TY - JOUR AU - Sanchez-Escudero, Pablo Juan AU - Aguillon, David AU - Valencia, Stella AU - Garcia-Barrera, A. Mauricio AU - Aguirre-Acevedo, Camilo Daniel AU - Trujillo, Natalia PY - 2025/4/2 TI - Digital Ergonomics of NavegApp, a Novel Serious Game for Spatial Cognition Assessment: Content Validity and Usability Study JO - JMIR Serious Games SP - e66167 VL - 13 KW - serious games KW - spatial cognition KW - digital neuropsychology KW - Alzheimer disease KW - content validity KW - usability N2 - Background: Alzheimer disease (AD) is the leading cause of dementia worldwide. With aging populations and limited access to effective treatments, there is an urgent need for innovative markers to support timely preventive interventions. Emerging evidence highlights spatial cognition (SC) as a valuable source of cognitive markers for AD. This study presents NavegApp, a serious game (SG) designed to assess 3 key components of SC, which show potential as cognitive markers for the early detection of AD. Objective: This study aimed to determine the content validity and usability perception of NavegApp across multiple groups of interest. Methods: A multistep process integrating methodologies from software engineering, psychometrics, and health measurement was implemented to validate the software. Our approach was structured into 3 stages, guided by the software life cycle for health and the Consensus-Based Standards for the Selection of Health Status Measurement Instruments (COSMIN) recommendations for evaluating the psychometric quality of health instruments. To assess content validity, a panel of 8 experts evaluated the relevance and representativeness of tasks included in the app. In addition, 212 participants, categorized into 5 groups based on their clinical status and risk level for AD, were recruited to evaluate the app?s digital ergonomics and usability at various stages of development. Complementary analyses were performed to identify group differences and to explore the association between task difficulty and user agreeableness. Results: NavegApp was validated as a highly usable tool by both experts and users. The expert panel confirmed that the tasks included in the game were representative (Aiken V=0.96-1.00) and relevant (Aiken V=0.96-1.00) for measuring SC components. Both experts and nonexperts rated NavegApp?s digital ergonomics positively, with minimal differences between groups (rrb 0.08-0.29). Differences in usability perceptions were observed among participants with sporadic mild cognitive impairment compared to cognitively healthy individuals (rrb 0.26-0.29). A moderate association was also identified between task difficulty and user agreeableness (Cramér V=0.37, 95% CI 0.28-0.54). Conclusions: NavegApp is a valid and user-friendly SG designed for SC assessment, developed by integrating software engineering and psychometric evaluation methodologies. While the results are promising, further studies are warranted to evaluate its diagnostic accuracy and construct validity. This work outlines a comprehensive framework for SG development in cognitive assessment, emphasizing the importance of incorporating psychometric validity measures from the outset of the design process. UR - https://games.jmir.org/2025/1/e66167 UR - http://dx.doi.org/10.2196/66167 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/66167 ER - TY - JOUR AU - Torabgar, Melika AU - Figeys, Mathieu AU - Esmail, Shaniff AU - Stroulia, Eleni AU - Ríos Rincón, M. Adriana PY - 2025/3/3 TI - Machine Learning Analysis of Engagement Behaviors in Older Adults With Dementia Playing Mobile Games: Exploratory Study JO - JMIR Serious Games SP - e54797 VL - 13 KW - dementia KW - gaming KW - engagement KW - cognition KW - machine learning KW - games KW - cognitive KW - screening KW - classification KW - Alzheimer disease KW - gerontology KW - geriatric KW - older adult KW - elderly KW - aging N2 - Background: The prevalence of dementia is expected to rise with an aging population, necessitating accessible early detection methods. Serious games have emerged as potential cognitive screening tools. They provide not only an engaging platform for assessing cognitive function but also serve as valuable indicators of cognitive health through engagement levels observed during play. Objective: This study aims to examine the differences in engagement-related behaviors between older adults with and without dementia during serious gaming sessions. Further, it seeks to identify the key contributors that enhance the effectiveness of machine learning for dementia classification based on engagement-related behaviors. Methods: This was an exploratory proof-of-concept study. Over 8 weeks, 20 older adults, 6 of whom were living with dementia, were enrolled in a single-case design study. Participants played 1 of 4 ?Vibrant Minds? serious games (Bejeweled, Whack-A-Mole, Mah-jong, and Word-Search) over 8 weeks (16 30-min sessions). Throughout the study, sessions were recorded to analyze engagement-related behaviors. This paper reports on the analysis of the engagement-related behaviors of 15 participants. The videos of these 15 participants (10 cognitively intact, 5 with dementia) were analyzed by 2 independent raters, individually annotating engagement-related behaviors at 15-second intervals using a coding system. This analysis resulted in 1774 data points categorized into 47 behavior codes, augmented by 54 additional features including personal characteristics, technical issues, and environmental factors. Each engagement-related behavior was compared between older adults living with dementia and older adults without dementia using the ?² test with a 2×2 contingency table with a significance level of .05. Codes underwent one-hot encoding and were processed using random forest classifiers to distinguish between participant groups. Results: Significant differences in 64% of engagement-related behaviors were found between groups, notably in torso movements, voice modulation, facial expressions, and concentration. Including engagement-related behaviors, environmental disturbances, technical issues, and personal characteristics resulted in the best model for classifying cases of dementia correctly, achieving an F1-score of 0.91 (95% CI 0.851?0.963) and an area under the receiver operating curve of 0.99 (95% CI 0.984?1.000). Conclusions: Key features distinguishing between older adults with and without dementia during serious gameplay included torso, voice, facial, and concentration behaviors, as well as age. The best performing machine learning model identified included features of engagement-related behavios, environmental disturbances, technical challenges, and personal attributes. Engagement-related behaviors observed during serious gaming offer crucial markers for identifying dementia. Machine learning models that incorporate these unique behavioral markers present a promising, noninvasive approach for early dementia screening in a variety of settings. UR - https://games.jmir.org/2025/1/e54797 UR - http://dx.doi.org/10.2196/54797 ID - info:doi/10.2196/54797 ER - TY - JOUR AU - Yang, Qin AU - Zhang, Liuxin AU - Chang, Fangyuan AU - Yang, Hongyi AU - Chen, Bin AU - Liu, Zhao PY - 2025/1/10 TI - Virtual Reality Interventions for Older Adults With Mild Cognitive Impairment: Systematic Review and Meta-Analysis of Randomized Controlled Trials JO - J Med Internet Res SP - e59195 VL - 27 KW - Alzheimer disease KW - virtual reality KW - VR KW - mild cognitive impairment KW - meta-analysis KW - health care KW - cognitive function KW - memory KW - attention KW - executive function KW - older adults N2 - Background: Alzheimer disease is incurable, but it is possible to intervene and slow down the progression of dementia during periods of mild cognitive impairment (MCI) through virtual reality (VR) technology. Objective: This study aimed to analyze the effects of VR interventions on older adults with MCI. The examined outcomes include cognitive abilities, mood, quality of life, and physical fitness, including general cognitive function, memory performance, attention and information processing speed, executive function, language proficiency, visuospatial abilities, depression, daily mobility of individuals, muscle performance, and gait and balance. Methods: A total of 4 web-based databases (Web of Science, PubMed, Embase, and Ovid) were searched up to December 30, 2023, for randomized controlled trials assessing the self-reported outcomes of VR-based technology on cognition, mood, quality of life, and physical fitness in older adults (aged ?55 years) with MCI. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk-of-bias sensitivity analysis, and subgroup analysis were performed where appropriate to explore potential moderators. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence. Results: This review analyzed 18 studies involving 722 older adults with MCI. VR was delivered through different immersion levels with VR cognitive training, VR physical training, or VR cognitive-motor dual-task training. VR interventions showed significant improvements in memory (standardized mean difference [SMD] 0.2, 95% CI 0.02-0.38), attention and information processing speed (SMD 0.25, 95% CI 0.06-0.45), and executive function (SMD 0.22, 95% CI 0.02-0.42). VR without therapist involvement improved memory as well as attention and information processing speed. VR cognitive training also resulted in significant improvements in attention and information processing speed in older adults with MCI (SMD 0.31, 95% CI 0.05-0.58). In addition, immersive VR had a significant impact on improving attention and information processing speed (SMD 0.25; 95% CI 0.01-0.50) and executive function (SMD 0.25; 95% CI 0.00-0.50). However, the effects of the intervention were very small in terms of general cognitive function, language proficiency, visuospatial abilities, depression, daily living ability, muscle performance, and gait and balance. Quality of evidence varied, with moderate ratings for certain cognitive functions and low ratings for others, based on the GRADE approach. Conclusions: VR interventions can improve memory, attention and information processing speed, and executive function in older adults with MCI. The quality of evidence is moderate to low, and further research is needed to confirm these findings and explore additional health-related outcomes. UR - https://www.jmir.org/2025/1/e59195 UR - http://dx.doi.org/10.2196/59195 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/59195 ER - TY - JOUR AU - Samson, Laurent AU - Carcreff, Lena AU - Noublanche, Frédéric AU - Noublanche, Sophie AU - Vermersch-Leiber, Hélène AU - Annweiler, Cédric PY - 2025/1/6 TI - User Experience of a Semi-Immersive Musical Serious Game to Stimulate Cognitive Functions in Hospitalized Older Patients: Questionnaire Study JO - JMIR Serious Games SP - e57030 VL - 13 KW - virtual reality KW - geriatrics KW - reminiscence KW - episodic memory KW - serious game KW - neurocognitive disorders KW - older adults KW - user experience N2 - Background: Reminiscence therapy through music is a psychosocial intervention with benefits for older patients with neurocognitive disorders. Therapies using virtual or augmented reality are efficient in ecologically assessing, and eventually training, episodic memory in older populations. We designed a semi-immersive musical game called ?A Life in Songs,? which invites patients to immerse themselves in a past era through visuals and songs from that time period. The game aspires to become a playful, easy-to-use, and complete tool for the assessment, rehabilitation, and prevention of neurocognitive decline associated with aging. Objective: This study aimed to assess the user experience (UX) associated with the newly designed serious game. Methods: After one or several sessions of the game guided by the therapist, patients of the geriatric wards were asked to answer questions selected from 2 widely known UX scales (AttrakDiff and meCUE [modular evaluation of the components of user experience]) with the therapist?s help. The internal consistency of the UX dimensions was assessed through Cronbach ? to verify the validity of the dimensions. The level of engagement of the patient throughout the experimental session was also assessed following an internally developed scale, which included 5 levels (interactive, constructive, active, passive, and disengaged behaviors). UX mean scores were computed and presented graphically. Verbal feedbacks were reported to support the quantitative results. Results: Overall, 60 inpatients with a mean age of 84.2 (SD 5.5) years, the majority of whom were women (41/60, 68%), were included. Their score on the Mini-Mental State Examination (MMSE) ranged between 12 and 29. A majority of patients (27/56, 48%) had no major neurocognitive disorder (MNCD), 22/56 (39%) had mild MNCD, and 7/56 (13%) had moderate MNCD. The results revealed very positive UX with mean values beyond the neutral values for every UX dimension of both scales. The overall mean (SD) judgment was rated 3.92 (SD 0.87) (on a scale of ?5 to 5). Internal consistency was acceptable to good for the emotional dimensions of the meCUE. Questionable to unacceptable consistency was found for the other UX dimensions. Participants were mostly active (23/60, 38%) and constructive (21/60, 35%). Conclusions: These findings demonstrated a very good appreciation of the game by geriatric inpatients. Participants? and health care professionals? verbal comments strongly aligned with the quantitative results. The poor internal consistency in the UX dimensions reflected the high heterogeneity among the included patients. Further studies are needed to evaluate the potential benefits of clinical factors such as neurocognitive functions, mood, depression, or quality of life. UR - https://games.jmir.org/2025/1/e57030 UR - http://dx.doi.org/10.2196/57030 ID - info:doi/10.2196/57030 ER - TY - JOUR AU - Paolillo, W. Emily AU - Bomyea, Jessica AU - Depp, A. Colin AU - Henneghan, M. Ashley AU - Raj, Anunay AU - Moore, C. Raeanne PY - 2024/11/25 TI - Characterizing Performance on a Suite of English-Language NeuroUX Mobile Cognitive Tests in a US Adult Sample: Ecological Momentary Cognitive Testing Study JO - J Med Internet Res SP - e51978 VL - 26 KW - digital health KW - cognition KW - cognitive aging KW - neuropsychology KW - mobile health KW - psychometrics KW - mobile phone KW - Ecological Momentary Assessment KW - EMA KW - NeuroUX N2 - Background: Mobile cognitive testing is growing in popularity, with numerous advantages over traditional cognitive testing; however, the field lacks studies that deeply examine mobile cognitive test data from general adult samples. Objective: This study characterized performance for a suite of 8 mobile cognitive tests from the NeuroUX platform in a sample of US adults across the adult lifespan. Methods: Overall, 393 participants completed 8 NeuroUX cognitive tests and a brief ecological momentary assessment survey once per day on their smartphones for 10 consecutive days; each test was administered 5 times over the testing period. The tests tapped the domains of executive function, processing speed, reaction time, recognition memory, and working memory. Participants also completed a poststudy usability feedback survey. We examined alternate form test-retest reliability; practice effects; and associations between scores (averages and intraindividual variability) and demographics as well as test-taking context (ie, smartphone type, being at home vs not at home, and being alone vs not alone). Results: Our final sample consisted of 393 English-speaking US residents (aged 20-79 y; female: n=198, 50.4%). Of the 367 participants who provided responses about their race and ethnicity, 258 (70.3%) were White. Of the 393 participants, 181 (46.1%) were iOS users, and 212 (53.9%) were Android users. Of 12 test scores derived from the 8 tests, 9 (75%) showed good to excellent test-retest reliability (intraclass correlation coefficients >0.76). Practice effects (ie, improvements in performance) were observed for 4 (33%) of the 12 scores. Older age was associated with worse performance on most of the test scores (9/12, 75%) and greater within-person variability for nearly all reaction time scores (3/4, 75%). Relationships with smartphone type showed better performance among iOS users and those with newer Android software versions compared to those with older software. Being at home (vs not at home) was associated with better performance on tests of processing speed. Being alone (vs not alone) was associated with better performance on tests of recognition and working memory. Poststudy feedback indicated that participants found NeuroUX easy to learn and use, an enjoyable experience, and an app that would be helpful in understanding their thinking skills. Only 4.2% (16/379) endorsed privacy concerns, and 77.3% (293/379) reported that they would be willing to share their results with their health care provider. Older age?but not other demographics?was associated with finding the tests more challenging. Conclusions: In a sample of adults across a wide age