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The field of serious games for people with dementia (PwD) is mostly driven by game-design principals typically applied to games created by and for younger individuals. Little has been done developing serious games to help PwD maintain cognition and to support functionality.
We aimed to create a theory-based serious game for PwD, with input from a multi-disciplinary team familiar with aging, dementia, and gaming theory, as well as direct input from end users (the iterative process). Targeting enhanced self-efficacy in daily activities, the goal was to generate a game that is acceptable, accessible and engaging for PwD.
The theory-driven game development was based on the following learning theories: learning in context, errorless learning, building on capacities, and acknowledging biological changes—all with the aim to boost self-efficacy. The iterative participatory process was used for game screen development with input of 34 PwD and 14 healthy community dwelling older adults, aged over 65 years. Development of game screens was informed by the bio-psychological aging related disabilities (ie, motor, visual, and perception) as well as remaining neuropsychological capacities (ie, implicit memory) of PwD. At the conclusion of the iterative development process, a prototype game with 39 screens was used for a pilot study with 24 PwD and 14 healthy community dwelling older adults. The game was played twice weekly for 10 weeks.
Quantitative analysis showed that the average speed of successful screen completion was significantly longer for PwD compared with healthy older adults. Both PwD and controls showed an equivalent linear increase in the speed for task completion with practice by the third session (
Our study demonstrated that PwD’s speed improved with practice at the same rate as healthy older adults. This implies that when tasks are designed to match PwD’s abilities, learning ensues. In addition, this pilot study of a serious game, designed for PwD, was accessible, acceptable, and enjoyable for end users. Games designed based on learning theories and input of end users and a multi-disciplinary team familiar with dementia and aging may have the potential of maintaining capacity and improving functionality of PwD. A larger longer study is needed to confirm our findings and evaluate the use of these games in assessing cognitive status and functionality.
Aging in place is a desirable social and economic goal in our rapidly aging global society [
A budding field of research is the use of computer games for people with dementia [
Serious games offer the promise of low cost interventions in the care of PwD [
This paper aimed to contribute to methodology of game design for PwD. Our goal was to create a serious game that is acceptable, accessible, and engaging for people with moderate and advanced dementia based on DSM-5 criteria [
The game was designed with input from a multi-disciplinary team familiar with aging and dementia and gaming theory as well as direct input from end users (the iterative process) [
The theoretical models that form the underpinnings of our game are based on a multidisciplinary model outlined in
Multidisciplinary constructs and theories in designing serious games for people with dementia.
The most important construct influencing our gaming strategy is aimed to enhance the self-efficacy of PwD, an important component of executive function [
The concept of self-efficacy has grown out of a social psychology construct of human agency [
One of the main characteristics of dementia relates to cognitive impairments, specifically, changes in memory encoding and memory retrieval. In addition, research supports that PwD also experience a reduction in executive functions—including planning, working memory, and selective attention [
Selective attention has been marked as one of the major areas of cognitive impairments in dementia in general and Alzheimer dementia specifically [
Research shows that PwD do not face only cognitive deficiencies related to executive function, but also other deficiencies in auditory [
To address the above listed challenges, we considered multisensory approaches to enhance PwD’s daily functionality, such as using a variety of cues [
Finally, sensory-motor degradation was considered in the design of the game environment. For example, during the iterative process, we learned from the comments of the end-users (34 PwD and 14 healthy community dwelling older adults) and the observations of the testers that the placement of the tablet has to be such as to allow visualization with natural light and no screen glare from artificial light or sun. The tablet should be placed in a comfortable position for the PwD, table height, and in a quiet environment with few distractions (again acknowledging cognitive changes).
