Serious Games for Dementia
University of Toronto
5 King’s College Road
Toronto, Ontario, Canada
Jonathan H. Chan
King Mongkut’s University of
University of Toronto
5 King’s College Road
Toronto, Ontario, Canada
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
Design, Human Factors
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.
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 . 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 . 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 , traumatic brain
injury , mid-life obesity and diabetes , and depression .
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. This “Executive Timed Target Game” (a version of the
whack-a-mole game) assesses inhibition ability, which is related
to overall executive functioning ability . Inhibition ability
declines with age in older adults . Reduced executive function
abilities, as people age, adversely impact functional abilities
required in completing activities of daily living (ADLs) such as
bathing and walking . 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
2. EXECUTIVE TIMED TARGET GAME
Our serious game mimics features of the classic psychological
Go/No-Go Discrimination Task , 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
. 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., ).
We evaluated our Executive Timed Target Game with a sample of
elderly emergency patients , 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)  and Montreal Cognitive Assessment
(MoCA) . 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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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 . 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
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 ) we obtained a specificity
of 86% (86/99) and sensitivity of 76% (13/17) (see Table 1) .
Thus, using a common MMSE cutoff value, we were able to
identify 13 out of 17 patients with dementia as identified using the
Table 1: Predicted versus actual MMSE scores using a serious
game RT cutoff of 1.1 seconds .
Actual MMSE Score
MMSE >= 24
MMSE < 24
MMSE >= 24
MMSE < 24
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 , we received comments on the
game from research assistant who helped carry out the study with
• “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
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  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
, mobile devices , 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 , 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  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  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  and observed improvements in game scores in the
bowling game . In addition,  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 . 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
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
, 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 
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
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
• 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
Memory Inhibition Object
Concentration Sports and News
Objects by Name
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., )
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., ). However, older people, and people with
dementia in particular, represent a more challenging population
(e.g., ) 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  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 , 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.  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 . 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 . 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.
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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