range, this study characterized features that are particularly important for the interpretation of remote, repeated mobile cognitive testing performance, including test-retest reliability, practice effects, smartphone type, and test-taking context. These data enhance the understanding and application of mobile cognitive testing, paving the way for improved clinical decision-making, personalized interventions, and advancements in cognitive research. UR - https://www.jmir.org/2024/1/e51978 UR - http://dx.doi.org/10.2196/51978 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/51978 ER - TY - JOUR AU - Kamnardsiri, Teerawat AU - Kumfu, Sirintip AU - Munkhetvit, Peeraya AU - Boripuntakul, Sirinun AU - Sungkarat, Somporn PY - 2024/10/29 TI - Home-Based, Low-Intensity, Gamification-Based, Interactive Physical-Cognitive Training for Older Adults Using the ADDIE Model: Design, Development, and Evaluation of User Experience JO - JMIR Serious Games SP - e59141 VL - 12 KW - exergame KW - physical-cognitive training KW - computer-based interventions KW - gamification KW - older adults KW - instructional design model KW - low-intensity N2 - Background: Declines in physical and cognitive function are natural biological processes, leading to an increased risk of falls. Promising evidence suggests that combined physical-cognitive exercise has beneficial effects in improving both physical and cognitive health. Although moderate-to-high exercise intensity is commonly recommended, it might be impractical for older adults facing physical limitations or contraindications. Thus, low-intensity exercise is a viable option. The main barriers to engaging in exercise in older adults include transportation, time, motivation, and enjoyment. To overcome these challenges, a home-based, gamification-based training system may provide an effective approach to enhance exercise adherence. Objective: This study aimed to develop and evaluate the usability of a low-intensity, gamification-based, interactive physical-cognitive exercise for older adults in a home-based setting. Methods: The prototype of a game-based physical-cognitive exercise was created following the ADDIE model (analysis, design, development, implementation, and evaluation) and assessed for user experience in older adults. A total of 15 older adults engaged in the game-based physical-cognitive exercise at home for 60 minutes per day, 3 days per week, for 4 weeks. The usability of the game-based training system was evaluated using the system usability scale (SUS) after completion of a 4-week training program. As for satisfaction, the 8-item Physical Activity Enjoyment Scale (PACES) questionnaire was used to assess participants? enjoyment level after 1 week and 4 weeks of training. Descriptive statistics were used to illustrate the SUS score. A Wilcoxon signed-rank test was used to compare the PACES scores between the first week and the end of the 4-week period, with significance set at P<.05. Results: As for experts? consensus, the game-based training consisted of 3 games: Ocean Diver, Road Runner, and Moving and Memorizing. The games had 3 levels of difficulty: beginner, intermediate, and advanced. A computer vision?based system was selected as the delivery platform for a home setting. The total SUS score for all participants was mean 87.22 (SD 5.76), indicating the user?s perception of the usability of a system ranging from good to excellent. At the end of the 4-week training, the total PACES score was significantly greater than the first week, suggesting an improvement in enjoyment (first week: mean 44.93, SD 3.99 vs fourth week: mean 50.53, SD 4.70; P=.001). Conclusions: The prototype of low-intensity, gamification-based, interactive physical-cognitive training was designed and developed using the ADDIE model, which included both experts and end users in the process. The findings showed that the exergame prototype was a usable and practical approach for a home-based setting, enhancing older adults? enjoyment and motivation. Further research is warranted to determine the effectiveness of such gamification-based training in promoting physical and cognitive functions. UR - https://games.jmir.org/2024/1/e59141 UR - http://dx.doi.org/10.2196/59141 ID - info:doi/10.2196/59141 ER - TY - JOUR AU - Kwan, Cho Rick Yiu AU - Liu, Justina AU - Sin, Kan Olive Suk AU - Fong, K. Kenneth N. AU - Qin, Jing AU - Wong, Yin Joe Chi AU - Lai, Claudia PY - 2024/9/11 TI - Effects of Virtual Reality Motor-Cognitive Training for Older People With Cognitive Frailty: Multicentered Randomized Controlled Trial JO - J Med Internet Res SP - e57809 VL - 26 KW - virtual reality KW - motor-cognitive training KW - cognitive frailty KW - gamification N2 - Background: Cognitive frailty refers to a clinical syndrome in which physical frailty and mild cognitive impairment coexist. Motor-cognitive training and virtual reality (VR) have been used to launch various therapeutic modalities to promote health in older people. The literature advocates that motor-cognitive training and VR are effective in promoting the cognitive and physical function of older people. However, the effects on older people with cognitive frailty are unclear. Objective: This study examined the effects of VR motor-cognitive training (VRMCT) on global cognitive function, physical frailty, walking speed, visual short-term memory, inhibition of cognitive interference, and executive function in older people with cognitive frailty. Methods: This study used a multicentered, assessor-blinded, 2-parallel-group randomized controlled trial design. Participants were recruited face-to-face in 8 older adult community centers. Eligible participants were aged ?60 years, were community dwelling, lived with cognitive frailty, had no dementia, and were not mobility restricted. In the intervention group, participants received VRMCT led by interventionists with 16 one-hour training sessions delivered twice per week for 8 weeks. In the control group, participants received the usual care provided by the older adult community centers that the investigators did not interfere with. The primary outcome was global cognitive function. The secondary outcomes included physical frailty, walking speed, verbal short-term memory, inhibition of cognitive interference, and executive function. Data were collected at baseline (T0) and the week after the intervention (T1). Generalized estimating equations were used to examine the group, time, and interaction (time × group) effects on the outcomes. Results: In total, 293 eligible participants enrolled in the study. The mean age of the participants was 74.5 (SD 6.8) years. Most participants were female (229/293, 78.2%), had completed primary education (152/293, 52.1%), were married (167/293, 57.2%), lived with friends (127/293, 43.3%), and had no VR experience (232/293, 79.5%). In the intervention group, 81.6% (119/146) of participants attended >80% (13/16, 81%) of the total number of sessions. A negligible number of participants experienced VR sickness symptoms (1/146, 0.7% to 5/146, 3%). VRMCT was effective in promoting global cognitive function (interaction effect: P=.03), marginally promoting executive function (interaction effect: P=.07), and reducing frailty (interaction effect: P=.03). The effects were not statistically significant on other outcomes. Conclusions: VRMCT is effective in promoting cognitive functions and reducing physical frailty and is well tolerated and accepted by older people with cognitive frailty, as evidenced by its high attendance rate and negligible VR sickness symptoms. Further studies should examine the efficacy of the intervention components (eg, VR vs non-VR or dual task vs single task) on health outcomes, the effect of using technology on intervention adherence, and the long-term effects of the intervention on older people with cognitive frailty at the level of daily living. Trial Registration: ClinicalTrials.gov NCT04730817; https://clinicaltrials.gov/study/NCT04730817 UR - https://www.jmir.org/2024/1/e57809 UR - http://dx.doi.org/10.2196/57809 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/57809 ER - TY - JOUR AU - Prinz, Alexander AU - Buerger, Dan AU - Krafft, Jelena AU - Bergmann, Matteo AU - Woll, Alexander AU - Barisch-Fritz, Bettina AU - Witte, Kerstin PY - 2024/8/21 TI - Use of Immersive Virtual Reality in Nursing Homes for People With Dementia: Feasibility Study to Assess Cognitive, Motor, and Emotional Responses JO - JMIR XR Spatial Comput SP - e54724 VL - 1 KW - persons with dementia KW - virtual reality KW - VR KW - immersive virtual reality KW - iVR KW - head-mounted display KW - HMD KW - physical performance KW - physical activity KW - physical function KW - motor performance KW - Alzheimer?s disease KW - Alzheimer?s KW - Alzheimer?s treatment KW - Alzheimer?s care KW - Alzheimer?s symptom control KW - dementia KW - dementia therapy KW - dementia care KW - cognitive decline KW - cognitive impairment KW - cognitive impairments KW - neurocognition KW - neurology KW - neurologist KW - neurologists KW - nursing home KW - nursing homes KW - nursing facility KW - senior home KW - long-term care center KW - long-term care facility N2 - Background: Physical activity interventions for people with dementia have shown promising effects in improving cognition and physical function or slowing disease-related decline. Immersive virtual reality (iVR), using head-mounted displays, facilitates realistic experiences by blurring the boundaries between VR and the real world. The use of iVR for people with dementia offers the potential to increase active time and improve dementia therapy and care through exercise interventions. However, the feasibility of using VR use in people with dementia, considering changes in motor, cognitive, psychological, and physiological parameters, remains insufficiently investigated. Objective: This study aims to investigate the feasibility of using iVR in people with dementia or mild cognitive impairment in nursing homes. Specifically, we examined changes in motor performance (balance and mobility), cognitive performance (global cognition and executive functions), emotional responses, and fear of falling using iVR. Methods: Utilizing a pre-post design, this study recruited 35 participants with mild-to-moderate dementia, assessed by the Mini-Mental State Examination (MMSE). Participants underwent a single session involving iVR exposure, with pre- and postexposure assessments and a feedback form, to exclude negative effects on cognitive and motor functions, mood, anxiety levels, and balance performance. The use of iVR involved 4 scenes, with a total length of 8 minutes. These scenes depicted a park with short and rather passive impressions presented as a 360° video in a head-mounted display. Before and after using the iVR, cognitive parameters were assessed using the Trail-Making Test A (TMT-A), motor parameters were assessed using the FICSIT-4 (Frailty and Injuries: Cooperative Studies of Intervention Techniques-4) and Timed-Up-and-Go (TUG) tests, and psychological parameters were assessed using the Dementia Mood Picture Test, State-Trait Anxiety Inventory, and Short Falls Efficacy Scale-International (Short FES-I). The Emotion Rating Scale and the duration of use were recorded during use, and a feedback questionnaire was completed afterward in addition to the posttests. Paired t tests and Wilcoxon tests were used to examine pre-post differences. Results: Of the 35 initial participants, 33 completed the study, which corresponds to a dropout rate of 6%. All 33 participants, who had a mean of 83.71 (SD 5.01) years, had dementia. They showed no statistically significant difference in cognitive and motor performance before and after iVR use. Thus, no negative effects on cognitive and motor functions, mood, anxiety levels, and balance performance were observed. The emotion rating scale also showed that 72% (n=24) felt joy and fun during iVR use, 100% (n=33) showed no emotions such as fear, sadness, or anger, and 93% (n=31) were attentive during iVR use. Conclusions: The feasibility of using iVR for people with dementia can be rated positively. There were no changes in motor, cognitive, or emotional parameters that would increase the risk of falls or other negative emotional reactions during or after iVR use. Further studies are needed to investigate prolonged use in a more stimulating computer-generated environment and possible physical and cognitive tasks for people with dementia in nursing homes. Trial Registration: German Clinical Trials Register DRKS00030616; https://drks.de/search/de/trial/DRKS00030616 UR - https://xr.jmir.org/2024/1/e54724 UR - http://dx.doi.org/10.2196/54724 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/54724 ER - TY - JOUR AU - Greene, Barry AU - Tobyne, Sean AU - Jannati, Ali AU - McManus, Killian AU - Gomes Osman, Joyce AU - Banks, Russell AU - Kher, Ranjit AU - Showalter, John AU - Bates, David AU - Pascual-Leone, Alvaro PY - 2024/8/19 TI - The Dual Task Ball Balancing Test and Its Association With Cognitive Function: Algorithm Development and Validation JO - J Med Internet Res SP - e49794 VL - 26 KW - cognitive function KW - dual task KW - inertial sensors KW - mHealth KW - tablet KW - MCI KW - Alzheimer KW - dementia KW - motor KW - older adults KW - cognitive impairment KW - balance? N2 - Background: Dual task paradigms are thought to offer a quantitative means to assess cognitive reserve and the brain?s capacity to allocate resources in the face of competing cognitive demands. The most common dual task paradigms examine the interplay between gait or balance control and cognitive function. However, gait and balance tasks can be physically challenging for older adults and may pose a risk of falls. Objective: We introduce a novel, digital dual-task assessment that combines a motor-control task (the ?ball balancing? test), which challenges an individual to maintain a virtual ball within a designated zone, with a concurrent cognitive task (the backward digit span task [BDST]). Methods: The task was administered on a touchscreen tablet, performance was measured using the inertial sensors embedded in the tablet, conducted under both single- and dual-task conditions. The clinical use of the task was evaluated on a sample of 375 older adult participants (n=210 female; aged 73.0, SD 6.5 years). Results: All older adults, including those with mild cognitive impairment (MCI) and Alzheimer disease?related dementia (ADRD), and those with poor balance and gait problems due to diabetes, osteoarthritis, peripheral neuropathy, and other causes, were able to complete the task comfortably and safely while seated. As expected, task performance significantly decreased under dual task conditions compared to single task conditions. We show that performance was significantly associated with cognitive impairment; significant differences were found among healthy participants, those with MCI, and those with ADRD. Task results were significantly associated with functional impairment, independent of diagnosis, degree of cognitive impairment (as indicated by the Mini Mental State Examination [MMSE] score), and age. Finally, we found that cognitive status could be classified with >70% accuracy using a range of classifier models trained on 3 different cognitive function outcome variables (consensus clinical judgment, Rey Auditory Verbal Learning Test [RAVLT], and MMSE). Conclusions: Our results suggest that the dual task ball balancing test could be used as a digital cognitive assessment of cognitive reserve. The portability, simplicity, and intuitiveness of the task suggest that it may be suitable for unsupervised home assessment of cognitive function. UR - https://www.jmir.org/2024/1/e49794 UR - http://dx.doi.org/10.2196/49794 UR - http://www.ncbi.nlm.nih.gov/pubmed/39158963 ID - info:doi/10.2196/49794 ER - TY - JOUR AU - Zuo, Xinyi AU - Tang, Yong AU - Chen, Yifang AU - Zhou, Zhimiao PY - 2024/7/31 TI - Effects of Electronic Serious Games on Older Adults With Alzheimer?s Disease and Mild Cognitive Impairment: Systematic Review With Meta-Analysis of Randomized Controlled Trials JO - JMIR Serious Games SP - e55785 VL - 12 KW - digital serious games KW - cognitive ability KW - daily behavioral capacity KW - mental health KW - depression KW - older adults with AD and MCI KW - AD KW - Alzheimer?s disease KW - MD KW - mild cognitive impairment KW - systematic review KW - meta-analysis N2 - Background: Serious games (SGs) are nonpharmacological interventions that are widely applied among older adults. To date, no evidence has been published regarding the effect of digital SGs on cognitive ability, daily behavioral capacity, or depression in older adults with Alzheimer?s disease (AD) and mild cognitive impairment (MCI). Objective: This study aimed to assess the effect of SGs on older adults with AD and MCI by summarizing and pooling the results of previous studies. Methods: This meta-analysis examined the effectiveness of digital SGs in improving cognitive ability, enhancing daily behavioral capacity, and alleviating depression in older adults with AD and MCI. We searched the following databases up to December 31, 2023, to identify relevant high-quality randomized controlled trials (RCTs): PubMed, Embase, Web of Science, Scopus, and Cochrane Library. Stata 15.1 and Review Manager 5.3 were used to screen the 14 studies, extract data, code the data, and perform meta-analysis. Mean differences and standardized mean differences (SMDs) with 95% CIs were used to calculate continuous variables. The Cochrane risk-of-bias assessment tool was used to evaluate the risk of bias. Eligibility criteria were developed in accordance with the Population, Intervention, Comparison, Outcomes, and Study Design framework: (1) population (older adults with AD and MCI), (2) intervention (digital SG intervention), (3) comparison (digital SG intervention vs routine health care), (4) outcomes (cognitive ability, daily behavioral capacity, and depression), and (5) study or research design (RCT). Sensitivity analysis was performed, and a funnel plot was constructed. Results: From January 2017 to December 2023, we enrolled 714 individuals across 14 RCTs, with 374 (52.4%) in the severe game group using digital SGs and 340 (47.6%) in the control group using traditional methods. The results of our meta-analysis indicated that using digital SGs in older adults with AD and MCI is more effective than traditional training methods in several key areas. Specifically, digital SG therapy signi?cantly increased cognitive ability, as found in the Mini-Mental State Examination (SMD 2.11, 95% CI 1.42-2.80; P<.001) and the Montreal Cognitive Assessment (SMD 2.75, 95% CI 1.98-3.51; P<.001), significantly increased daily behavioral capacity (SMD 0.53, 95% CI 0.06-0.99; P=.03), and significantly reduced depression (SMD ?2.08, 95% CI ?2.94 to ?1.22; P<.001) in older adults with AD and MCI. No publication bias was detected based on the results of Begg and Egger tests. Conclusions: Digital SGs offer a viable and effective nonpharmacological approach for older adults with AD and MCI, yielding better results compared to traditional formats. However, caution is warranted in interpreting these findings due to limited RCTs, small sample sizes, and low-quality meta-analyzed evidence. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews: CRDCRD42023486090; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=486090 UR - https://games.jmir.org/2024/1/e55785 UR - http://dx.doi.org/10.2196/55785 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/55785 ER - TY - JOUR AU - Bhargava, Yesoda AU - Baths, Veeky PY - 2024/6/28 TI - Experience of Youths and Older People With Virtual Reality Games for Cognitive Assessment: Inductive Thematic Analysis and Insights for Key Stakeholders JO - JMIR XR Spatial Comput SP - e59197 VL - 1 KW - virtual reality KW - cognitive assessment games KW - inductive thematic analysis KW - youth KW - older adult KW - cognitive KW - cognitive assessment KW - virtual reality games KW - game KW - games KW - thematic analysis KW - neurological KW - utility KW - cognitive assessment tools KW - game based KW - cognitive games N2 - Background: Virtual reality (VR)?based goal-oriented games for cognitive assessment are rapidly emerging and progressively being used in neuropsychological settings. These games have been validated quantitatively, but minimal qualitative insights from users currently exist. Such insights on user experience are essential to answering critical questions linked to the games? large-scale usability, adoption in hospital settings, and game design refinement. Current qualitative studies on these games have used general questionnaires or web-based reviews to answer these questions, but direct observation from primary settings is missing. We believe that direct observation of participants playing these games and subsequent interaction with them is critical to developing a more objective, clear, and unbiased view of the games? efficacy, usability, and acceptability. Objective: In this study, we aimed to extract constructive and relevant insights directly from the participants who played VR-based goal-oriented games. We used these insights to answer vital questions linked to the practical utility of VR-based cognitive assessment. On the basis of these results, we also aimed to provide actionable insights to key stakeholders in the field, such as researchers, game developers, business personnel, and neuropsychology and allied professionals. Methods: Interview data from 82 younger (aged 18-28 years) and 42 older adult (aged >60 years) participants were used. The interview data were obtained from the 2 pilot studies we conducted on VR games for cognitive assessment. Inductive thematic analysis was conducted on the interview data, and later, the findings were carefully interpreted to develop implications for the key stakeholders. Results: We identified 5 themes: ergonomic issues, learning and training, postgame effects, game feedback, and system purpose. Regarding hardware, headset weight, adjustment straps, and controllers need to be improved to promote easy use of the device. Regarding software, graphics quality, immersion experience, and game mechanics are the primary deciding factors for a positive user experience. The younger group prioritized purpose and utility for long-term use, whereas the older participants cherished the entertainment aspect. Researchers and game developers must conceptualize and develop games that can provide maximum insights into real-world abilities. Manufacturing businesses need to improve the headset and accessories to make them more user-friendly. Finally, neuropsychology and allied practitioners must identify strategies to engage and train the participants to try VR-based cognitive assessment games. Conclusions: VR-based games for cognitive assessment are promising tools to improve the current practices of neuropsychological evaluations; however, a few changes are required to make the overall user experience enjoyable, purposeful, and sustainable. In addition, all the key stakeholders need to focus on meaning and purpose over the hype of VR and are advised to work in synergy. UR - https://xr.jmir.org/2024/1/e59197 UR - http://dx.doi.org/10.2196/59197 UR - http://www.ncbi.nlm.nih.gov/pubmed/ ID - info:doi/10.2196/59197 ER - TY - JOUR AU - Park, Bogyeom AU - Kim, Yuwon AU - Park, Jinseok AU - Choi, Hojin AU - Kim, Seong-Eun AU - Ryu, Hokyoung AU - Seo, Kyoungwon PY - 2024/4/17 TI - Integrating Biomarkers From Virtual Reality and Magnetic Resonance Imaging for the Early Detection of Mild Cognitive Impairment Using a Multimodal Learning Approach: Validation Study JO - J Med Internet Res SP - e54538 VL - 26 KW - magnetic resonance imaging KW - MRI KW - virtual reality KW - VR KW - early detection KW - mild cognitive impairment KW - multimodal learning KW - hand movement KW - eye movement N2 - Background: Early detection of mild cognitive impairment (MCI), a transitional stage between normal aging and Alzheimer disease, is crucial for preventing the progression of dementia. Virtual reality (VR) biomarkers have proven to be effective in capturing behaviors associated with subtle deficits in instrumental activities of daily living, such as challenges in using a food-ordering kiosk, for early detection of MCI. On the other hand, magnetic resonance imaging (MRI) biomarkers have demonstrated their efficacy in quantifying observable structural brain changes that can aid in early MCI detection. Nevertheless, the relationship between VR-derived and MRI biomarkers remains an open question. In this context, we explored the integration of VR-derived and MRI biomarkers to enhance early MCI detection through a multimodal learning approach. Objective: We aimed to evaluate and compare the efficacy of VR-derived and MRI biomarkers in the classification of MCI while also examining the strengths and weaknesses of each approach. Furthermore, we focused on improving early MCI detection by leveraging multimodal learning to integrate VR-derived and MRI biomarkers. Methods: The study encompassed a total of 54 participants, comprising 22 (41%) healthy controls and 32 (59%) patients with MCI. Participants completed a virtual kiosk test to collect 4 VR-derived biomarkers (hand movement speed, scanpath length, time to completion, and the number of errors), and T1-weighted MRI scans were performed to collect 22 MRI biomarkers from both hemispheres. Analyses of covariance were used to compare these biomarkers between healthy controls and patients with MCI, with age considered as a covariate. Subsequently, the biomarkers that exhibited significant differences between the 2 groups were used to train and validate a multimodal learning model aimed at early screening for patients with MCI among healthy controls. Results: The support vector machine (SVM) using only VR-derived biomarkers achieved a sensitivity of 87.5% and specificity of 90%, whereas the MRI biomarkers showed a sensitivity of 90.9% and specificity of 71.4%. Moreover, a correlation analysis revealed a significant association between MRI-observed brain atrophy and impaired performance in instrumental activities of daily living in the VR environment. Notably, the integration of both VR-derived and MRI biomarkers into a multimodal SVM model yielded superior results compared to unimodal SVM models, achieving higher accuracy (94.4%), sensitivity (100%), specificity (90.9%), precision (87.5%), and F1-score (93.3%). Conclusions: The results indicate that VR-derived biomarkers, characterized by their high specificity, can be valuable as a robust, early screening tool for MCI in a broader older adult population. On the other hand, MRI biomarkers, known for their high sensitivity, excel at confirming the presence of MCI. Moreover, the multimodal learning approach introduced in our study provides valuable insights into the improvement of early MCI detection by integrating a diverse set of biomarkers. UR - https://www.jmir.org/2024/1/e54538 UR - http://dx.doi.org/10.2196/54538 UR - http://www.ncbi.nlm.nih.gov/pubmed/38631021 ID - info:doi/10.2196/54538 ER - TY - JOUR AU - Wiley, Katelyn AU - Berger, Phaedra AU - Friehs, Achim Maximilian AU - Mandryk, Lee Regan PY - 2024/4/10 TI - Measuring the Reliability of a Gamified Stroop Task: Quantitative Experiment JO - JMIR Serious Games SP - e50315 VL - 12 KW - cognitive assessment KW - gamification KW - serious games KW - Stroop task KW - reliability N2 - Background: Few gamified cognitive tasks are subjected to rigorous examination of psychometric properties, despite their use in experimental and clinical settings. Even small manipulations to cognitive tasks require extensive research to understand their effects. Objective: This study aims to investigate how game elements can affect the reliability of scores on a Stroop task. We specifically investigated performance consistency within and across sessions. Methods: We created 2 versions of the Stroop task, with and without game elements, and then tested each task with participants at 2 time points. The gamified task used points and feedback as game elements. In this paper, we report on the reliability of the gamified Stroop task in terms of internal consistency and test-retest reliability, compared with the control task. We used a permutation approach to evaluate internal consistency. For test-retest reliability, we calculated the Pearson correlation and intraclass correlation coefficients between each time point. We also descriptively compared the reliability of scores on a trial-by-trial basis, considering the different trial types. Results: At the first time point, the Stroop effect was reduced in the game condition, indicating an increase in performance. Participants in the game condition had faster reaction times (P=.005) and lower error rates (P=.04) than those in the basic task condition. Furthermore, the game condition led to higher measures of internal consistency at both time points for reaction times and error rates, which indicates a more consistent response pattern. For reaction time in the basic task condition, at time 1, rSpearman-Brown=0.78, 95% CI 0.64-0.89. At time 2, rSpearman-Brown=0.64, 95% CI 0.40-0.81. For reaction time, in the game condition, at time 1, rSpearman-Brown=0.83, 95% CI 0.71-0.91. At time 2, rSpearman-Brown=0.76, 95% CI 0.60-0.88. Similarly, for error rates in the basic task condition, at time 1, rSpearman-Brown=0.76, 95% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95% CI 0.58-0.86. For error rates in the game condition, at time 1, rSpearman-Brown=0.76, 95% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95% CI 0.58-0.86. Test-retest reliability analysis revealed a distinctive performance pattern depending on the trial type, which may be reflective of motivational differences between task versions. In short, especially in the incongruent trials where cognitive conflict occurs, performance in the game condition reaches peak consistency after 100 trials, whereas performance consistency drops after 50 trials for the basic version and only catches up to the game after 250 trials. Conclusions: Even subtle gamification can impact task performance albeit not only in terms of a direct difference in performance between conditions. People playing the game reach peak performance sooner, and their performance is more consistent within and across sessions. We advocate for a closer examination of the impact of game elements on performance. UR - https://games.jmir.org/2024/1/e50315 UR - http://dx.doi.org/10.2196/50315 UR - http://www.ncbi.nlm.nih.gov/pubmed/38598265 ID - info:doi/10.2196/50315 ER - TY - JOUR AU - Kirkham, Rebecca AU - Kooijman, Lars AU - Albertella, Lucy AU - Myles, Dan AU - Yücel, Murat AU - Rotaru, Kristian PY - 2024/2/26 TI - Immersive Virtual Reality?Based Methods for Assessing Executive Functioning: Systematic Review JO - JMIR Serious Games SP - e50282 VL - 12 KW - virtual reality KW - executive functioning KW - neuropsychological assessment KW - systematic review KW - psychometric properties KW - cybersickness KW - immersion KW - cognition N2 - Background: Neuropsychological assessments traditionally include tests of executive functioning (EF) because of its critical role in daily activities and link to mental disorders. Established traditional EF assessments, although robust, lack ecological validity and are limited to single cognitive processes. These methods, which are suitable for clinical populations, are less informative regarding EF in healthy individuals. With these limitations in mind, immersive virtual reality (VR)?based assessments of EF have garnered interest because of their potential to increase test sensitivity, ecological validity, and neuropsychological assessment accessibility. Objective: This systematic review aims to explore the literature on immersive VR assessments of EF focusing on (1) EF components being assessed, (2) how these assessments are validated, and (3) strategies for monitoring potential adverse (cybersickness) and beneficial (immersion) effects. Methods: EBSCOhost, Scopus, and Web of Science were searched in July 2022 using keywords that reflected the main themes of VR, neuropsychological tests, and EF. Articles had to be peer-reviewed manuscripts written in English and published after 2013 that detailed empirical, clinical, or proof-of-concept studies in which a virtual environment using a head-mounted display was used to assess EF in an adult population. A tabular synthesis method was used in which validation details from each study, including comparative assessments and scores, were systematically organized in a table. The results were summed and qualitatively analyzed to provide a comprehensive overview of the findings. Results: The search retrieved 555 unique articles, of which 19 (3.4%) met the inclusion criteria. The reviewed studies encompassed EF and associated higher-order cognitive functions such as inhibitory control, cognitive flexibility, working memory, planning, and attention. VR assessments commonly underwent validation against gold-standard traditional tasks. However, discrepancies were observed, with some studies lacking reported a priori planned correlations, omitting detailed descriptions of the EF constructs evaluated using the VR paradigms, and frequently reporting incomplete results. Notably, only 4 of the 19 (21%) studies evaluated cybersickness, and 5 of the 19 (26%) studies included user experience assessments. Conclusions: Although it acknowledges the potential of VR paradigms for assessing EF, the evidence has limitations. The methodological and psychometric properties of the included studies were inconsistently addressed, raising concerns about their validity and reliability. Infrequent monitoring of adverse effects such as cybersickness and considerable variability in sample sizes may limit interpretation and hinder psychometric evaluation. Several recommendations are proposed to improve the theory and practice of immersive VR assessments of EF. Future studies should explore the integration of biosensors with VR systems and the capabilities of VR in the context of spatial navigation assessments. Despite considerable promise, the systematic and validated implementation of VR assessments is essential for