Serious games for older adults should be engaging and fun and further contribute to easing the personal burden of families and caregivers of PwD, as Robert and colleagues [
The majority of serious games, or games for health, have utilized the important construct of entertainment as the major motivator for game construction. In our efforts to create a game for PwD based on information and communication technology (ICT), we put emphasis on age appropriate entertainment venues as defined by the end users themselves, and based on the concept that fun “learning in context” is a framework that induces capacity building for all persons and especially those people with disabilities, both physical and cognitive [
“Learning in context” has been defined in a variety of ways, however, the basic supposition is that adult learning does not take place in a vacuum, but within a sociocultural model, or as Hassin coined: learning “outside the mind” [
Learning in context has been linked with basic cognitive constructs. Nisbett [
Given the cognitive, physical, and sensory challenges of aging people with dementia, we focused on the above cited literature on learning theories to support our use of game screens, based on contextual learning. Specifically, our game screens utilized cultural memories and implicit memory, which are relatively more preserved for PwD. Implicit memory is one of the two main types of long-term memory which has recently been actively investigated as an important construct of cognitive function and overlooked to the usually measured explicit memory. Implicit memory includes procedural learning (eg, skills and habits), priming, and classical conditioning. These learning processes do not require conscious recollection of information, instead learning is expressed through performance or behavior [
Explicit memory, on the other hand, refers to the conscious, intentional recollection of factual information, previous experiences and concepts. While the literature documents well an age-related decline in explicit memory, numerous studies have shown that implicit memory is spared in older adults [
Within the framework of situated cognition learning in context, errorless learning methodology and cueing offers an important path to present the task so that a PwD overcomes inhibitions and limitations arising from low perceived self-efficacy. Errorless learning is “a teaching technique whereby people are prevented, as far as possible, from making mistakes while they are learning a new skill or acquiring new information” [
In the pertinent literature, there is an ongoing debate about the benefits of erroneous [
It is important to highlight the fact that there is something lost in an “errorless learning” approach. Psychological research in learning and memory identifies the opportunity to engage in difficult (hence error-prone) as very important in successful learning, most specifically for retrieval of learnt information (for a review, see [
In summary, all other factors being equal, it appears that there is ample evidence to suggest that errorless learning procedures are likely to improve retrieval in people with memory impairments relative to erroneous methods [
In addition to errorless learning in PwD, the procedure of cueing or priming and semantic structuring of instructions are important elements in cognitive functioning especially in semantic dementia. Priming is an implicit memory effect in which exposure to one stimulus (ie, perceptual pattern) influences the response to another stimulus [
Consequently, we chose in our game the use of visual-spatial cueing or priming [
Special attention in the design of the game was given to the linguistics and semantic challenges of PwD, (for example, see [
We adopted modern viewpoints on cognitive performance in aging that consider the full context rather than focus on performance alone. In these views, all the elements of the model interact to shape performance. This complex interplay guides us in our design of the game and in our focus on human-centered technology, as discussed in the next section. For example, sensory changes were noted to affect performance on cognitive tasks in older age (sensory degradation hypothesis [
This interplay can be exemplified in the variety of elements that are best classified as “built environment.” Built environment encompasses the design parameters related to the technological (machine) and screen design characteristics, as well as the physical environment within which the prototype game was pilot tested. In describing their CREATE model on designing technology for older adults, Rogers and Fink [
In our overall strategy, we focused on person-centered technology, including the following 2 central guidelines: the Human Centered Design (HCD) and the Iterative Process [
The definition is outlined in the International Standardization Organization (ISO) standard Human Centered Design for Interactive Systems: ISO 9241-210 [
For example, at first we planned to use laptops, because we thought the portability would be convenient and the screen size would be appropriate for older adults. However, during the iterative development process, we learned from the end-users and observations of the testers that tablets were preferable, therefor the game development was switched from laptops to tablets. Tablets are easily mobile and can be easily disassociated from the keypad—a technology that often appears intimidating to PwD. Moreover, tablets use a touch screen and/or a stylus, an object resembling a pen, an element likely to be culturally more familiar to PwD then a keyboard. As we live in a society where technology is ubiquitous, our theoretical presupposition is that self-efficacy of PwD would be enhanced by their successful use of tablet technology [
Broadly speaking, we developed a matrix based on the aforementioned theoretical frameworks that guided the creation of every game screen. A brief summary of these variables is depicted in
Examples of variables taken into consideration for game screen frames.
Challenges | Variables | Solutions |
Sensory degradation | Visual | Avoid blue or yellow combination, script choice |
Spatial placement of fields of action | Center of screen | |
Learning | “Learning in context” visual elements | Culturally relevant |
Cuing | Placing correct answer center screen, reminder by reading instructions over | |
Feedback | Positively framed, immediate, errorless, and entertaining | |
Cognitive changes | Semantics | Simple action oriented instruction |
Uncluttered (inhibition) | No unnecessary information | |
Technology complexity | Each time the game is played, it is preceded by practice exercises related to tablet use (ie, touch and drag functions). The practice exercises aren’t included in the analytics of the game session |
We identified a set of functional simple daily tasks that are essential and culturally relevant to daily life. Each task was then divided into subtasks, utilizing an occupational therapy methodology, primarily adapted from neuro-rehabilitation [
Each game screen was person-centered [
One sample game frame is presented in
At the end of the iterative development stage, we had developed a prototype of a tablet-based game for PwD with 39 game screens. The prototype was used for the proof of concept pilot study that we report on next.
Game screens: game types and skills involved. A list of the nine major game types used in the study, with all relevant physical and cognitive skills targeted.
