United
States. There appear to be a number of risk factors for AD,
including family members with dementia [13], traumatic brain
injury [14], mid-life obesity and diabetes [3], and depression [6].
Since cognition is a highly complex construct that involves many
different types of abilities, we will describe a serious game that
provides a general assessment of executive function (a unified
approach), as well as being potentially applicable to a range of
disorders related to aging. We will also propose development of
specialized serious games that can be targeted to other more
specialized components of cognition (a fractionated approach). To
demonstrate this fractionated approach, we consider specific
examples of serious games that assess functions that are expected
to decline as people progress through the dementia lifecycle.
In the following discussion, we begin by discussing a serious
game for individuals with cognitive impairment that we have
developed. ThisExecutive Timed Target Game(a version of the
whack-a-mole game) assesses inhibition ability, which is related
to overall executive functioning ability [17]. Inhibition ability
declines with age in older adults [23]. Reduced executive function
abilities, as people age, adversely impact functional abilities
required in completing activities of daily living (ADLs) such as
bathing and walking [10]. Thus in developing the game we
hypothesized that performance on the game should be related to a
number of clinical assessments, not only of cognitive status, but
also of other measures related to executive functioning, such as
ADLs.
2. EXECUTIVE TIMED TARGET GAME
Our serious game mimics features of the classic psychological
Go/No-Go Discrimination Task [33], a measure of inhibition
ability. As implemented, our game is similar to the carnival game
“whack-a-mole” (see Figure 1). In a previous study with healthy
younger adults we found that our serious game had a significant
relationship (r = 0.60, p < 0.01, one-tailed), with the Stroop task
[28]. The Stroop task is a test of the inhibitory executive function,
which declines with age, and which has been shown to correlate
with white matter loss in the brain (e.g., [20]).
We evaluated our Executive Timed Target Game with a sample of
elderly emergency patients [29], and compared response time
(RT) performance on the serious game to scores on standard
cognitive assessment methods such as the Mini Mental State
Examination (MMSE) [9] and Montreal Cognitive Assessment
(MoCA) [18]. Median game RT was significantly correlated with
both the MMSE (r =-0.558, p < 0.001), and MoCA (r =-0.339, p <
0.001) in elderly emergency department (ED) patients and
differences were in the expected direction (slower game RT for
people with possible mild cognitive impairment assessed using the
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ACM 978-1-4503-4913-0/17/04.
DOI: http://dx.doi.org/10.1145/3041021.3054930
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MoCA, and for people with dementia as assessed using the
MMSE). In our study, we observed a correlation of r = 0.630 (p <
0.001) between the MMSE and MoCA scores. This compares
fairly well with the correlations of r = 0.430 between the MMSE
and MoCA scores for healthy controls and r = 0.600 for patients
with mild cognitive impairment found previously [30]. Overall,
the correlation of our serious game with existing methods of
clinical cognitive assessment appears to be almost as strong as the
correlations of the clinical assessment methods with themselves.
The correlations between the global mental status tests observed
in this study are similar to results seen in other research.
Figure 1: Screen capture of the Executive Timed Target
Game.
We examined the relationship between serious game performance
and MMSE scores, using a cutoff where an MMSE score of less
than 24 was indicative of possible dementia [9,19]. Using a
serious game median RT cutoff of 1.1 seconds, (approximately
the same as a 1.13 second value used for delirium screening we
had identified in previous research [29]) we obtained a specificity
of 86% (86/99) and sensitivity of 76% (13/17) (see Table 1) [29].
Thus, using a common MMSE cutoff value, we were able to
identify 13 out of 17 patients with dementia as identified using the
MMSE.
Table 1: Predicted versus actual MMSE scores using a serious
game RT cutoff of 1.1 seconds [29].
Actual MMSE Score
MMSE >= 24
Predicted
MMSE
Score
MMSE >= 24
86
MMSE < 24
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In addition to the Executive Timed Target Task being able to
screen for signs of cognitive impairment by examining overall
executive function of inhibition, it is also an enjoyable and usable
game for patients at risk of or with cognitive impairments. In our
study with older ED patients [29], we received comments on the
game from research assistant who helped carry out the study with
patients:
“Loved the game, she was playing games on her iPhone
before I approached her”
“Enjoyed the game, he would play on his own,”
“Really loved the tablet, wanted to keep playing even
after testing was over.”
Overall, this case study demonstrates the feasibility of using
serious games for cognitive assessment of older adults in clinical
settings.
3. A MULTIPLICITY OF SERIOUS
GAMES FOR DEMENTIA
In the preceding section, we showed how one serious game that
assesses the overall executive function of inhibition can be
predictive of a number of different clinical assessment tools, can
also be enjoyable for older adults to play in a clinical context. In
this section, we consider alternative types of game that might be
relevant to the assessment of particular cognitive functions within
people with dementia.