ensuring their practical utility in real-world applications. UR - https://games.jmir.org/2024/1/e50282 UR - http://dx.doi.org/10.2196/50282 UR - http://www.ncbi.nlm.nih.gov/pubmed/38407958 ID - info:doi/10.2196/50282 ER - TY - JOUR AU - Appel, Lora AU - Appel, Eva AU - Kisonas, Erika AU - Lewis-Fung, Samantha AU - Pardini, Susanna AU - Rosenberg, Jarred AU - Appel, Julian AU - Smith, Christopher PY - 2024/1/30 TI - Evaluating the Impact of Virtual Reality on the Behavioral and Psychological Symptoms of Dementia and Quality of Life of Inpatients With Dementia in Acute Care: Randomized Controlled Trial (VRCT) JO - J Med Internet Res SP - e51758 VL - 26 KW - digital therapies KW - nonpharmacological KW - cognitive impairment KW - behavioral and psychological symptoms of dementia KW - BPSDs KW - randomized controlled trial KW - virtual reality N2 - Background: Virtual reality (VR) is increasingly considered a valuable therapeutic tool for people with dementia. However, rigorous studies are still needed to evaluate its impact on behavioral and psychological symptoms of dementia (BPSDs) and quality of life (QoL) across care settings. Objective: The primary aim of this study was to evaluate the impact of VR therapy on managing BPSDs, falls, length of stay, and QoL in inpatients with dementia admitted to an acute care hospital. The secondary aim was to evaluate the intervention?s feasibility in terms of acceptability, safety, and patient experience. Methods: A prospective, open-label, mixed methods, randomized controlled clinical trial was conducted between April 2019 and March 2020. A total of 69 participants (aged ?65 years with a diagnosis of dementia and who did not meet the exclusion criteria) were randomly assigned to either the control (n=35, 51%) or VR (n=34, 49%) arm. Participants in the experimental (VR) arm were visited by a researcher and watched 360° VR films on a head-mounted display for up to 20 minutes every 1 to 3 days, whereas individuals in the control arm received standard of care. Instances of daily BPSDs and falls were collected from nurses? daily notes. QoL was measured through semistructured interviews and the Quality of Life in Late-Stage Dementia scale. Structured observations and semistructured interviews were used to measure treatment feasibility. The primary outcomes were analyzed at a 95% significance level based on the intention-to-treat method. Results: VR therapy had a statistically significant effect on reducing aggressiveness (ie, physical aggression and loud vociferation; P=.01). Substantial impact of VR therapy was not found for other BPSDs (eg, apathy), falls, length of stay, or QoL as measured using the Quality of Life in Late-Stage Dementia scale. The average VR therapy session lasted 6.8 (SD 6.6; range 0-20) minutes, and the intervention was overall an acceptable and enjoyable experience for participants. No adverse events occurred as a result of VR therapy. Conclusions: Immersive VR therapy appears to have an effect on aggressive behaviors in patients with dementia in acute care. Although the randomized controlled trial was stopped before reaching the intended sample size owing to COVID-19 restrictions, trends in the results are promising. We suggest conducting future trials with larger samples and, in some cases, more sensitive data collection instruments. Trial Registration: ClinicalTrials.gov NCT03941119; https://clinicaltrials.gov/study/NCT03941119 International Registered Report Identifier (IRRID): RR2-10.2196/22406 UR - https://www.jmir.org/2024/1/e51758 UR - http://dx.doi.org/10.2196/51758 UR - http://www.ncbi.nlm.nih.gov/pubmed/38289666 ID - info:doi/10.2196/51758 ER - TY - JOUR AU - Lau, Cassandra Regine AU - Anderson, John Peter AU - Wiley, F. Joshua AU - Huang, Derek AU - Surjatin, Faisha AU - McIntosh, Paul AU - Gathercole, Susan AU - Spencer-Smith, Megan PY - 2023/9/19 TI - Working Memory Training for Children Using the Adaptive, Self-Select, and Stepwise Approaches to Setting the Difficulty Level of Training Activities: Protocol for a Randomized Controlled Trial JO - JMIR Res Protoc SP - e47496 VL - 12 KW - children KW - working memory KW - memory training KW - adaptive training KW - cognitive training KW - transfer effects KW - training effects KW - cognitive outcomes KW - randomized controlled trial N2 - Background: A common yet untested assumption of cognitive training in children is that activities should be adaptive, with difficulty adjusted to the individual?s performance in order to maximize improvements on untrained tasks (known as transfer). Working memory training provides the ideal testbed to systematically examine this assumption as it is one of the most widely studied domains in the cognitive training literature, and is critical for children?s learning, including following instructions and reasoning. Objective: This trial aimed to examine children?s outcomes of working memory training using adaptive, self-select (child selects difficulty level), and stepwise (difficulty level increases incrementally) approaches to setting the difficulty of training activities compared to an active control condition immediately and 6-month postintervention. While the aim is exploratory, we hypothesized that children allocated to a working memory training condition would show greater improvements: (1) on near transfer measures compared to intermediate and far transfer measures and (2) immediately postintervention compared to 6-month postintervention. Methods: This double-blinded, active-controlled, parallel-group randomized trial aimed to recruit 128 children aged 7 to 11 years from 1 metropolitan primary school in Melbourne, Australia. Following baseline testing, children were randomized into 1 of 4 conditions: adaptive, self-select, or stepwise working memory training, or active control. An experimental intervention embedded in Minecraft was developed for teachers to deliver in class over 2 consecutive weeks (10 × 20-minute sessions). The working memory training comprised 2 training activities with processing demands similar to daily activities: backward span and following instructions. The control comprised creative activities. Pre- and postintervention, children completed a set of working memory tests (near and intermediate transfer) and the Raven?s Standard Progressive Matrices (far transfer) to determine training outcomes, as well as motivation questionnaires to determine if motivations toward learning and the intervention were similar across conditions. Caregivers completed the ADHD-Rating Scale-5 to measure their child?s attention (far transfer). Statistical analysis will include traditional null hypothesis significance testing and Bayesian methods to quantify evidence for both the null and alternative hypotheses. Results: Data collection concluded in December 2022. Data are currently being processed and analyzed. Conclusions: This trial will determine whether the adaptive approach to setting the difficulty of training activities maximizes cognitive training outcomes for children. This trial has several strengths: it adopts best practices for cognitive training studies (design, methods, and analysis plan); uses a range of measures to detect discrete levels of transfer; has a 6-month postintervention assessment; is appropriately powered; and uses an experimental working memory training intervention based on our current understanding of the cognitive mechanisms of training. Findings will inform future research and design of cognitive training interventions and highlight the value of the evidence-based principles of cognitive training. Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12621000990820; https://www.anzctr.org.au/ACTRN12621000990820.aspx International Registered Report Identifier (IRRID): DERR1-10.2196/47496 UR - https://www.researchprotocols.org/2023/1/e47496 UR - http://dx.doi.org/10.2196/47496 UR - http://www.ncbi.nlm.nih.gov/pubmed/37725418 ID - info:doi/10.2196/47496 ER - TY - JOUR AU - Wong, Po Ka AU - Qin, Jing PY - 2023/9/18 TI - Effectiveness of Social Virtual Reality Training in Enhancing Social Interaction Skills in Children With Attention-Deficit/Hyperactivity Disorder: Protocol for a Three-Arm Pilot Randomized Controlled Trial JO - JMIR Res Protoc SP - e48208 VL - 12 KW - attention-deficit/hyperactivity disorder KW - social interaction skills KW - executive functioning KW - emotional control KW - 3-arm randomized controlled trial KW - ADHD KW - attention deficit KW - hyperactive KW - hyperactivity KW - randomized KW - RCT KW - social interaction KW - social interactions KW - social skills KW - child KW - children KW - youth KW - pediatric KW - pediatrics KW - VR KW - virtual reality KW - childhood KW - neurodevelopmental N2 - Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental disorders among children. Children with ADHD have challenges in understanding social cues and behavioral problems when entering a social setting. Virtual reality (VR) has been applied to improve cognitive behaviors in children with ADHD. Previous studies have not adopted VR to improve social interaction competence and appropriateness in children with ADHD. VR offers a more effective alternative to therapeutic strategies for children with ADHD. Objective: This study aims to examine the feasibility and effectiveness of social VR training in enhancing social interaction skills compared to traditional social skills training in children with ADHD. We hypothesize that participants in the social VR training group are likely to perform better on social interaction skills than those in the traditional social skills training group. Methods: In this nonblinded, 3-arm randomized controlled trial (RCT), 90 participants with ADHD recruited from the community will be randomized 1:1:1 to the social VR intervention group, traditional social skills training group, or waitlist control group. The child psychiatrist will conduct assessments for each participant at baseline and after the intervention. The Social Skills Rating Scale?Parent will be used to assess the social interaction skills of the participants before and after the intervention. Participants in the social VR intervention group and traditional social skills training group will receive twelve 20-minute training sessions for 3 weeks. The participants in the waitlist control group will receive no training. The primary outcome measure is training acceptability and compliance. The secondary outcome measures are the child psychiatrist's assessment and the Social Skills Rating Scale?Parent before and after the intervention. Another outcome measure is the Behavior Rating Inventory of Executive Function and Attention. Differences in the scale scores will be examined using a t test and an F test. Results: This study is set to commence in the fourth quarter of 2023. It is anticipated that participants in the social VR intervention group will exhibit superior social interaction skills than those in the traditional social skills training group. Conclusions: To our knowledge, this RCT is the first study examining the feasibility and effectiveness of a social VR-based intervention for enhancing the social interaction skills of children with ADHD in Hong Kong. The VR-based social skills training is expected to provide a safer and more effective environment for children with ADHD to learn than the traditional approach. This study can lead to a full-scale RCT. Trial Registration: ClinicalTrials.gov NCT05778526; https://clinicaltrials.gov/study/NCT05778526 International Registered Report Identifier (IRRID): PRR1-10.2196/48208 UR - https://www.researchprotocols.org/2023/1/e48208 UR - http://dx.doi.org/10.2196/48208 UR - http://www.ncbi.nlm.nih.gov/pubmed/37721790 ID - info:doi/10.2196/48208 ER - TY - JOUR AU - Choi, Ju-Young AU - Ha, Sang-Won AU - Jeong, Da-Eun AU - Lee, Jaeho AU - Kim, Donghoon AU - Min, Jin-Young AU - Min, Kyoung-Bok PY - 2023/7/10 TI - Association Between the Loss of Gait Harmony and Cognitive Impairment: Cross-Sectional Study JO - JMIR Public Health Surveill SP - e46264 VL - 9 KW - cognitive function KW - gait phase KW - physical performance KW - dementia KW - older adult KW - aging KW - asymmetric KW - balance KW - gait analysis KW - cognition KW - cognitive impairment KW - gait KW - gait pattern N2 - Background: Functional limitations and disabilities have been associated with a decrease in cognitive function due to increasing age. Gait performance and cognitive function have been associated with gait variability in executive function, the phase domain in memory, and gait abnormalities in cognitive decline. Objective: Our study aimed to investigate whether gait harmony was associated with cognitive function in the older adult population. Moreover, we aimed to investigate whether gait harmony was associated with cognitive function and explore each cognitive function in a specific harmonic state. Methods: The study population included 510 adults aged ?60 years who visited the Department of Neurology at the Veterans Health Service Medical Center, Seoul, South Korea. Gait data were collected using a 3D motion capture device with a wireless inertial measurement unit system. For cognitive function assessments, we used the Seoul Neuropsychological Screening Battery-Core test, which evaluates the level of cognitive function or impairment in 5 cognitive domains. Results: In general, the association between the Seoul Neuropsychological Screening Battery-Core tests and the stance-to-swing ratio in the >1.63 ratio group yielded lower ? coefficients than those in the 1.50-1.63 ratio group. After adjustment for confounders, the odds ratio (OR) for the Digit Symbol Coding test (adjusted OR 0.42, 95% CI 0.20-0.88) and the Korean version of the Color Word Stroop Test: 60 seconds (adjusted OR 0.51, 95% CI 0.29-0.89) for frontal and executive function were significantly lower for the >1.63 ratio group than the reference group. Conclusions: Our findings suggest that the gait phase ratio is a valuable indicator of walking deficits and may also be associated with cognitive impairment in older adults. UR - https://publichealth.jmir.org/2023/1/e46264 UR - http://dx.doi.org/10.2196/46264 UR - http://www.ncbi.nlm.nih.gov/pubmed/37428538 ID - info:doi/10.2196/46264 ER - TY - JOUR AU - Cheng, Xiangyi AU - Gilmore, C. Grover AU - Lerner, J. Alan AU - Lee, Kiju PY - 2023/5/16 TI - Computerized Block Games for Automated Cognitive Assessment: Development and Evaluation Study JO - JMIR Serious Games SP - e40931 VL - 11 KW - cognitive assessment KW - computerized block games KW - adaptive serious games KW - computerized cognitive assessment N2 - Background: Cognitive assessment using tangible objects can measure fine motor and hand-eye coordination skills along with other cognitive domains. Administering such tests is often expensive, labor-intensive, and error prone owing to manual recording and potential subjectivity. Automating the administration and scoring processes can address these difficulties while reducing time and cost. e-Cube is a new vision-based, computerized cognitive assessment tool that integrates computational measures of play complexity and item generators to enable automated and adaptive testing. The e-Cube games use a set of cubes, and the system tracks the movements and locations of these cubes as manipulated by the player. Objective: The primary objectives of the study were to validate the play complexity measures that form the basis of developing the adaptive assessment system and evaluate the preliminary utility and usability of the e-Cube system as an automated cognitive assessment tool. Methods: This study used 6 e-Cube games, namely, Assembly, Shape-Matching, Sequence-Memory, Spatial-Memory, Path-Tracking, and Maze, each targeting different cognitive domains. In total, 2 versions of the games, the fixed version with predetermined sets of items and the adaptive version using the autonomous item generators, were prepared for comparative evaluation. Enrolled participants (N=80; aged 18-60 years) were divided into 2 groups: 48% (38/80) of the participants in the fixed group and 52% (42/80) in the adaptive group. Each was administered the 6 e-Cube games; 3 subtests of the Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV; Block Design, Digit Span, and Matrix Reasoning); and the System Usability Scale (SUS). Statistical analyses at the 95% significance level were applied. Results: The play complexity values were correlated with the performance indicators (ie, correctness and completion time). The adaptive e-Cube games were correlated with the WAIS-IV subtests (r=0.49, 95% CI 0.21-0.70; P<.001 for Assembly and Block Design; r=0.34, 95% CI 0.03-0.59; P=.03 for Shape-Matching and Matrix Reasoning; r=0.51, 95% CI 0.24-0.72; P<.001 for Spatial-Memory and Digit Span; r=0.45, 95% CI 0.16-0.67; P=.003 for Path-Tracking and Block Design; and r=0.45, 95% CI 0.16-0.67; P=.003 for Path-Tracking and Matrix Reasoning). The fixed version showed weaker correlations with the WAIS-IV subtests. The e-Cube system showed a low false detection rate (6/5990, 0.1%) and was determined to be usable, with an average SUS score of 86.01 (SD 8.75). Conclusions: The correlations