Game types | Physical, cognitive skills targeted | Skills targeted on all games |
1. Identify, find and touch | Gnosis | Eye hand coordination, language skills (reading, comprehension), understanding and following instructions, praxis, memory, sustained attention, and object recognition. |
2. Identify, find and drag | Association, gnosis | |
3. Identify, find, touch alternating correct answers | Mental rigidity | |
4. Find, sort and drag | Gnosis | |
5. Time orientation | Recognition, abstraction, association, match activity with time of day | |
6. Space orientation | Recognition, gnosis | |
7. Hold release action | Inhibition, basic math skills | |
8. Drag things on screen into a sequence | Logic, executive functions | |
9. Language exercises | Word finding, letter recognition, gnosis, semantic sequencing |
Sample game frame.
The aim of our research was to answer the following questions: (1) Are serious computer games acceptable accessible and engaging for people with moderate and advanced dementia? (2) Are people with moderate and advanced dementia able to use a tablet? and (3) Can PwD improve the speed of performing a task with practice, indicating their ability to learn?
A pilot study for proof of concept was conducted to answer the above questions. The game was played with the PwD and a tester present in a quiet room, located in the MELABEV dementia day center, Jerusalem, Israel. MELABEV has four day-care centers attended by approximately 500 PwDs, ranging from people with moderate cognitive impairment (MCI) to advanced dementia. MELABEV’s professional staff routinely uses computer games on a one-to-one basis for cognitive stimulation gaming [
Meaningful informed consent for people with dementia is challenging. Thus, for our pilot study, we utilized the participatory consent process [
During the 10 week pilot study, the PwD played the prototype game 1-2 times a week under supervision of testers. There were 6 different testers. All testers had past experience working with the PwD population: occupational therapist, gerontologist, social worker, pre-med student, occupational therapist student, and activity worker. Only 2 of the 6 were involved in the development of the game.
Testers’ main task was to observe the sessions and manually record their observations related to the PwD’s interaction with the game for each game frame. They also recorded unsolicited, unprompted spontaneous verbal comments made by the PwD while using the game. Also, testers assisted PwD to maintain their attention on the game throughout the session by prompting them to refocus, when this was called for. Finally, testers were instructed to assist with any technological issues that might arrive.
Each game session was between 20-30 minutes, a recommended time for therapy sessions with PwD. All sessions took place at approximately the same time of day in a quiet room. In every game session, each PwD had the opportunity to play the complete game of 39 game screens. Each game screen was played in the following way. If they were successful, they received a success message (audibly and visually) relevant to the activity performed. If the PwD did not succeed at first, they were cued (audibly and visually). The cueing procedure repeated 3 times, and then, even if the person didn't complete the screen successfully, the game advanced to the next screen. Success or failure, as well as other variables were recorded internally by the tablet.
Out of about 200 PwD from two of MELABEV’s day care centers with moderate to advanced dementia, 24 persons were found to fit the inclusion criteria and participated in the pilot study (age range: 65 years – 90 years, 15 women, and 9 men). The PwD included had cognitive assessment scores (as tested by the Montreal Cognitive Assessment MoCA) as low as 6/30 [
Fourteen healthy community dwelling older adults (age range: 65 years – 90 years; 11 women, 3 men) also volunteered to participate in this process. Game sessions took place in their homes at the time that was convenient for them. These older adults served as an age-matched control group and could verbalize their opinions relating to the games accessibility and acceptability better than PwD.
A mixed methods approach was utilized for evaluation [
Qualitative data included the observations of the 6 testers from each game session they participated in, as well as the spontaneous comments from participants during the game session. The testers recorded their observations and the participant’s comments relating to each game screen in an Excel document immediately after each game session. The Excel (Microsoft) document was analyzed for themes using grounded theory by 2 researchers and a research assistant, each one separately. Analysis was then discussed as a group between the 3 researchers until consensus about common themes was reached. A list of 10 themes emerged. One of the major themes relates to self-efficacy of PwD and is discussed in this paper. Other themes will be discussed in a future paper.
Of the 24 PwD who began the pilot study, 12 (50%) dropped out during the study. Reasons for dropping out included: rapid deterioration of physical and/or cognitive condition, vision deterioration, did not attend day care center due to illness, institutionalization, death, preference of other programs going on in the activity room, lack of interest in the game, and found the game to be too easy. Of those that dropped out 3 (12.5%) were game related (too easy, didn’t interest them) and 9 (37.5%) were aging or dementia related.
As expected, quantitative analysis showed that the average speed of successful screen completion was significantly longer for PwD compared with healthy older adults,
Next,
In sum, these results may suggest that the tasks were well designed for the PwD group that is challenging enough to encourage improved performance, but not too challenging as to frustrate learning. For our control group, it appears that the tasks were easy and they quickly reached a ceiling of performance. Most importantly, it appears that when tasks are designed with PwD in mind, the rate of improvement in performance with practice (ie, learning) is not significantly different than the rate for healthy age-matched controls.