3.1 Previous Research
There are existing games that have either been designed for
patients with dementia or have been used in research studies with
dementia patients. Work by [16] suggests that serious games for
dementia can be broken down into three primary areas which are:
cognitive, physical and social/emotional. A variety of games for
dementia are available on different mediums including computers
[26], mobile devices [15], and gaming consoles such as the
Nintendo Wii [4,8,11,21,27].
The computer game, SmartBrain Games, is a collection of online
cognitive training games designed for adults of all ages. This
software was evaluated by [26], which compared the efficacy of
using this software while participating in an integrated psycho-
stimulated program (IPP), to a group receiving only the IPP, and
another group receiving cholinesterase inhibitors. Their findings
suggest that patients in groups that played the game and received
IPP, demonstrated higher cognition than those that only received
IPP. Moreover, other form factors such as mobile devices have
been explored as a medium for playing games by dementia
patients. Research by [15] demonstrated that a majority of their
sample with mild dementia were able to play the MasterQuiz
game independently on a tablet device.
A Nintendo Wii game (Wii Sports) has been explored by [11] to
assess this system’s usability by AD patients and performance
improvements were observed. Other researchers have also studied
the entertainment and physical value of Wii Sports, and
demonstrated that dementia patients found this suite of games
enjoyable [27] and observed improvements in game scores in the
bowling game [8]. In addition, [21] demonstrated that AD patients
that played the Nintendo WiiFit, experienced significant
improvements in their gait and balance compared to the control
group who participated in a walking program.
Another Nintendo Wii game called MINWii, which is a music
therapy game designed for AD and dementia patients, was
investigated by [4]. This research demonstrated that patients were
able to use a virtual keyboard to interact with the game. The
researchers noted that this game encouraged meaningful
interactions between patients and their caregivers. Overall,
research using the Wii has demonstrated that dementia and AD
patients may benefit from playing games on the Wii system for
their physical and emotional health.
3.2 Proposed Approach
While executive functioning is an important component of
cognitive status, it is not the only component. In this section, we
consider the challenge of designing games for dementia using a
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fractionated approach. Dementia is a multi-faceted disease that
tends to manifest different symptoms as it progresses. In the
following discussion, we will focus on loss of cognitive function
within AD, where the disease typically evolves within an
individual in a relatively predictable progression. According to
[5], dementia progresses from the entorhinal cortex to the dentate
gyrus and the hippocampus generally and then on through other
parts of the brain. One reason for this progression may be some
kind of pathogenic protein spread of neuro-degeneration (see [31]
for a critical review of this hypothesis). If the staging of dementia
by brain locations were characterized in detail, then it should be
possible to trace the progression of AD by degradation in
performance of a succession of cognitive tests that target the
different parts of the brain corresponding to the different stages of
AD progression. In the meantime, however, it is still possible to
enumerate critical abilities that are targeted by dementia as it
progresses, regardless of the order of that progression, and to
design detailed cognitive assessments for each of those abilities
[5].
In the approach recommended here, we propose designing serious
games for dementia that target different cognitive abilities. For
instance, some of the key cognitive functions lost as dementia
progresses include:
Short-term memory (acquisition of new information)
Long-term memory (retention of old information)
Switching (the ability to switch quickly and easily
between different tasks)
Word or object recognition
Time and place orientation
Serious games can be developed to target each of these functions
(see Figure 2). The advantage of this approach is that individuals
with dementia with different cognitive abilities can enjoy games.
In addition, these serious games can also help create a profile
across different components of cognitive status relatively easily in
non-clinical settings (e.g., long-term care). For example, a
cognitive impaired adult experiencing difficult with a task
switching game may be experiencing loss in this cognitive domain
and can potentially benefit from playing games that focus on this
ability.
Dementia
Short-Term
Memory
Long-Term
Memory Inhibition Object
Recognition Orientation
Concentration Sports and News
Trivia
Executive Timed
Target Task
Recognizing
Objects by Name
and Function
Reminiscence
Shifting
Trail-Stepping
Figure 2: Roadmap of serious games for cognitive screening in AD dementia.
Figure 2 shows some initial mappings between possible games
that can be used by people living with dementia and
corresponding cognitive components affected by dementia. For
short-term memory, the focus is on the acquisition of new
information. This can be over a short period of time (e.g.,
remembering where matching card pairs are in the Concentration
memory card game) or for a longer period (e.g., remembering a
new person’s name). In Figure 2, we have included
Concentration, as it is an existing game that people like to play
and it assesses short-term memory. For longer-term storage of
new material, one might develop a game where the player meets
new people and has to remember their names.
Trivia Games, such as Trivial Pursuit, are tests of long-term
memory. Their validity depends on the relevance of the content to
the person being tested. For instance, a sports trivia game will not
be a good form of long-term memory assessment if the person had
no interest in sports when they were younger. Thus a trivia game
would first need to test for a person’s interests and then focus on
content that was meaningful to that person. For executive
functioning, we recommend the use of the Executive Timed
Target Game because it has been shown to be related to overall
executive function (inhibition) and, as noted above, it is correlated
with existing measures of delirium, dementia, and frailty.
Ideally, an enjoyable existing game could be selected that was a
relatively pure measure of each cognitive component of interest.