between the play complexity values and performance indicators supported the validity of the play complexity measures. Correlations between the adaptive e-Cube games and the WAIS-IV subtests demonstrated the potential utility of the e-Cube games for cognitive assessment, but a further validation study is needed to confirm this. The low false detection rate and high SUS scores indicated that e-Cube is technically reliable and usable. UR - https://games.jmir.org/2023/1/e40931 UR - http://dx.doi.org/10.2196/40931 UR - http://www.ncbi.nlm.nih.gov/pubmed/37191993 ID - info:doi/10.2196/40931 ER - TY - JOUR AU - Gabaldón-Pérez, Ana-Marta AU - Dolón-Poza, María AU - Eckert, Martina AU - Máximo-Bocanegra, Nuria AU - Martín-Ruiz, María-Luisa AU - Pau De La Cruz, Iván PY - 2023/4/26 TI - Serious Game for the Screening of Central Auditory Processing Disorder in School-Age Children: Development and Validation Study JO - JMIR Serious Games SP - e40284 VL - 11 KW - serious games KW - central auditory processing disorder KW - process mining KW - screening KW - school environment KW - children N2 - Background: Currently, many central auditory processing disorder screening tests are available for children, and serious games (SGs) are frequently used as a tool for the diagnosis of different neural deficits and disorders in health care. However, it has not been possible to find a proposal that unifies both ideas. In addition, the validation and improvement of SGs, in general, does not take into account the player-game interaction, thus omitting valuable information about the playability and usability of the game. Objective: This study presented Amalia?s Planet, a game conceived for use in school environments, which allows a first assessment of a child through their performance of the proposed tasks related to different aspects of auditory performance. In addition, the game defines a series of events in relation to the execution of the tasks, which were evaluated for the subsequent optimization of its performance and the improvement of its usability. Methods: Using screening tools based on the use of SG technologies, a total of 87 school-age children were evaluated to test the various hypotheses proposed in this study. By grouping users according to whether they had personal history of hearing pathologies, the discriminant power, playability, and usability of the final solution were examined using traditional statistical techniques and process mining (PM) algorithms. Results: With a confidence level of 80% for test 2 (P=.19), there was no statistical evidence to reject the null hypothesis that a player?s performance is affected by whether the player had a previous auditory pathology. Furthermore, the tool allowed the screening of 2 players initially categorized as healthy because of their low level of performance in the tests and the similarity of their behavior with that of the group of children with a previous pathology. With regard to the validation of the proposed solution, the use of PM techniques made it possible to detect the existence of events that lasted too long, which can lead to player frustration, and to discover small structural flaws in the game. Conclusions: SGs seem to be an appropriate tool for the screening of children at risk of central auditory processing disorder. Moreover, the set of PM techniques provides a reliable source of information regarding the playability and usability of the solution to the development team, allowing its continuous optimization. UR - https://games.jmir.org/2023/1/e40284 UR - http://dx.doi.org/10.2196/40284 UR - http://www.ncbi.nlm.nih.gov/pubmed/37099359 ID - info:doi/10.2196/40284 ER - TY - JOUR AU - Mantell, Rhys AU - Withall, Adrienne AU - Radford, Kylie AU - Kasumovic, Michael AU - Monds, Lauren AU - Hwang, Jane Ye In PY - 2023/4/17 TI - Design Preferences for a Serious Game?Based Cognitive Assessment of Older Adults in Prison: Thematic Analysis JO - JMIR Serious Games SP - e45467 VL - 11 KW - serious game KW - gamification KW - cognitive assessment KW - prison KW - older adults KW - older prisoners KW - game design KW - self-determination theory N2 - Background: Serious games have the potential to transform the field of cognitive assessment. The use of serious game?based cognitive assessments in prison environments is particularly exciting. This is because interventions are urgently needed to address the rapid increase in the number of currently incarcerated older adults globally and because of the heightened risks of dementia and cognitive decline present in this population. Game-based assessments are assumed to be fun, engaging, and suitable alternatives to traditional cognitive testing, but these assumptions remain mostly untested in older adults. This is especially true for older adults in prison, whose preferences and needs are seldom heard and may deviate from those previously captured in studies on cognition and serious games. Objective: This study aimed to understand the design preferences of older adults in prison for a game-based cognitive assessment. Methods: This study used reflexive thematic analysis, underpinned by critical realism, and applied the technique of abduction. Overall, 4 focus groups with a total of 20 participants were conducted with older adults (aged ?50 years; aged ?45 years for Aboriginal and Torres Strait Islander people) across 3 distinct prison environments in Australia. Results: Self-determination theory was used as a theoretical foundation to interpret the results. Overall, 3 themes were generated: Goldilocks?getting gameplay difficulty just right through optimal challenge (the first theme emphasizes the participants? collective desire for an individualized optimal level of difficulty in serious gameplay), Avoiding Childish Graphics?gimmicky gameplay can be condescending (the second theme raises the importance of avoiding immature and childlike gameplay features, as some older end users in prison felt that these can be condescending), and A Balanced Diet?meaningful choice and variety keeps game-based assessments fun (the third theme highlights the strong user preference for meaningful choice and variety in any serious game?based cognitive assessment to maximize in-game autonomy). Conclusions: The collection of these themes provides novel insights into key game design preferences of marginalized older adults. UR - https://games.jmir.org/2023/1/e45467 UR - http://dx.doi.org/10.2196/45467 UR - http://www.ncbi.nlm.nih.gov/pubmed/37067850 ID - info:doi/10.2196/45467 ER - TY - JOUR AU - Nitsan, Gal AU - Baharav, Shai AU - Tal-Shir, Dalith AU - Shakuf, Vered AU - Ben-David, M. Boaz PY - 2022/7/28 TI - Speech Processing as a Far-Transfer Gauge of Serious Games for Cognitive Training in Aging: Randomized Controlled Trial of Web-Based Effectivate Training JO - JMIR Serious Games SP - e32297 VL - 10 IS - 3 KW - aging KW - cognitive aging KW - cognitive games KW - serious games KW - speech processing KW - spoken language processing KW - eye tracking KW - visual world paradigm N2 - Background: The number of serious games for cognitive training in aging (SGCTAs) is proliferating in the market and attempting to combat one of the most feared aspects of aging?cognitive decline. However, the efficacy of many SGCTAs is still questionable. Even the measures used to validate SGCTAs are up for debate, with most studies using cognitive measures that gauge improvement in trained tasks, also known as near transfer. This study takes a different approach, testing the efficacy of the SGCTA?Effectivate?in generating tangible far-transfer improvements in a nontrained task?the Eye tracking of Word Identification in Noise Under Memory Increased Load (E-WINDMIL)?which tests speech processing in adverse conditions. Objective: This study aimed to validate the use of a real-time measure of speech processing as a gauge of the far-transfer efficacy of an SGCTA designed to train executive functions. Methods: In a randomized controlled trial that included 40 participants, we tested 20 (50%) older adults before and after self-administering the SGCTA Effectivate training and compared their performance with that of the control group of 20 (50%) older adults. The E-WINDMIL eye-tracking task was administered to all participants by blinded experimenters in 2 sessions separated by 2 to 8 weeks. Results: Specifically, we tested the change between sessions in the efficiency of segregating the spoken target word from its sound-sharing alternative, as the word unfolds in time. We found that training with the SGCTA Effectivate improved both early and late speech processing in adverse conditions, with higher discrimination scores in the training group than in the control group (early processing: F1,38=7.371; P=.01; ?p2=0.162 and late processing: F1,38=9.003; P=.005; ?p2=0.192). Conclusions: This study found the E-WINDMIL measure of speech processing to be a valid gauge for the far-transfer effects of executive function training. As the SGCTA Effectivate does not train any auditory task or language processing, our results provide preliminary support for the ability of Effectivate to create a generalized cognitive improvement. Given the crucial role of speech processing in healthy and successful aging, we encourage researchers and developers to use speech processing measures, the E-WINDMIL in particular, to gauge the efficacy of SGCTAs. We advocate for increased industry-wide adoption of far-transfer metrics to gauge SGCTAs. UR - https://games.jmir.org/2022/3/e32297 UR - http://dx.doi.org/10.2196/32297 UR - http://www.ncbi.nlm.nih.gov/pubmed/35900825 ID - info:doi/10.2196/32297 ER - TY - JOUR AU - Harrington, Kyle AU - Craven, P. Michael AU - Wilson, L. Max AU - Landowska, Aleksandra PY - 2022/6/20 TI - Perceptions of Cognitive Training Games and Assessment Technologies for Dementia: Acceptability Study With Patient and Public Involvement Workshops JO - JMIR Serious Games SP - e32489 VL - 10 IS - 2 KW - dementia KW - cognitive assessment KW - cognitive training KW - serious games KW - patient and public involvement N2 - Background: Cognitive training and assessment technologies offer the promise of dementia risk reduction and a more timely diagnosis of dementia, respectively. Cognitive training games may help reduce the lifetime risk of dementia by helping to build cognitive reserve, whereas cognitive assessment technologies offer the opportunity for a more convenient approach to early detection or screening. Objective: This study aims to elicit perspectives of potential end users on factors related to the acceptability of cognitive training games and assessment technologies, including their opinions on the meaningfulness of measurement of cognition, barriers to and facilitators of adoption, motivations to use games, and interrelationships with existing health care infrastructure. Methods: Four linked workshops were conducted with the same group, each focusing on a specific topic: meaningful improvement, learning and motivation, trust in digital diagnosis, and barriers to technology adoption. Participants in the workshops included local involvement team members acting as facilitators and those recruited via Join Dementia Research through a purposive selection and volunteer sampling method. Group activities were recorded, and transcripts were analyzed using thematic analysis with a combination of a priori and data-driven themes. Using a mixed methods approach, we investigated the relationships between the categories of the Capability, Opportunity, and Motivation?Behavior change model along with data-driven themes by measuring the ? coefficient between coded excerpts and ensuring the reliability of our coding scheme by using independent reviewers and assessing interrater reliability. Finally, we explored these themes and their relationships to address our research objectives. Results: In addition to discussions around the capability, motivation, and opportunity categories, several important themes emerged during the workshops: family and friends, cognition and mood, work and hobbies, and technology. Group participants mentioned the importance of functional and objective measures of cognitive change, the social aspect of activities as a motivating factor, and the opportunities and potential shortcomings of digital health care provision. Our quantitative results indicated at least moderate agreement on all but one of the coding schemes and good independence of our coding categories. Positive and statistically significant ? coefficients were observed between several coding themes between categories, including a relatively strong positive ? coefficient between capability and cognition (0.468; P<.001). Conclusions: The implications for researchers and technology developers include assessing how cognitive training and screening pathways would integrate into existing health care systems; however, further work needs to be undertaken to address barriers to adoption and the potential real-world impact of cognitive training and screening technologies. International Registered Report Identifier (IRRID): RR2-10.1007/978-3-030-49065-2_4 UR - https://games.jmir.org/2022/2/e32489 UR - http://dx.doi.org/10.2196/32489 UR - http://www.ncbi.nlm.nih.gov/pubmed/35723912 ID - info:doi/10.2196/32489 ER - TY - JOUR AU - Anwar, Naveed AU - Karimi, Hossein AU - Ahmad, Ashfaq AU - Gilani, Amir Syed AU - Khalid, Kehkshan AU - Aslam, Sohaib Ahmed AU - Hanif, Asif PY - 2022/6/13 TI - Virtual Reality Training Using Nintendo Wii Games for Patients With Stroke: Randomized Controlled Trial JO - JMIR Serious Games SP - e29830 VL - 10 IS - 2 KW - stroke KW - virtual reality KW - Fugl-Meyer score KW - rehabilitation KW - training KW - physical therapy KW - therapy KW - balance KW - function KW - randomized controlled trial N2 - Background: Stroke is a leading cause of disability. It is difficult to devise an optimal rehabilitation plan once stroke survivors are back home. Conventional rehabilitative therapies are extensively used in patients with stroke to recover motor functioning and disability, but these are arduous and expensive. Virtual reality (VR) video games inspire patients to get involved in their therapeutic exercise routine in a fun way. VR in the form of games provides a fruitful, secure, and challenging learning environment for motor control and neural plasticity development in rehabilitation. The effects of upper limb sensorimotor functioning and balance are the main focus of this trial. Objective: The aim of this study is to compare the effects of VR training and routine physical therapy on balance and upper extremity sensorimotor function in patients with stroke. Methods: It was a single assessor-blinded randomized clinical trial. A total of 74 participants with their first chronic stroke were included and rehabilitated in a clinical setting. The lottery method was used to randomly assign patients to either the VR group (n=37) or the routine physical therapy group (n=37). The VR group received a 1-hour session of VR training for 3 weekdays over 6 weeks, and the routine physical therapy group received different stretching and strengthening exercises. The outcome measuring tools were the Berg Balance Scale for balance and the Fugl-Meyer Assessment (upper extremity) scale for sensorimotor, joint pain, and range assessment. The assessment was done at the start of treatment and after the 6 weeks of intervention. Data analysis was done using SPSS 22. Results: The trial was completed by 68 patients. A significant difference between the two groups was found in the Berg Balance Scale score (P<.001), Fugl-Meyer Assessment for motor function (P=.03), and Fugl-Meyer Assessment for joint pain and joint range (P<.001); however, no significant difference (P=.19) in the Fugl-Meyer Assessment for upper extremity sensation was noted. Conclusions: VR training is helpful for improving balance and function of the upper extremities in the routine life of patients with stroke; although, it was not found to be better than conventional training in improving upper limb sensation. VR training can be a better option in a rehabilitation plan designed to increase functional capability. Trial Registration: Iranian Registry of Clinical Trials RCT20190715044216N1; https://www.irct.ir/user/trial/40898/view UR - https://games.jmir.org/2022/2/e29830 UR - http://dx.doi.org/10.2196/29830 UR - http://www.ncbi.nlm.nih.gov/pubmed/35699989 ID - info:doi/10.2196/29830 ER - TY - JOUR AU - Ho, Ying Ka AU - Cheung, Mang Po AU - Cheng, Wing Tap AU - Suen, Yin Wing AU - Ho, Ying Hiu AU - Cheung, Ki Daphne Sze PY - 2022/5/11 TI - Virtual Reality Intervention for Managing Apathy in People With Cognitive Impairment: Systematic Review JO - JMIR Aging SP - e35224 VL - 5 IS - 2 KW - virtual reality KW - apathy KW - cognitive impairment KW - dementia KW - systematic review N2 - Background: Apathy is common in people with cognitive impairment. It leads to different consequences, such as more severe cognitive deficits, rapid functional decline, and decreased quality of life. Virtual reality (VR) interventions are increasingly being used to manage apathy in individuals with cognitive