Qualitative analysis of the PwD spontaneous comments (eg, expressed while playing the game), as recorded manually by testers, reveal the following major themes in accessibility, acceptability, engagement, and self-efficacy.
First, it appears that the PwD were able to interact with the tablet and the game was acceptable to them and they even enjoyed playing it as indicated by the following:
“Thanks for choosing me to play the game.” C.
“I will recommend it to all my friends.” G.
“It was lovely.” C.
The enjoyment was not dependent on cognitive ability or on getting the correct answer. This was even the case with PwD who performed poorly on the game. For example, one woman would sing along with the game with a smile on her face even when she did not get the correct answer. Healthy older adults, on the other hand, found the game too easy, and on the most part not highly engaging.
In addition, we have some preliminary qualitative indicators that PwD’s self-efficacy was improved. Quotes from the PwD expressed a sense of self-worth and an increase in their self-esteem with the use of the game as the testers heard quotes such as
“I did it!” M.
“Now I know what utensil goes with what” M.
Increase in self-reported self-efficacy was found and seen with PwD only, and not reported by the healthy community dwelling older adults.
The PwD were able to remember certain game components, both those that were easy for them and those that were more difficult, as demonstrated from this spontaneous comment from a PwD to the tester accompanying him:
We observed learning and special learning techniques used by the PwD in order to progress in the game. For example, one tester overheard the PwD speak to the tablet, which asked him for the answer for a second time saying,
Testers observed that auditory cueing improved PwD’s performance and engagement with the game.
Average speed in seconds of successful screen completion for people with dementia and controls.
Average speed in seconds of successful screen completion for people with dementia and controls as a function of practice in the first three sessions.
The field of serious games for PwD is in its infancy. Our paper reporting on a research and development project aims to add much needed initial knowledge in this area. In relation to our original research questions, we learned that: (1) serious computer games can be acceptable and accessible to PwD; (2) people with moderate and advanced dementia are able to use a tablet; and (3) PwD improved in their speed of successful screen completion with practice, at a non-significantly different rate than healthy older adults, implying some form of significant learning occurred (see
From qualitative analysis of PwD spontaneous comments, we learned that PwD enjoyed using the game. Our findings are consistent with previous research suggesting that technology can be empowering and satisfying to participants [
Although it is generally assumed that PwD cannot learn new information and skills, our exploratory data show that some of those who used the game learned how to do many of its activities. Future research will test exactly what is learned in the game, and more importantly, if there is a transfer of knowledge from the game to real life scenarios over time.
There are several additional key themes that emerged in this pilot study that may be useful for clinical intervention and future game design. First, from the observations of the occupational therapists it appears that PwD can use a tablet better than a laptop. It was found to be easier for them to manipulate [
Finally, it was encouraging to see that even people with dementia, who at the outset were hesitant to play the game, also had a positive interaction with the technology. Specifically, PwD who initially said that “this is not for me” because “I don’t know anything about tablets,” reported enjoying the game after their initial trial session and learning how to interact with it.
This initial exploration has several limitations. The sample size was small, the duration was rather short, and not all the testers involved in the pilot were independent from the game development process. We also acknowledge that, in this stage, it is not possible to point out which of the factors considered during the development had the most effect on the results.
Mccallum and Boletsis [
Based on both qualitative and quantitative analyses, our pilot, proof of concept study demonstrates that our game was acceptable, accessible, enjoyable, and engaging for PwD. We believe that this type of game set may be useful in creating activities for people with moderate to advanced dementia. These types of serious games may provide meaningful activities for the dyad—PwD and the caregivers of PwD. Such games may also be a good way to assess cognitive status of PwD in a nonthreatening way [
The significant improved speed for task completion may also suggest that the theoretical methodology used in constructing the game screens is suitable for PwD as it utilizes their remaining capacities - implicit memory and stimulates learning. Our future goal is to expand the game activities based on our holistic theory driven matrix. We aim to add more game screens and be able to study the transferability effect from game screens to functionality in real life scenarios. We plan to develop a training manual for professional and family caregivers related to how to use the game and deploy the package in a large practical trial with PwD living in the community setting. Finally, to test the game’s efficacy, we wish to evaluate, through a randomized trial, the trajectories of functionality in people with moderate to advanced dementia and the impact of playing the game on this trajectory.
activities of daily living
human centered design
international standardization organization
information and communication technology
moderate cognitive impairment
Montreal Cognitive Assessment
mini mental state examination
people with dementia
We would like to thank the Israeli Ministry of Economy, Office of the Chief scientist, and the Israeli Ministry of Immigrant Absorption, new immigrant Scientists for helping to fund this research. We would also like to thank our medical student, Ayala Farkash, and our occupational therapy student, Sari Reichman, for help with this research.
None declared.