In practice, this may be hard to do. For a function like object
recognition, assessment should probably involve recognizing
objects by name and function. However, this type of recognition
task does not seem intrinsically enjoyable and thus it may be
difficult to get people to play it repeatedly unless some kind of
reward is provided for playing the game. Gamification (e.g., [25])
is a strategy for making tasks more game-like. Leaderboards and
badges have been found to motivate young people to carry out
gamified tasks (e.g., [7]). However, older people, and people with
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4
dementia in particular, represent a more challenging population
(e.g., [15]) and games will need to be crafted carefully, not only to
match physical and cognitive abilities, but also to match interests.
Part B of the Trail-Making Test [12] is a shifting/switching task
where the person has to trace out two sequences of numbers and
letters in an alternating fashion (A-1-B-2…etc.). An example of a
recent game that implements shifting using a trail making
approach is Trail-Stepping [24], which is a step-version of the
Trail-Making Test, based on the game Dance, Dance Revolution,
that trains visual attention and set-shifting. The game requires
participants to step on mat panels to connect numbers, or numbers
and letters, in alternating order as fast as possible. A
representation of the mat is projected on to a screen in front of the
participant and circles with numbers and/or letters appear in
random order on the panels onto which the participant steps. A red
line (trail) is then drawn between circles when correct steps were
made, thus providing feedback. [24] tested Trail-Stepping with
community-living adults. While it worked well in that context, it
seems likely that the game is too complex for people with
dementia. However, Trail-Stepping shows how shifting functions
can be assessed using a serious game, and it, or something similar,
might be useful in tracking possible progressions from mild
cognitive impairment to dementia.
The final cognitive component considered here is orientation.
Loss of orientation may involve losing track of what day it is, but
may also include loss of sense of self and failures in
autobiographical memory, which tend to be more prevalent for
people with dementia [2]. Reminiscence therapy has been
developed as a way to strengthen sense of self and improve
communication although strong research results in support of the
method are not yet available [32]. Reminiscence games can
provide people with photos, videos, and other clippings from their
life so that they can tell part of their life story to other people, or
else re-experience their own memories.
4. CONCLUSIONS
In this paper, we focused on serious games for individuals with
dementia. Since our focus was on games that are enjoyable but
somewhat challenging it is possible that they may potentially be
useful for brain fitness exercise, but a consideration of such usage
is outside the scope of this paper.
This paper outlines two major types of serious game for dementia.
A game like the Executive Timed Target Game assesses a very
generalized cognitive ability (executive functioning) and
consequently we have found it to be potentially useful in cognitive
screening for a variety of conditions (delirium and, dementia,
while also being related to cognitive aspects of frailty and to
ADLs). A second type of game then focuses on more specific
cognitive abilities. For instance, Trail-Stepper assesses shifting
ability. Further research is needed to develop a taxonomy of
cognitive abilities affected by conditions such as dementia, and to
develop fractionated serious games targeted to each of the specific
cognitive abilities in that the taxonomy.
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... This same neurological condition is suffered, in some why or another, by humans and dogs. To alleviate this cognitive decline (and to improve their state of mind or quality of life by aiding their memory faculties), several playful artefacts -from intelligent toys to digital games -have been developed over the years for humans and dogs [7,23]. Unfortunately, no such games have yet been designed for domestic cats. ...
... Secondly, there are several serious games in the market which target humans with cognitive impairment. Some prime examples are: the digital computer game SmartBrain Games, the Nintendo Wii game MinWii, and another Nintendo Wii game Wii Sports [23]. There are also several games which target animals with cognitive impairment, although they are significantly less in number. ...
... These generally fall under the term Games for Health (G4H) or more specifically Serious Games for Dementia (SG4D) [74]. Some prime examples are: the digital computer game SmartBrain Games which is a collection of cognitive training games designed for adults, a Nintendo Wii game MinWii which is a music therapy game designed for AD patients, another Nintendo Wii game Wii Sports which has shown promise for patients battling with Alzheimer's Disease [23], and a Nintendo DS game Dr Kawashima's Brain Training: How Old Is Your Brain? which involves multiple number games, word puzzles, and reading exercises [75]. ...