impairment. However, reports of VR interventions are scattered across studies, which has hindered the development and use of the interventions. Objective: This study aimed to systematically review existing evidence on the use of VR interventions for managing apathy in people with cognitive impairment with regard to the effectiveness, contents, and implementation of the interventions. Methods: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The PubMed, Embase, CINAHL, and PsycINFO databases were systematically searched for experimental studies published up to March 13, 2022, that reported the effects of VR interventions on apathy in older adults with cognitive impairment. Hand searching and citation chasing were conducted. The results of the included studies were synthesized by using a narrative synthesis. Their quality was appraised by using the Effective Public Health Practice Project quality assessment tool. However, because the VR interventions varied in duration, content, and implementation across studies, a meta-analysis was not conducted. Results: A total of 22 studies were identified from the databases, of which 6 (27%) met the inclusion criteria. Of these 6 studies, 2 (33%) were randomized controlled trials, 1 (17%) was a controlled clinical trial, and 3 (50%) were quasi-experimental studies. Individual studies showed significant improvement in apathy and yielded within-group medium to large effect sizes. The level of immersion ranged from low to high. Minor adverse effects were reported. The VR content mostly included natural scenes, followed by city views and game-based activities. A background soundtrack was often used with natural scenes. Most (5/6, 83%) of the studies were conducted in a residential care setting and were implemented by health care professionals or researchers. Safety precautions were taken in most (5/6, 83%) of the studies. Conclusions: Although preliminary evidence shows that VR interventions may be effective and feasible for alleviating apathy in people with cognitive impairment, the methodological limitations in the included studies make it difficult to reach a firm conclusion on these points. The implementation of the interventions was highlighted and discussed. More rigorous studies are encouraged. Trial Registration: PROSPERO International Prospective Register of Systematic Reviews CRD42021268289; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021268289 UR - https://aging.jmir.org/2022/2/e35224 UR - http://dx.doi.org/10.2196/35224 UR - http://www.ncbi.nlm.nih.gov/pubmed/35544317 ID - info:doi/10.2196/35224 ER - TY - JOUR AU - Redlinger, Eric AU - Glas, Bernhard AU - Rong, Yang PY - 2022/4/28 TI - Impact of Visual Game-Like Features on Cognitive Performance in a Virtual Reality Working Memory Task: Within-Subjects Experiment JO - JMIR Serious Games SP - e35295 VL - 10 IS - 2 KW - HMD KW - working memory KW - gamification KW - cognitive training KW - serious game KW - game KW - cognitive activity KW - user performance KW - visual memory KW - cognitive KW - mobile phone N2 - Background: Although the pursuit of improved cognitive function through working memory training has been the subject of decades of research, the recent growth in commercial adaptations of classic working memory tasks in the form of gamified apps warrants additional scrutiny. In particular, the emergence of virtual reality as a platform for cognitive training presents opportunities for the use of novel visual features. Objective: This study aimed to add to the body of knowledge regarding the use of game-like visual design elements by specifically examining the application of two particular visual features common to virtual reality environments: immersive, colorful backgrounds and the use of 3D depth. In addition, electroencephalography (EEG) data were collected to identify potential neural correlates of any observed changes in performance. Methods: A simple visual working memory task was presented to participants in several game-like adaptations, including the use of colorful, immersive backgrounds and 3D depth. The impact of each adaptation was separately assessed using both EEG and performance assessment outcomes and compared with an unmodified version of the task. Results: Results suggest that although accuracy and reaction time may be slightly affected by the introduction of such game elements, the effects were small and not statistically significant. Changes in EEG power, particularly in the beta and theta rhythms, were significant but failed to correlate with any corresponding changes in performance. Therefore, they may only reflect cognitive changes at the perceptual level. Conclusions: Overall, the data suggest that the addition of these specific visual features to simple cognitive tasks does not appear to significantly affect performance or task-dependent cognitive load. UR - https://games.jmir.org/2022/2/e35295 UR - http://dx.doi.org/10.2196/35295 UR - http://www.ncbi.nlm.nih.gov/pubmed/35482373 ID - info:doi/10.2196/35295 ER - TY - JOUR AU - Michalski, Carlo Stefan AU - Szpak, Ancret AU - Ellison, Caroline AU - Cornish, Rowena AU - Loetscher, Tobias PY - 2022/4/7 TI - Using Virtual Reality to Improve Classroom Behavior in People With Down Syndrome: Within-Subjects Experimental Design JO - JMIR Serious Games SP - e34373 VL - 10 IS - 2 KW - virtual reality KW - Down syndrome KW - intellectual disability KW - drawing KW - art KW - behavior KW - mood KW - attention KW - classroom KW - self-report N2 - Background: People with Down syndrome face various learning challenges. Introducing new and enjoyable experiences in learning settings may improve learning outcomes. Immersive and interactive technologies such as virtual reality can be used to deliver rich visual experiences in classrooms. Objective: The aim of this study was to investigate the feasibility and benefits of virtual reality exposure for people with Down syndrome in learning settings. Methods: To address this aim, we used a within-subjects design to assess the effect of a brief virtual reality drawing experience and conventional drawing experience on subsequent behavior in 16 participants. Results: Large positive effects were found for virtual reality drawing (t15=5.020, P<.001) and conventional drawing (t15=3.720, P=.002) in improving subsequent behavior in a learning setting. Irrespective of the intervention, the participant?s mood, attention, and overall behavior significantly improved. No significant differences were found between the interventions (t15=?0.648; P=.53). Conclusions: This study?s results are encouraging for researchers and educators interested in using virtual reality for people with Down syndrome, as virtual reality was found to be highly feasible. Recommendations are made for researchers and educators interested in providing virtual reality experiences for people with Down syndrome. UR - https://games.jmir.org/2022/2/e34373 UR - http://dx.doi.org/10.2196/34373 UR - http://www.ncbi.nlm.nih.gov/pubmed/35124567 ID - info:doi/10.2196/34373 ER - TY - JOUR AU - Kleschnitzki, Marina Jana AU - Beyer, Luzi AU - Beyer, Reinhard AU - Großmann, Inga PY - 2022/4/1 TI - The Effectiveness of a Serious Game (MemoreBox) for Cognitive Functioning Among Seniors in Care Facilities: Field Study JO - JMIR Serious Games SP - e33169 VL - 10 IS - 2 KW - serious game KW - cognitive function KW - mental health KW - seniors KW - care facilities KW - aging KW - cognitive impairments KW - health technology N2 - Background: Serious games have been found to have enhancing and preventative effects on cognitive abilities in healthy older adults. Yet, there are few results on the effects in older seniors with age-related low cognitive impairments. Their special needs were considered when designing and using innovate technology in the area of prevention, which is especially relevant owing to the continuously aging population. Objective: The objective of this study was to evaluate the impact of a serious game on the cognitive abilities of seniors in order to potentially implement innovative resource-oriented technological interventions that can help to meet future challenges. Methods: In this controlled trial, we tested the serious game MemoreBox, which features modules specifically designed for seniors in nursing homes. Over a period of 1 year, we tested the cognitive abilities of 1000 seniors at 4 time points using the Mini-Mental Status Test. Only half of the participating seniors engaged with the serious game. Results: The study included an intervention group (n=56) and a control group (did not play; n=55). Based on the in-game data collection, a second intervention group (n=38) was identified within the original intervention group, which exactly followed the planned protocol. There were no noteworthy differences between the demographic and main variables of the overall sample. The large reduction in the sample size was due to the effects of the COVID-19 pandemic (drop-out rate: 88.9%). The CI was set at 5%. Mixed analysis of variance (ANOVA) between the cognitive abilities of the intervention and control groups did not show a statistically significant difference between time and group (F2.710,295.379=1.942; P=.13; partial ?²=0.018). We noted approximately the same findings for mixed ANOVA between the cognitive abilities of the second intervention and control groups (F3,273=2.574; P=.054; partial ?²=0.028). However, we did observe clear tendencies and a statistically significant difference between the 2 groups after 9 months of the intervention (t88.1=?2.394; P=.02). Conclusions: The results of this study show similarities with the current research situation. Moreover, the data indicate that the intervention can have an effect on the cognitive abilities of seniors, provided that they regularly play the serious game of MemoreBox. The small sample size means that the tendency toward improvement cannot be proven as statistically significant. However, the tendency shown warrants further research. Establishing an effective prevention tool as part of standard care in nursing homes by means of an easy-to-use serious game would be a considerable contribution to the weakened health care system in Germany as it would offer a means of activating senior citizens in partially and fully inpatient care facilities. Trial Registration: German Clinical Trials Register DRKS00016633; https://tinyurl.com/2e4765nj UR - https://games.jmir.org/2022/2/e33169 UR - http://dx.doi.org/10.2196/33169 UR - http://www.ncbi.nlm.nih.gov/pubmed/35172959 ID - info:doi/10.2196/33169 ER - TY - JOUR AU - Zhu, KaiYan AU - Zhang, QiongYao AU - He, BingWei AU - Huang, MeiZhen AU - Lin, Rong AU - Li, Hong PY - 2022/2/21 TI - Immersive Virtual Reality?Based Cognitive Intervention for the Improvement of Cognitive Function, Depression, and Perceived Stress in Older Adults With Mild Cognitive Impairment and Mild Dementia: Pilot Pre-Post Study JO - JMIR Serious Games SP - e32117 VL - 10 IS - 1 KW - cognitive intervention KW - dementia KW - immersive virtual reality KW - mild cognitive impairment KW - cognitive impairment KW - virtual reality KW - VR KW - older patients KW - usability KW - memory KW - stress N2 - Background: The incidence of dementia is increasing annually, resulting in varying degrees of adverse effects for individuals, families, and society. With the continuous development of computer information technology, cognitive interventions are constantly evolving. The use of immersive virtual reality (IVR) as a cognitive intervention for older adults with mild cognitive impairment (MCI) and mild dementia (MD) is promising, although only few studies have focused on its use. Objective: The Chinese virtual supermarket (CVSM) IVR system was developed to provide a comprehensive and individual cognitive intervention program for older patients with MCI and MD. The aim of this study was to explore the feasibility and clinical effectiveness of this 5-week IVR-based cognitive intervention. Methods: A pretest-posttest study design was conducted with 31 older adults with MCI and MD from August 2020 to January 2021. All participants participated in a 5-week immersive virtual cognitive training program using the CVSM system. Feasibility was assessed as the incidence and severity of cybersickness symptoms and participant satisfaction based on questionnaires conducted after the intervention. Clinical effectiveness was evaluated using neuropsychological assessments, including several commonly used measures of cognitive function, depression, perceived stress, and activities of daily living. Measurements were obtained at baseline and after the intervention period. Results: A total of 18 patients with MCI (mean age 82.94 [SD 5.44] years; 12 females) and 13 patients with MD (mean age 85.7 [SD 4.67] years, 10 females) participated in this pilot study. Both groups showed significant improvements in all cognitive function measurements (P<.001). The MD group had a significantly greater improvement in general cognitive function compared to the MCI group in Montreal Cognitive Assessment Scale, Symbol Digit Modalities Test, Shape Trail Test, and Auditory Verbal Learning Test. Furthermore, an intervention effect was observed in the improvement of perceived stress (P=.048 for MD group, P=.03 for MCI group ). Conclusions: The use of the CVSM system may be effective in enhancing the cognitive function of patients with MCI and MD, including general cognitive function, memory, executive function, and attention. IVR technology enriches cognitive intervention approaches and provides acceptable, professional, personalized, and interesting cognitive training for older adults with cognitive impairment. Trial Registration: ClinicalTrials ChiCTR2100043753; https://trialsearch.who.int/Trial2.aspx?TrialID=ChiCTR2100043753 UR - https://games.jmir.org/2022/1/e32117 UR - http://dx.doi.org/10.2196/32117 UR - http://www.ncbi.nlm.nih.gov/pubmed/35188466 ID - info:doi/10.2196/32117 ER - TY - JOUR AU - Yang, Chao AU - Han, Xiaolei AU - Jin, Mingxue AU - Xu, Jianhui AU - Wang, Yiren AU - Zhang, Yajun AU - Xu, Chonglong AU - Zhang, Yingshi AU - Jin, Enshi AU - Piao, Chengzhe PY - 2021/12/30 TI - The Effect of Video Game?Based Interventions on Performance and Cognitive Function in Older Adults: Bayesian Network Meta-analysis JO - JMIR Serious Games SP - e27058 VL - 9 IS - 4 KW - video game KW - performance KW - cognitive function KW - older KW - Bayesian network meta-analysis N2 - Background: The decline in performance of older people includes balance function, physical function, and fear of falling and depression. General cognitive function decline is described in terms of processing speed, working memory, attention, and executive functioning, and video game interventions may be effective. Objective: This study evaluates the effect of video game interventions on performance and cognitive function in older participants in terms of 6 indicators: balance function, executive function, general cognitive function, physical function, processing speed, and fear of falling and depression. Methods: Electronic databases were searched for studies from inception to June 30, 2020. Randomized controlled trials and case-controlled trials comparing video game interventions versus nonvideo game control in terms of performance and cognitive function outcomes were incorporated into a Bayesian network meta-analysis. All data were continuous variables. Results: In total, 47 studies (3244 participants) were included. In pairwise meta-analysis, compared with nonvideo game control, video game interventions improved processing speed, general cognitive function, and depression scores. In the Bayesian network meta-analysis, interventions with video games improved balance function time (standardized mean difference [SMD] ?3.34, 95% credible interval [CrI] ?5.54 to ?2.56), the cognitive function score (SMD 1.23, 95% CrI 0.82-1.86), processing speed time (SMD ?0.29, 95% CrI ?0.49 to ?0.08), and processing speed number (SMD 0.72, 95% CrI 0.36-1.09), similar to the pairwise meta-analysis. Interventions with video games with strong visual senses and good interactivity ranked first, and these might be more beneficial for the elderly. Conclusions: Our comprehensive Bayesian network meta-analysis provides evidence that video game interventions could be considered for the elderly for improving performance and cognitive function, especially general cognitive scores and processing speed. Games with better interactivity and visual stimulation have better curative effects. Based on the available evidence, we recommend video game interventions for the elderly. Trial Registration: PROSPERO CRD42020197158; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197158 UR - https://games.jmir.org/2021/4/e27058 UR - http://dx.doi.org/10.2196/27058 UR - http://www.ncbi.nlm.nih.gov/pubmed/34967759 ID - info:doi/10.2196/27058 ER - TY - JOUR AU - Yan, Mingli AU - Yin, Huiru AU - Meng, Qiuyan AU - Wang, Shuo AU - Ding, Yiwen AU - Li, Guichen AU - Wang, Chunyan AU - Chen, Li PY - 2021/12/3 TI - A Virtual Supermarket Program for the Screening of Mild Cognitive Impairment in Older Adults: Diagnostic Accuracy Study JO - JMIR Serious Games SP - e30919 VL - 9 IS - 4 KW - virtual reality KW - mild cognitive impairment KW - dementia KW - ambient intelligence KW - digital health KW - elderly population KW - aging N2 - Background: Mild cognitive impairment (MCI) is often a precursor of dementia, and patients with MCI develop dementia at a higher rate than healthy older adults. Early detection of cognitive decline at the MCI stage supports better planning of care and interventions. At present, the use of virtual reality (VR) in screening for MCI in older adults is promising, but there is little evidence regarding the use of virtual supermarkets to screen for MCI. Objective: The objectives of this study are to validate a VR game?based test, namely, the Virtual Supermarket Program (VSP), for differentiating patients with MCI and healthy controls and to identify cutoff scores for different age levels. Methods: Subjects were recruited from several nursing homes and communities in Changchun, China. They were divided into a healthy control group (n=64) and an MCI group (n=62). All subjects were administered the VSP and a series of neuropsychological examinations. The study determined the optimal cutoff, discriminating validity, concurrent validity, and retest reliability of the VSP. We used the area under the receiver operating characteristic curve (AUC) to evaluate the discriminating validity and obtain the optimal cutoff values. Pearson correlation analysis and the intraclass correlation coefficient were used to evaluate the concurrent validity and retest reliability, respectively. Results: A cutoff score of 46.4 was optimal for the entire sample, yielding a sensitivity of 85.9% and specificity of 79.0% for differentiating individuals with MCI and healthy controls, and the AUC was 0.870 (95% CI 0.799-0.924). The median index of VSP score was 51.1 (range 42.6-60.0). There was a moderate positive correlation between the VSP total score and Mini-Mental State Examination score (r=0.429, P<.001). There was a strong positive correlation between VSP total score and Montreal Cognitive Assessment score (r=0.645, P<.001). The retest reliability of the VSP was feasible (r=0.588, P=.048). Conclusions: The VSP is interesting and feasible for subjects. It shows high sensitivity and specificity for the identification of MCI in older adults, which makes it a promising screening method. The VSP may be generalized to older adults in other countries, although some cultural adaptation may be necessary. Trial Registration: Chinese Clinical Trial Registry ChiCTR2000040074; https://www.chictr.org.cn/showprojen.aspx?proj=64639 UR - https://games.jmir.org/2021/4/e30919 UR - http://dx.doi.org/10.2196/30919 UR - http://www.ncbi.nlm.nih.gov/pubmed/34870610 ID - info:doi/10.2196/30919 ER - TY - JOUR AU - Kim, Euisung AU - Han, Jieun AU - Choi, Hojin AU - Prié, Yannick AU - Vigier, Toinon AU - Bulteau, Samuel AU - Kwon, Hyun Gyu PY - 2021/11/24 TI - Examining the Academic Trends in Neuropsychological Tests for Executive Functions Using Virtual Reality: Systematic Literature Review JO - JMIR Serious Games SP - e30249 VL - 9 IS - 4 KW - virtual reality KW - neuropsychological test KW - executive function KW - cognitive ability KW - brain disorder KW - immersive KW - digital health KW - cognition KW - academic trends KW - neurology N2 - Background: In neuropsychology, fully immersive virtual reality (VR) has been spotlighted as a promising tool. It is considered that VR not only overcomes the existing limitation of neuropsychological tests but is also appropriate for treating executive functions (EFs) within activities of daily living (ADL) due to its high ecological validity. While fully immersive VR offers new possibilities of neuropsychological tests, there are few studies that overview the intellectual landscape and academic trends in the research related to mainly targeted EFs with fully immersive VR. Objective: The objective of this study is to get an overview of the research trends that use VR in neuropsychological tests and to analyze the research trends using fully immersive VR neuropsychological tests with experimental articles. Methods: This review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were searched in three web databases using keywords related to VR, EFs, and cognitive abilities. The study was conducted in two steps, keyword analysis and in-depth systematic review. In the web database search from 2000 to 2019, 1167 articles were initially collected, of which 234 articles in the eligibility phase were used to conduct keyword analysis and a total of 47 articles were included for systematic review. Results: In keyword analysis, the number of articles focused on dementia including the keywords ?MCI,? ?SCD,? and ?dementia? were highlighted over the period, rather than other symptoms. In addition, we identified that the use of behavioral and physiological data in virtual environments (VEs) has dramatically increased in recent studies. In the systematic review, we focused on the purpose of study, assessment, treatment, and validation of usability and structure. We found that treatment studies and uncategorized studies including presence and cybersickness issues have emerged in the recent period. In addition, the target symptoms and range of participants were diversified. Conclusions: There has been a continuously increasing interest in dealing with neuropsychology by using fully immersive VR. Target cognitive abilities have been diversified, as well as target symptoms. Moreover, the concept of embodied cognition was transplanted in this research area. UR - https://games.jmir.org/2021/4/e30249 UR - http://dx.doi.org/10.2196/30249 UR - http://www.ncbi.nlm.nih.gov/pubmed/34822341 ID - info:doi/10.2196/30249 ER - TY - JOUR AU - Gielis, Karsten AU - Vanden Abeele, Marie-Elena AU - De Croon, Robin AU - Dierick, Paul AU - Ferreira-Brito, Filipa AU - Van Assche, Lies AU - Verbert, Katrien AU - Tournoy, Jos AU - Vanden Abeele, Vero PY - 2021/11/4 TI - Dissecting Digital Card Games to Yield Digital Biomarkers for the Assessment of Mild Cognitive Impairment: Methodological Approach and Exploratory Study JO - JMIR Serious Games SP - e18359 VL - 9 IS - 4 KW - mild cognitive impairment KW - Klondike Solitaire KW - card games KW - generalized linear mixed effects analysis KW - expert study KW - monitoring KW - screening KW - cognition KW - dementia KW - older adults KW - mobile phone N2 - Background: Mild cognitive impairment (MCI), the intermediate cognitive status between normal cognitive decline and pathological decline, is an important clinical construct for signaling possible prodromes of dementia. However, this condition is underdiagnosed. To assist monitoring and screening, digital biomarkers derived from commercial off-the-shelf video games may be of interest. These games maintain player engagement over a longer period of time and support longitudinal measurements of cognitive performance. Objective: This paper aims to explore how the player actions of Klondike Solitaire relate to cognitive functions and to what extent the digital biomarkers derived from these player actions are indicative of MCI. Methods: First, 11 experts in the domain of cognitive impairments were asked to correlate 21 player actions to 11 cognitive functions. Expert agreement was verified through intraclass correlation, based on a 2-way, fully crossed design with type consistency. On the basis of these player actions, 23 potential digital biomarkers of performance for Klondike Solitaire were defined. Next, 23 healthy participants and 23 participants living with MCI were asked to play 3 rounds of Klondike Solitaire, which took 17 minutes on average to complete. A generalized linear mixed model analysis was conducted to explore the differences in digital biomarkers between the healthy participants and those living with MCI, while controlling for age, tablet experience, and Klondike Solitaire experience. Results: All intraclass correlations for player actions and cognitive functions scored higher than 0.75, indicating good to excellent reliability. Furthermore, all player actions had, according to the experts, at least one cognitive function that was on average moderately to strongly correlated to a cognitive function. Of the 23 potential digital biomarkers, 12 (52%) were revealed by the generalized linear mixed model analysis to have sizeable effects and significance levels. The analysis indicates sensitivity of the derived digital biomarkers to MCI. Conclusions: Commercial off-the-shelf games such as digital card games show potential as a complementary tool for screening and monitoring cognition. Trial Registration: ClinicalTrials.gov NCT02971124; https://clinicaltrials.gov/ct2/show/NCT02971124 UR - https://games.jmir.org/2021/4/e18359 UR - http://dx.doi.org/10.2196/18359 UR - http://www.ncbi.nlm.nih.gov/pubmed/34734825 ID - info:doi/10.2196/18359 ER - TY - JOUR AU - Henrique, Bazzanello Patrícia Paula AU - Perez, Pelle Fabrízzio Martin AU - Becker, Cemin Osvaldo Henrique AU - Bellei, Andrei Ericles AU - Biduski, Daiana AU - Korb, Arthiese AU - Pochmann, Daniela AU - Dani, Caroline AU - Elsner, Rostirola Viviane AU - De Marchi, Bertoletti Ana Carolina PY - 2021/10/13 TI - Kinesiotherapy With Exergaming as a Potential Modulator of Epigenetic Marks and Clinical Functional Variables of Older Women: Protocol for a Mixed Methods Study JO - JMIR Res Protoc SP - e32729 VL - 10 IS - 10 KW - elderly women KW - exergame KW - epigenome KW - cognition KW - kinesiotherapy N2 - Background: Kinesiotherapy is an option to mitigate worsening neuropsychomotor function due to human aging. Moreover, exergames are beneficial for the practice of physical therapy by older patients. Physical exercise interventions are known to alter the epigenome, but little is known about their association with exergames. Objective: We aim to evaluate the effects of kinesiotherapy with exergaming on older women?s epigenetic marks and cognitive ability, as well as on their clinical functional variables. Our hypothesis states that this kind of therapy can elicit equal or even better outcomes than conventional therapy. Methods: We will develop a virtual clinic exergame with 8 types of kinesiotherapy exercises. Afterward, we will conduct a 1:1 randomized clinical trial to compare the practice of kinesiotherapy with exergames (intervention group) against conventional kinesiotherapy (control group). A total of 24 older women will be enrolled for 1-hour sessions performed twice a week, for 6 weeks, totaling 12 sessions. We will assess outcomes using epigenetic blood tests, the Montreal Cognitive Assessment test, the Timed Up and Go test, muscle strength grading in a hydraulic dynamometer, and the Game Experience Questionnaire at various stages. Results: The project was funded in October 2019. Game development took place in 2020. Patient recruitment and a clinical trial are planned for 2021. Conclusions: Research on this topic is likely to significantly expand the understanding of kinesiotherapy and the impact of exergames. To the best of our knowledge, this may be one of the first studies exploring epigenetic outcomes of exergaming interventions. Trial Registration: Brazilian Clinical Trials Registry/Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR-9tdrmw; https://ensaiosclinicos.gov.br/rg/RBR-9tdrmw. International Registered Report Identifier (IRRID): DERR1-10.2196/32729 UR - https://www.researchprotocols.org/2021/10/e32729 UR - http://dx.doi.org/10.2196/32729 UR - http://www.ncbi.nlm.nih.gov/pubmed/34643543 ID - info:doi/10.2196/32729 ER - TY - JOUR AU - Wiley, Katelyn AU - Robinson, Raquel AU - Mandryk, L. Regan PY - 2021/8/9 TI - The Making and Evaluation of Digital Games Used for the Assessment of Attention: Systematic Review JO - JMIR Serious Games SP - e26449 VL - 9 IS - 3 KW - cognitive assessment KW - attention KW - serious games KW - gamification KW - systematic review KW - mobile phone N2 - Background: Serious games are now widely used in many contexts, including psychological research and clinical use. One area of growing interest is that of cognitive assessment, which seeks to measure different cognitive functions such as memory, attention, and perception. Measuring these functions at both the population and individual levels can inform research and indicate health issues. Attention is an important function to assess, as an accurate measure of attention can help diagnose many common disorders, such as attention-deficit/hyperactivity disorder and dementia. However, using games to assess attention poses unique problems, as games inherently manipulate attention through elements such as sound effects, graphics, and rewards, and research on adding game elements to assessments (ie, gamification) has shown mixed results. The process for developing cognitive tasks is robust, with high psychometric standards that must be met before these tasks are used for assessment. Although games offer more diverse approaches for assessment, there is no standard for how they should be developed or evaluated. Objective: To better understand the field and provide guidance to interdisciplinary researchers, we aim to answer the question: How are digital games used for the cognitive assessment of attention made and measured? Methods: We searched several databases for papers that described a digital game used to assess attention that could be deployed remotely without specialized hardware. We used Rayyan, a systematic review software, to screen the records before conducting a systematic review. Results: The initial database search returned 49,365 papers. Our screening process resulted in a total of 74 papers that used a digital game to measure cognitive functions related to attention. Across the studies in our review, we found three approaches to making assessment games: gamifying cognitive tasks, creating custom games based on theories of cognition, and exploring potential assessment properties of commercial games. With regard to measuring the assessment properties of these games (eg, how accurately they assess attention), we found three approaches: comparison to a traditional cognitive task, comparison to a clinical diagnosis, and comparison to knowledge of cognition; however, most studies in our review did not evaluate the game?s properties (eg, if participants enjoyed the game). Conclusions: Our review provides an overview of how games used for the assessment of attention are developed and evaluated. We further identified three barriers to advancing the field: reliance on assumptions, lack of evaluation, and lack of integration and standardization. We then recommend the best practices to address these barriers. Our review can act as a resource to help guide the field toward more standardized approaches and rigorous evaluation required for the widespread adoption of assessment games. UR - https://games.jmir.org/2021/3/e26449 UR - http://dx.doi.org/10.2196/26449 UR - http://www.ncbi.nlm.nih.gov/pubmed/34383674 ID - info:doi/10.2196/26449 ER - TY - JOUR AU - Kwan, Cho Rick Yiu AU - Liu, Wa Justina Yat AU - Fong, Kuen Kenneth Nai AU - Qin, Jing AU - Leung, Kwok-Yuen Philip AU - Sin, Kan Olive Suk AU - Hon, Yuen Pik AU - Suen, W. Lydia AU - Tse, Man-Kei AU - Lai, KY Claudia PY - 2021/8/6 TI - Feasibility and Effects of Virtual Reality Motor-Cognitive Training in Community-Dwelling Older People With Cognitive Frailty: Pilot Randomized Controlled Trial JO - JMIR Serious Games SP - e28400 VL - 9 IS - 3 KW - virtual reality KW - motor-cognitive training KW - cognitive frailty KW - game KW - feasibility KW - VR KW - training KW - older adults KW - frail KW - pilot study KW - randomized controlled trial N2 - Background: Cognitive frailty refers to the coexistence of physical frailty and cognitive impairment, and is associated with many adverse health outcomes. Although cognitive frailty is prevalent in older people, motor-cognitive training is effective at enhancing cognitive and physical function. We proposed a virtual reality (VR) simultaneous motor-cognitive training program, which allowed older people to perform daily activities in a virtual space mimicking real environments. Objective: We aimed to (1) explore the feasibility of offering VR simultaneous motor-cognitive training to older people with cognitive frailty and (2) compare its effects with an existing motor-cognitive training program in the community on the cognitive function and physical function of older people with cognitive frailty. Methods: A two-arm (1:1), assessor-blinded, parallel design, randomized controlled trial was employed. The eligibility criteria for participants were: (1) aged ?60 years, (2) community dwelling, and (3) with cognitive frailty. Those in the intervention group received cognitive training (ie, cognitive games) and motor training (ie, cycling on an ergometer) simultaneously on a VR platform, mimicking the daily living activities of older people. Those in the control group received cognitive training (ie, cognitive games) on tablet computers and motor training (ie, cycling on the ergometer) sequentially on a non-VR platform. Both groups received a 30-minute session twice a week for 8 