Thesis
The affects of the combination of game (and toy) design and Animal Welfare Informatics has been studied and applied in relation to multiple species; categorised into domesticated, wild, shelter, zoo, circus, and factory farmed animals. By observing current research, it may easily be deduced that the majority of such research has been conducted in relation to domestic dogs. The domestic dog (canis familiaris) has been part of the daily lives of humans for thousands of years, however this same statement may be applied to the domestic cat (felis silvestris catus or felis catus) as well. On a global scale, domestic cats actually outnumber domestic dogs. However, comparatively, most of animal-centred research has focused on dogs. A major reason for this is that researchers believe that cats are uncooperative which is not always the actual case. Both domesticated species should be given importance so as to aid in their welfare. In fact, all of the differently categorised species should be given such importance. That being said, this is not the incentive behind this dissertation. Certain elements which will be delved into may however prove to be applicable to these other species. The motivation behind this dissertation is the fact that, similar to domestic dogs, domestic cats may suffer from cognitive decline due to a combination of a progression of age and a lack of mental stimulation. Over the years, several playful artefacts-from intelligent toys to digital games-have been developed for domestic dogs to lessen this cognitive decline but unfortunately, no such games have yet been designed for domestic cats. The objective of this dissertation is thus to provide a basis for the design of a playful artefact which, after its future development, will potentially alleviate cognitive decline in domestic cats. Originally however, the main objective behind this dissertation was to design and develop a digital memory game to possibly alleviate cognitive decline in domestic cats. This changed in time due to several analyses of background information as well as my own deductions and personal reflections. This research ended up being centred around the analysis of any existing related research , and the proposition of a set of game design guidelines in the context of feline cognitive decline following the existing research. Part of this contribution of knowledge centred around the introduction of game concept documents which were based on the research and proposed guidelines, the discussion of how each concept was formulated, and the corresponding comparatory analysis. To explain this in more detail, a set of twenty-two guidelines were proposed and applied to design two separate concept documents-one for a non-digital system and the other for a digital system. The comparatory analysis of these two concepts resulted in the conclusion that, while both systems have potential, it may be safer in the long run to develop the non-digital system (at the current time frame of this dissertation). This result stemmed mostly from the fact that the digital system's concept did not make use of all of the guidelines due to the current technological availability, and that we had no means of accurately testing whether the act of not implementing all of the guidelines would negatively impact the domestic cat or not. After all, the domestic cat's welfare is given top priority in this research. Future work following this research may involve (but is not limited to) the development of the proposed non-digital system, the development of the proposed digital system, a series of practical tests or playthroughs of the developed system/s on some domestic cats, recording of data from the conducted practical tests, and possible iterations of design and development for the system/s based on the acquired test results.
... The results are matched with the arrival of shortterm neurosynaptic plasticity changes in corresponding neocortical amygdaloidhippocampal-prefrontal cortical networks [51], as demonstrated by fMRI images offered in the Human Connectome Project (HCP) database [52,53], relative to the disease etiology. XR-investigations are appropriate before stages of profound delirium in advanced dementia [54]. Delirium is defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) to include acute disturbance in attention, awareness, and cognition. ...
... The engagement parlays into recognition behaviors which can be recorded as data with simultaneous autonomic cardiologic variation measurements as frequently as needed in devices that stream the videogame up to 60 or more frames a second. Also known as serious games or medical virtual reality behavioral tests [54,57], these videogames require a minimum set of calibration so that the collection of data from the patient (also referred to as the player) is medicalmeaningful in investigations of decision-making decline and more. ...
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Non-voluntary euthanization of dementia patients, the majority of whom are severely conscious-state transition-impaired because of both high levels of anti-somnogenic cytokine levels and circadian disruption, indicates the lack of measurement of decision-making decline and conscious-state transition in palliative care settings. This chapter explains why and how to setup medically-meaningful tests to collect these measurements based on environmental-interactive parameters of nonconscious testing in circadian calibrated XR or virtual reality platforms. It also mentions worthy opportunities in relationship to the Human Connectome Project, including the Alzheimer’s Disease Connectome Project.
... The Interactive Media Lab's previous work has shown the value of using exergaming to improve cognitive and physical health (e.g., [8,9]). The Ryerson Tech Lab's previous work has included theaterinspired robotics (e.g., [10]). ...
Conference Paper
This workshop explores socially expressive technology design us- ing collaborative principles of theater, dance and music. Building on shared roots of making something together, technologies (including virtual agents, physical devices, storytelling multimedia) and artistic provocation can create playful, productive and healthy experiences for communities. How do we: Improve collaboration between performance art and creative technology? Design apps and artistic collaboration/learning for mental health? Use theater performativity and technology to enhance our lives? As smart devices become ubiquitous, yet solidarity and cooperation remain elusive in competitive/hierarchical societies, understanding how performance art and technology collaborate can improve how we work, play and care for our and each other’s health. This workshop is a forum and creative space to discuss and play with the future of performative expression and collaborative computing. We welcome researchers and practitioners from varied disciplines including technical implementation, design, theater, dance, improv, physiology and psychology. The program features collaborative creation modules across the expressive human spectrum (movement, sound, text) using digital dramaturgy (Budde, 2017) and pleasure of learning (Brecht, 2001). It also includes participants’ presentations, expert talks and videos exploring the expressive side of computing technology. Accepted applicants are invited to share perspectives and collaborate on creative exercises on art/artefacts/artificiality.
... Mapping refers to reusing an existing game (cognitive and classical games) as a cognitive task and can save considerable time and effort that have been applied in the design of explored games [98,99]. The mapping technique was used by 21 of the 63 studies (eg, [72,92,93,[100][101][102][103][104]). Explored games should be adjusted appropriately since they usually do not provide cognitive psychologists with sufficient quantitative data about the participant's performance and progression on one hand. ...
Article
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Background: Cognitive tasks designed to measure or train cognition are often repetitive and presented in a monotonous manner, features that lead to participant boredom and disengagement. In this situation, participants do not put forth their best effort to do these tasks well. As a result, neuropsychologists cannot draw accurate conclusions about the data collected, and intervention effects are reduced. It is assumed that greater engagement and motivation will manifest as improved data quality. Gamification, the use of game elements in nongame settings, has been heralded as a potential mechanism for increasing participant engagement in cognitive tasks. Some studies have reported a positive effect of gamification on participant performance, although most studies have shown mixed results. One reason for these contrasting findings is that most studies have applied poor and heterogeneous design techniques to gamify cognitive tasks. Therefore, an appropriate gamification design framework is needed in these tasks. Objective: This study aimed to propose a framework to guide the design of gamification in cognitive tasks. Methods: We employed a design science research (DSR) approach to provide a framework for gamifying cognitive assessments and training by synthesizing current gamification design frameworks and gamification works in cognitive assessment and training, as well as incorporating field experiences. The prototypes of the framework were iteratively evaluated with 17 relevant experts. Results: We proposed a framework consisting of 7 phases: (1) preparation; (2) knowing users; (3) exploring existing tools for assessing or training a targeted cognitive context and determining the suitability of game-up and mapping techniques; (4) ideation; (5) prototyping using the Objects, Mechanics, Dynamics, Emotions (OMDE) design guideline; (6) development; and (7) disseminating and monitoring. Conclusions: We found that (1) an intermediate design framework is needed to gamify cognitive tasks, which means that game elements should be selected by considering current cognitive assessment or training context characteristics since game elements may impose an irrelevant cognitive load that, in turn, can jeopardize data quality; (2) in addition to developing a new gamified cognitive task from scratch, 2 gamification techniques are widely used (first, adding game elements to an existing cognitive task and second, mapping an existing game to a cognitive function or impairment to assess or train it); and (3) further research is required to investigate the interplay of cognitive processes and game mechanics.
... Mapping refers to reusing an existing game (cognitive and classical games) as a cognitive task and can save considerable time and effort that have been applied in the design of explored games [98,99]. The mapping technique was used by 21 of the 63 studies (eg, [72,92,93,[100][101][102][103][104]). Explored games should be adjusted appropriately since they usually do not provide cognitive psychologists with sufficient quantitative data about the participant's performance and progression on one hand. ...
Article
Full-text available
Background: Cognitive tasks designed to measure or train cognition are often repetitive and are often in a monotonous manner presented, which finally these features lead to participant boredom and disengagement. In this situation, participants do not put forth their best effort to do these tasks well. As a result, neuropsychologists cannot draw accurate conclusions about the data collected, and intervention effects reduce. It is assumed that greater engagement and motivation will manifest data quality improvement. Gamification, the use of game elements in non-game settings, has been heralded as a potential mechanism for increasing participant engagement in cognitive tasks. Some studies have reported a positive effect of gamification on participant performance, although most studies have shown mixed results. One reason for these contrasting findings is that most studies have applied poor and heterogeneous design techniques to gamify cognitive tasks. Therefore, an appropriate gamification design framework is needed in these tasks. Objective: This study aims to propose a framework to guide the design of gamification in cognitive tasks. Methods: We employed a Design Science Research (DSR) approach to provide a framework for gamifying cognitive assessment and training by synthesizing current gamification design frameworks, gamification works in cognitive assessment and training, and incorporating in the field experiences. The prototypes of the framework were evaluated with 17 relevant experts iteratively. Results: We proposed a framework consists of 7 phases: (1) preparation; (2) knowing users; (3) exploring existing tools for assessing/ training targeted cognitive context and determining the suitability of game-up and mapping techniques; (4) ideation; (5) prototyping using Objects, Mechanics, Dynamics, Emotions (OMDE) design guideline; (6) development and; (7) disseminating and monitoring. Conclusions: We found that: (1) an intermediate design framework is needed to gamify cognitive tasks means that game elements should be selected by considering current cognitive assessment/ training context characteristics since game elements may impose irrelevant cognitive load that, in turn, can jeopardize data quality; (2) in addition of developing a new gamified cognitive task from scratch, two gamification techniques are widely used: first, adding game elements to an existing cognitive task, and second, mapping an existing game to a cognitive function/ impairment to assess or train it and; (3) further research is required to investigate the interplay of cognitive processes and game mechanics. Clinicaltrial:
... There are also applications for people with dementia that focus on the person's inhibition capacity, physical activity using virtual reality, and reminiscence therapy [13] [3] [7]. Some aspects to be taken into account, as well as the technical requirements, for the development of applications for dementia are mentioned, but they are not completely clear from medical personnel and developers point of view. ...
Chapter
Dementia describes a group of symptoms affecting memory, thinking and social abilities. Treatments aim to improve levels of functionality of patients with dementia. Some patients may experience catastrophic episodes during their treatment, these episodes are characterised by excessive emotions or physical response. Psychiatrists have used supportive tools and therapies to improve patients’ levels of functionality, trying to prevent and decrease catastrophic episodes. In this study, we present Memento, an application designed for catastrophic episodes management in patients with dementia through Information Technology. To develop Memento, we identified design aspects that should be considered when developing an application to reduce catastrophic episodes. Our main contribution is the classification of these aspects. To do this, we have analysed our findings in specifications which include the patient needs and characteristics; therapy guidelines; area or environment of interaction; dementia action protocol; and user interface navigation. Our findings may serve as guidelines for the design and development of interactive applications targeted at patients with dementia.
... SG for PwD have been developed as assistive tools, to promote physical, cognitive, and emotional stimulation to lead to a better quality of life [12,29,30]. Moreover, novel SG are being developed to assess cognitive decline at the early stages of dementia [31][32][33]. The investment in such computer applications can provide an opportunity to reduce institutional related healthcare costs and enhance the quality of life of both family caregivers and PwD [34]. ...
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Background: Serious games (SGs) are used as complementary approaches to stimulate patients with dementia. However, many of the SGs use out-of-the-shelf technologies that may not always be suitable for such populations, as they can lead to negative behaviors, such as anxiety, fatigue, and even cybersickness. Objective: This study aims to evaluate how patients with dementia interact and accept 5 out-of-the-shelf technologies while completing 10 virtual reality tasks. Methods: A total of 12 participants diagnosed with dementia (mean age 75.08 [SD 8.07] years, mean Mini-Mental State Examination score 17.33 [SD 5.79], and mean schooling 5.55 [SD 3.30]) at a health care center in Portugal were invited to participate in this study. A within-subject experimental design was used to allow all participants to interact with all technologies, such as HTC VIVE, head-mounted display (HMD), tablet, mouse, augmented reality (AR), leap motion (LM), and a combination of HMD with LM. Participants' performance was quantified through behavioral and verbal responses, which were captured through video recordings and written notes. Results: The findings of this study revealed that the user experience using technology was dependent on the patient profile; the patients had a better user experience when they use technologies with direct interaction configuration as opposed to indirect interaction configuration in terms of assistance required (P=.01) and comprehension (P=.01); the participants did not trigger any emotional responses when using any of the technologies; the participants' performance was task-dependent; the most cost-effective technology was the mouse, whereas the least cost-effective was AR; and all the technologies, except for one (HMD with LM), were not exposed to external hazards. Conclusions: Most participants were able to perform tasks using out-of-the-shelf technologies. However, there is no perfect technology, as they are not explicitly designed to address the needs and skills of people with dementia. Here, we propose a set of guidelines that aim to help health professionals and engineers maximize user experience when using such technologies for the population with dementia.
... To address symptoms of cognitive impairment, some games were proposed. Tong et al. [40]designed an Executive Timed Target Game which can enhance the reaction of patients. Also, Imbeault et al. [41] applied Point-and-click game based on the cooking scenario into the treatment of dementia. ...
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Dementia is a severe disease threatening ageing societies, which not only causes great harm to patients both physically and psychologically but also places a heavy burden on patients’ families. Medications have been used for the treatment of dementia but with little success. However, serious games, as a new form of dementia therapy, stand out from various therapeutic methods and pave the way for dementia treatment. In the field of serious games for dementia care (SGDC) in ageing societies, there exists abundant research related to this topic. While, a detailed review of the development route and a category framework for characteristics of dementia are still needed. Besides, due to the large number of games, it is difficult to select out effective ones. Yet, there is no unified and comprehensive assessment methods for SGDC. So a reliable assessment model is worth studying. In this paper, we review these existing research work on SGDC from two perspectives: (1) the development of SGDC; (2) the different symptoms in different dementia stages. We also propose a comprehensive and professional assessment model of the therapeutic effectiveness of SGDC to compensate for the simplicity of existing assessment methods. Finally, a discussion related to SGDC is presented.
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The ABLE.family project deploys disability and crip approaches and universal design, to create a platform that engages diverse older adults with dementia (OAD) and their carers in social engagement and play. Our prototyped gaming platform, created with OAD stakeholders and carers aims to decrease loneliness and despair experienced by OAD and carers during the COVID-19 pandemic, by increasing opportunities for intergenerational family engagement. Pleasurable interactions are encouraged through real-time collaborative play (e.g. art and turn based games) and real-time video-calling embedded in the platform. Our human-centered design approach works with OAD and their carer networks to design the platform interface with features that can be used to effectively collaborate, interact and produce sustainable platforms for OAD and their carer community. This project is supported generously by funding from CABHI (Centre for Aging and Brain Health Innovation), the Alzheimer Society of Hamilton and Halton, and MIRA (the McMaster Institute for Research on Aging); resources and spaces supporting this work are provided by Pulse Lab (funded by the Asper Foundation) and McMaster University.
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The present review aims to analyze distinctive features of gamification in rehabilitation from neurodegenerative disorders. This work is an effort to decipher various gamified elements which are commonly used for the rehabilitation of patients suffering from neurodegenerative diseases including the scope of these gamified techniques towards their role with traditional methods for recovery of such disorders. Further, gamified tools and techniques used in the treatment process are studied in depth. Moreover, an overview of the inclusion of gamified techniques used in healthcare for neurodegenerative diseases towards enhancing patient engagement is reviewed and modeling of gamification effectiveness using statistical tools have also been discussed. Subsequently, it is found out that the virtual reality games, active video games and serious games are most commonly used in rehabilitation of neurodegenerative diseases. The most used gamified techniques are found to be virtual reality and mobile video games followed by serious games. Moreover, despite some limitations, it is concluded that the gamified methods prove to be a valuable addition to traditional treatments as they enhance patient engagement, socialization, feedback, adherence to the treatment process and provides better health outcomes. Finally, it adds motivation, literacy and helps in diverting patients from painful treatments with effective therapeutics.
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Serious games for dementia (SG4D) hold their own, unique and significant space within the Games for Health domain. However, the SG4D field still has not been fully mapped out and classified. In this work, we present a generic taxonomy of serious games for dementia, based on the health functions and the health purposes they serve. Firstly, we classify dementia games based on the health function they serve, in: cognitive, physical and social-emotional games. Each of these functions serves a variety of health purposes, leading us to a second, lower level of classification in: preventative, rehabilitative, assessing and educative games. Furthermore, we provide an ex-post evaluation of the proposed taxonomy by exploring whether the existing serious games for dementia can be validly classified, based on the proposed taxonomic characters. To this end, we collect and analyse a set of dementia-related serious games (e.g. WiiSports, Big Brain Academy, Cognifit, MinWii, et al.) by performing a literature review. The results show that the taxonomical system covers a sub-field of “games for health” and indicates areas which are under-explored by current games.
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Background: We propose the use of serious games to screen for abnormal cognitive status in situations where it may be too costly or impractical to use standard cognitive assessments (eg, emergency departments). If validated, serious games in health care could enable broader availability of efficient and engaging cognitive screening. Objective: The objective of this work is to demonstrate the feasibility of a game-based cognitive assessment delivered on tablet technology to a clinical sample and to conduct preliminary validation against standard mental status tools commonly used in elderly populations. Methods: We carried out a feasibility study in a hospital emergency department to evaluate the use of a serious game by elderly adults (N=146; age: mean 80.59, SD 6.00, range 70-94 years). We correlated game performance against a number of standard assessments, including the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Confusion Assessment Method (CAM). Results: After a series of modifications, the game could be used by a wide range of elderly patients in the emergency department demonstrating its feasibility for use with these users. Of 146 patients, 141 (96.6%) consented to participate and played our serious game. Refusals to play the game were typically due to concerns of family members rather than unwillingness of the patient to play the game. Performance on the serious game correlated significantly with the MoCA (r=-.339, P <.001) and MMSE (r=-.558, P <.001), and correlated (point-biserial correlation) with the CAM (r=.565, P <.001) and with other cognitive assessments. Conclusions: This research demonstrates the feasibility of using serious games in a clinical setting. Further research is required to demonstrate the validity and reliability of game-based assessments for clinical decision making.
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Background: The Montreal Cognitive Assessment (MoCA) was developed to enable earlier detection of mild cognitive impairment (MCI) relative to familiar multi-domain tests like the Mini-Mental State Exam (MMSE). Clinicians need to better understand the relationship between MoCA and MMSE scores. Methods: For this cross-sectional study, we analyzed 219 healthy control (HC), 299 MCI, and 100 Alzheimer's disease (AD) dementia cases from the Alzheimer's Disease Neuroimaging Initiative (ADNI)-GO/2 database to evaluate MMSE and MoCA score distributions and select MoCA values to capture early and late MCI cases. Stepwise variable selection in logistic regression evaluated relative value of four test domains for separating MCI from HC. Functional Activities Questionnaire (FAQ) was evaluated as a strategy to separate dementia from MCI. Equi-percentile equating produced a translation grid for MoCA against MMSE scores. Receiver Operating Characteristic (ROC) analyses evaluated lower cutoff scores for capturing the most MCI cases. Results: Most dementia cases scored abnormally, while MCI and HC score distributions overlapped on each test. Most MCI cases scored ≥17 on MoCA (96.3 %) and ≥24 on MMSE (98.3 %). The ceiling effect (28-30 points) for MCI and HC was less using MoCA (18.1 %) versus MMSE (71.4 %). MoCA and MMSE scores correlated most for dementia (r = 0.86; versus MCI r = 0.60; HC r = 0.43). Equi-percentile equating showed a MoCA score of 18 was equivalent to MMSE of 24. ROC analysis found MoCA ≥ 17 as the cutoff between MCI and dementia that emphasized high sensitivity (92.3 %) to capture MCI cases. The core and orientation domains in both tests best distinguished HC from MCI groups, whereas comprehension/executive function and attention/calculation were not helpful. Mean FAQ scores were significantly higher and a greater proportion had abnormal FAQ scores in dementia than MCI and HC. Conclusions: MoCA and MMSE were more similar for dementia cases, but MoCA distributes MCI cases across a broader score range with less ceiling effect. A cutoff of ≥17 on the MoCA may help capture early and late MCI cases; depending on the level of sensitivity desired, ≥18 or 19 could be used. Functional assessment can help exclude dementia cases. MoCA scores are translatable to the MMSE to facilitate comparison.
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Interest is growing in gamification, the use of game techniques and mechanics to engage and motivate. Future predictions suggest that this interest will continue to grow especially in the use of games to change individual behavior. However, applying gamification concepts and principles is challenging. Despite the growing interest, few gamification efforts have documented the challenges associated with the game development and application process. This article illustrates how gamification concepts and principles were applied to the development of an online, multiuser, substance abuse, and relationship violence prevention game for youths. We discuss challenges encountered during the efforts to develop and test a prototype version of the game and then present concrete and practical strategies for addressing these challenges. This article provides guidance for other researchers and practitioners who may want to gamify human service processes and use gamification techniques within a behavior change framework.
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Gamification and serious games are becoming increasingly important for training, wellness, and other applications. How can games be developed for non-traditional gaming populations such as the elderly, and how can gaming be applied in non-traditional areas such as cognitive assessment? The application that we were interested in is detection of cognitive impairment in the elderly. Example use cases where gamified cognitive assessment might be useful are: prediction of delirium onset risk in emergency departments and postoperative hospital wards; evaluation of recovery from stroke in neuro-rehabilitation; monitoring of transitions from mild cognitive impairment to dementia in long-term care. With the rapid increase in cognitive disorders in many countries, inexpensive methods of measuring cognitive status on an ongoing basis, and to large numbers of people, are needed. In order to address this challenge we have developed a novel game-based method of cognitive assessment. In this paper, we present findings from a usability study conducted on the game that we developed for measuring changes in cognitive status. We report on the game's ability to predict cognitive status under varying game parameters, and we introduce a method to calibrate the game that takes into account differences in speed and accuracy, and in motor coordination. Recommendations concerning the development of serious games for cognitive assessment are made, and detailed recommendations concerning future development of the whack-a-mole game are also provided.
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How can we support elderly living in special housing to be active and on the move? Around Europe and US there is a rapidly growing interest for use of computer games encouraging physical motion, such as the Nintendo Wii, within healthcare and rehabilitation. We report a study where we introduced and used this game at a special housing for old people with severe dementia in Ockelbo in Sweden. It was supposed to be a pilot-study during one month but the growing interest among all involved, especially the players, led to an over six month long study. An example is 91-year old Elsa saying "the motivation to win is still present", "It is really exciting and fun – we have a match every day". Examples of comments from the caregivers are "The ones I thought would never do this has been the ones that liked it the most and has played a lot", "This is not something especially for old people, everyone does it", "we need to change the repertoire of activities we propose for our elderly – me myself would get crazy if I when old were to be put in a room using potato-printing techniques on table clothes". Bridging the gap between differences in physical abilities to be able to play, compete or meet on an equal arena is tricky within elderly care. A conclusion is that Wii managed to bridge part of that gap, another that many of the elderly like to be more physically active, when the opportunities and the technologies are accessible for them.
Article
Lifelong bilingualism is associated with the delayed diagnosis of dementia, suggesting bilingual experience is relevant to brain health in aging. While the effects of bilingualism on cognitive functions across the lifespan are well documented, less is known about the neural substrates underlying differential behavior. It is clear that bilingualism affects brain regions that mediate language abilities and that these regions are at least partially overlapping with those that exhibit age-related decline. Moreover, the behavioral advantages observed in bilingualism are generally found in executive function performance, suggesting that the frontal lobes may also be sensitive to bilingualism, which exhibit volume reductions with age. The current study investigated structural differences in the brain of lifelong bilingual older adults (n=14, mean age=70.4) compared with older monolinguals (n=14, mean age= 70.6). We employed two analytic approaches: 1) we examined global differences in grey and white matter volumes; and, 2) we examined local differences in volume and cortical thickness of specific regions of interest previously implicated in bilingual/monolingual comparisons (temporal pole) or in aging (entorhinal cortex and hippocampus). We expected bilinguals would exhibit greater volume of the frontal lobe and temporal lobe (grey and white matter), given the importance of these regions in executive and language functions, respectively. We further hypothesized that regions in the medial temporal lobe, which demonstrate early changes in aging and exhibit neural pathology in dementia, would be more preserved in the bilingual group. As predicted, bilinguals exhibit greater frontal lobe white matter compared with monolinguals. Moreover, increasing age was related to decreasing temporal pole cortical thickness in the monolingual group, but no such relationship was observed for bilinguals. Finally, Stroop task performance was positively correlated with frontal lobe white matter, emphasizing the importance of preserved white matter in maintaining executive function in aging. These results underscore previous findings implicating an association between bilingualism and preserved frontal and temporal lobe function in aging. Copyright © 2015. Published by Elsevier B.V.