weeks. Feasibility was measured by adherence, adverse outcomes, and successful learning. The outcomes were cognitive function, physical frailty level, and walking speed. Results: Seventeen participants were recruited and randomized to either the control group (n=8) or intervention group (n=9). At baseline, the median age was 74.0 years (IQR 9.5) and the median Montreal Cognitive Assessment score was 20.0 (IQR 4.0). No significant between-group differences were found in baseline characteristics except in the number of chronic illnesses (P=.04). At postintervention, the intervention group (Z=?2.67, P=.01) showed a significantly larger improvement in cognitive function than the control group (Z=?1.19, P=.24). The reduction in physical frailty in the intervention group (Z=?1.73, P=.08) was similar to that in the control group (Z=?1.89, P=.06). Improvement in walking speed based on the Timed Up-and-Go test was moderate in the intervention group (Z=?0.16, P=.11) and greater in the control group (Z=?2.52, P=.01). The recruitment rate was acceptable (17/33, 52%). Both groups had a 100% attendance rate. The intervention group had a higher completion rate than the control group. Training was terminated for one participant (1/9, 11%) due to minimal VR sickness (Virtual Reality Sickness Questionnaire score=18.3/100). Two participants (2/8, 25%) in the control group withdrew due to moderate leg pain. No injuries were observed in either group. Conclusions: This study provides preliminary evidence that the VR simultaneous motor-cognitive training is effective at enhancing the cognitive function of older people with cognitive frailty. The effect size on frailty was close to reaching a level of significance and was similar to that observed in the control group. VR training is feasible and safe for older people with cognitive frailty. Trial Registration: ClinicalTrials.gov NCT04467216; https://clinicaltrials.gov/ct2/show/NCT04467216 UR - https://games.jmir.org/2021/3/e28400 UR - http://dx.doi.org/10.2196/28400 UR - http://www.ncbi.nlm.nih.gov/pubmed/34383662 ID - info:doi/10.2196/28400 ER - TY - JOUR AU - Louw, Gidion Jacobus AU - van Heerden, Alastair AU - Olivier, Leana AU - Lambrechts, Tersius AU - Broodryk, Mandi AU - Bunge, Liska AU - Vosloo, Martlé AU - Tomlinson, Mark PY - 2021/7/2 TI - Executive Function After Prenatal Alcohol Exposure in Children in a South African Population: Cross-sectional Study JO - JMIR Form Res SP - e20658 VL - 5 IS - 7 KW - fetal alcohol spectrum disorders KW - FASD KW - cognitive KW - executive function KW - experimental games KW - brain drug effects KW - child development KW - serious games KW - games KW - alcohol KW - training N2 - Background: Alcohol is a teratogen; its consumption during pregnancy can lead to negative birth outcomes, collectively referred to as fetal alcohol spectrum disorders. Neurodevelopmental delays in higher-order cognitive functions that affect development of executive functions are a common feature. Studies on executive function in children have focused on children diagnosed with fetal alcohol spectrum disorder, and there is a lack of information on the impact on children not diagnosed with fetal alcohol spectrum disorder but who had been exposed to alcohol. Objective: The aim of this study was to compare the development of executive function in children between 4 and 6 years of age with and without prenatal exposure to alcohol. Methods: Children both exposed and not exposed to alcohol were recruited as part of a feasibility RCT evaluating a computer-based cognitive training program for improving executive function development. The study was conducted in a low?socioeconomic status community in South Africa with a high prevalence of fetal alcohol spectrum disorder. Neurodevelopment was assessed in participating children; NEPSY-II standardized scores for executive function domains were compared using a multivariate analysis of variance with group membership as the predictor variable. Results: No significant differences in executive functions assessments (P=.39) were found between children in the alcohol-exposed group (n=76) and those in the nonexposed group (n=40). Both groups showed moderate to severe delays in domains. In all but one subtest, the average score for both groups was below the 25th percentile of expected norms. Conclusions: We expected that alcohol exposure would have a measurable impact on executive function development. The lack of differences highlights the prevalence of developmental delays in low?socioeconomic status communities in South Africa and suggests that children are exposed to various threats to cognitive development. International Registered Report Identifier (IRRID): RR2-10.2196/14489 UR - https://formative.jmir.org/2021/7/e20658 UR - http://dx.doi.org/10.2196/20658 UR - http://www.ncbi.nlm.nih.gov/pubmed/34255647 ID - info:doi/10.2196/20658 ER - TY - JOUR AU - Israsena, Pasin AU - Jirayucharoensak, Suwicha AU - Hemrungrojn, Solaphat AU - Pan-Ngum, Setha PY - 2021/6/15 TI - Brain Exercising Games With Consumer-Grade Single-Channel Electroencephalogram Neurofeedback: Pre-Post Intervention Study JO - JMIR Serious Games SP - e26872 VL - 9 IS - 2 KW - neurofeedback KW - serious gaming KW - serious game KW - brain exercise KW - cognition training KW - EEG KW - aging KW - cognition KW - cognitive KW - brain game N2 - Background: The aging population is one of the major challenges affecting societies worldwide. As the proportion of older people grows dramatically, so does the number of age-related illnesses such as dementia-related illnesses. Preventive care should be emphasized as an effective tool to combat and manage this situation. Objective: The aim of this pilot project was to study the benefits of using neurofeedback-based brain training games for enhancing cognitive performance in the elderly population. In particular, aiming for practicality, the training games were designed to operate with a low-cost consumer-grade single-channel electroencephalogram (EEG) headset that should make the service scalable and more accessible for wider adoption such as for home use. Methods: Our training system, which consisted of five brain exercise games using neurofeedback, was serviced at 5 hospitals in Thailand. Participants were screened for cognitive levels using the Thai Mental State Examination and Montreal Cognitive Assessment. Those who passed the criteria were further assessed with the Cambridge Neuropsychological Test Automated Battery (CANTAB) computerized cognitive assessment battery. The physiological state of the brain was also assessed using 16-channel EEG. After 20 sessions of training, cognitive performance and EEG were assessed again to compare pretraining and posttraining results. Results: Thirty-five participants completed the training. CANTAB results showed positive and significant effects in the visual memory (delayed matching to sample [percent correct] P=.04), attention (median latency P=.009), and visual recognition (spatial working memory [between errors] P=.03) domains. EEG also showed improvement in upper alpha activity in a resting state (open-eyed) measured from the occipital area (P=.04), which similarly indicated improvement in the cognitive domain (attention). Conclusions: Outcomes of this study show the potential use of practical neurofeedback-based training games for brain exercise to enhance cognitive performance in the elderly population. UR - https://games.jmir.org/2021/2/e26872 UR - http://dx.doi.org/10.2196/26872 UR - http://www.ncbi.nlm.nih.gov/pubmed/34128816 ID - info:doi/10.2196/26872 ER - TY - JOUR AU - Kim, Heon Ho AU - An, Il Jae AU - Park, Rang Yu PY - 2021/6/4 TI - A Prediction Model for Detecting Developmental Disabilities in Preschool-Age Children Through Digital Biomarker-Driven Deep Learning in Serious Games: Development Study JO - JMIR Serious Games SP - e23130 VL - 9 IS - 2 KW - developmental delay KW - diagnosis prediction KW - deep learning KW - serious games KW - digital health KW - digital phenotyping KW - digital biomarkers N2 - Background: Early detection of developmental disabilities in children is essential because early intervention can improve the prognosis of children. Meanwhile, a growing body of evidence has indicated a relationship between developmental disability and motor skill, and thus, motor skill is considered in the early diagnosis of developmental disability. However, there are challenges to assessing motor skill in the diagnosis of developmental disorder, such as a lack of specialists and time constraints, and thus it is commonly conducted through informal questions or surveys to parents. Objective: This study sought to evaluate the possibility of using drag-and-drop data as a digital biomarker and to develop a classification model based on drag-and-drop data with which to classify children with developmental disabilities. Methods: We collected drag-and-drop data from children with typical development and developmental disabilities from May 1, 2018, to May 1, 2020, via a mobile application (DoBrain). We used touch coordinates and extracted kinetic variables from these coordinates. A deep learning algorithm was developed to predict potential development disabilities in children. For interpretability of the model results, we identified which coordinates contributed to the classification results by applying gradient-weighted class activation mapping. Results: Of the 370 children in the study, 223 had typical development, and 147 had developmental disabilities. In all games, the number of changes in the acceleration sign based on the direction of progress both in the x- and y-axes showed significant differences between the 2 groups (P<.001; effect size >0.5). The deep learning convolutional neural network model showed that drag-and-drop data can help diagnose developmental disabilities, with an area under the receiving operating characteristics curve of 0.817. A gradient class activation map, which can interpret the results of a deep learning model, was visualized with the game results for specific children. Conclusions: Through the results of the deep learning model, we confirmed that drag-and-drop data can be a new digital biomarker for the diagnosis of developmental disabilities. UR - https://games.jmir.org/2021/2/e23130 UR - http://dx.doi.org/10.2196/23130 UR - http://www.ncbi.nlm.nih.gov/pubmed/34085944 ID - info:doi/10.2196/23130 ER - TY - JOUR AU - Khaleghi, Ali AU - Aghaei, Zahra AU - Mahdavi, Amin Mohammad PY - 2021/5/18 TI - A Gamification Framework for Cognitive Assessment and Cognitive Training: Qualitative Study JO - JMIR Serious Games SP - e21900 VL - 9 IS - 2 KW - cognitive tasks KW - boredom KW - motivation KW - gamification KW - game elements KW - framework KW - process KW - gamification design KW - cognitive training KW - cognitive assessment N2 - 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. UR - https://games.jmir.org/2021/2/e21900 UR - http://dx.doi.org/10.2196/21900 UR - http://www.ncbi.nlm.nih.gov/pubmed/33819164 ID - info:doi/10.2196/21900 ER - TY - JOUR AU - Chau, Hing Pui AU - Kwok, Jojo Yan Yan AU - Chan, Maggie Mee Kie AU - Kwan, Daniel Ka Yu AU - Wong, Lun Kam AU - Tang, Ho Ying AU - Chau, Peter Kan Lung AU - Lau, Matthew Sheung Wa AU - Yiu, Yannex Yan Yan AU - Kwong, Fanny Mei Yan AU - Lai, Thomas Wai Ting AU - Leung, Kit Mun PY - 2021/5/4 TI - Feasibility, Acceptability, and Efficacy of Virtual Reality Training for Older Adults and People With Disabilities: Single-Arm Pre-Post Study JO - J Med Internet Res SP - e27640 VL - 23 IS - 5 KW - virtual reality KW - rehabilitation KW - older adults, people with disabilities KW - evaluation N2 - Background: Unlike most virtual reality (VR) training programs that are targeted at homogenous populations, a set of VR games for rehabilitation purposes targeted at a heterogeneous group of users was developed. The VR games covered physical training, cognitive training (classification and reality orientation), community-living skills training, and relaxing scenery experiences. Special considerations for local older adults and people with disabilities were made in terms of hardware choice and software design. Objective: This study aimed to evaluate the feasibility, acceptance, and efficacy of VR training among users with varying abilities. Methods: A single-arm pretest-posttest evaluation study was conducted. The participants of the evaluation study were encouraged to undergo 30-minute VR training three times a week for 6 weeks. The 30-minute session consisted of 10 minutes of upper-limb motion games, 10 minutes of lower-limb motion games, and 10 minutes of cognitive games/community-living skills training/relaxing scenery experiences, as appropriate. On completion of each session, usage statistics were documented via the built-in VR software, whereas feedback on the experience of the VR games and adverse events was collected via self-reports and staff observations. Feasibility was reflected by usage statistics, and acceptance was reflected by positive feedback. In addition, health outcomes, including upper-limb dexterity, functional mobility, cognitive function, and happiness, were assessed at baseline, as well as 6 weeks and 3 months after baseline. The primary outcomes were upper-limb dexterity and acceptance of playing VR games. Results: A total of 135 participants with a mean age of 62.7 years (SD 21.5) were recruited from May 2019 to January 2020, and 124 (91.9%) completed at least one follow-up. Additionally, 76.3% (103/135) of the participants could attend at least 70% of the proposed 18 sessions, and 72.5% (1382/1906) of the sessions had a training time of at least 20 minutes. Linear mixed effect models showed statistically significant effects in terms of upper-limb dexterity (small effect) and cognitive function (moderate effect). Among the 135 participants, 88 provided positive comments. Additionally, 10.4% (14/135) reported mild discomfort, such as dizziness, and none reported severe discomfort. Conclusions: A set of VR training games for rehabilitation could be applied to users with heterogeneous abilities. Our VR games were acceptable to local older adults and those with different disabilities. Benefits in upper-limb dexterity and cognitive function were observed despite partial compliance to the training protocol. Service providers could refer to our experiences when developing VR training systems for their clients. UR - https://www.jmir.org/2021/5/e27640 UR - http://dx.doi.org/10.2196/27640 UR - http://www.ncbi.nlm.nih.gov/pubmed/33944795 ID - info:doi/10.2196/27640 ER - TY - JOUR AU - Yeo, Shi Pei AU - Nguyen, Ngoc Tu AU - Ng, Ern Mary Pei AU - Choo, Munn Robin Wai AU - Yap, Kiat Philip Lin AU - Ng, Pin Tze AU - Wee, Liang Shiou PY - 2021/4/27 TI - Evaluation of the Implementation and Effectiveness of Community-Based Brain-Computer Interface Cognitive Group Training in Healthy Community-Dwelling Older Adults: Randomized Controlled Implementation Trial JO - JMIR Form Res SP - e25462 VL - 5 IS - 4 KW - group-based computerized cognitive training KW - cognition KW - gait KW - community program implementation KW - healthy older adults KW - cognitive KW - community program KW - cognitive training KW - elderly KW - aging N2 - Background: Cognitive training can improve cognition in healthy older adults. Objective: The objectives are to evaluate the implementation of community-based computerized cognitive training (CCT) and its effectiveness on cognition, gait, and balance in healthy older adults. Methods: A single-blind randomized controlled trial with baseline and follow-up assessments was conducted at two community centers in Singapore. Healthy community-dwelling adults aged 55 years and older participated in a 10-week CCT program with 2-hour instructor-led group classes twice a week. Participants used a mobile app to play games targeting attention, memory, decision making, visuospatial abilities, and cognitive flexibility. Implementation was assessed at the participant, provider, and community level (eg, reach, implementation, and facilitators and barriers). Effectiveness measures were the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Color Trails Test 2 (CTT-2), Berg Balance Scale, and GAITRite walkway measures (single and dual task gait speed, dual task cost, and single and dual task gait variability index [GVI]). Results: A total of 94 healthy community-dwelling adults participated in the CCT program (mean age 68.8 [SD 6.3] years). Implementation measures revealed high reach (125/155, 80.6%) and moderate adherence but poor penetration of sedentary older adults (43/125, 34.4%). The effectiveness data were based on intention-to-treat (ITT) and per-protocol (PP) analysis. In the ITT analysis, single task GVI increased (b=2.32, P=.02, 95% CI [0.30 to 4.35]) and RBANS list recognition subtest deteriorated (b=?0.57, P=.01, 95% CI [?1.00 to ?0.14]) in both groups. In the PP analysis, time taken to complete CTT-2 (b=?13.5, P=.01, 95% CI [?23.95 to ?3.14]; Cohen d effect size = 0.285) was faster in the intervention group. Single task gait speed was not statistically significantly maintained in the intervention group (b=5.38, P=.06, 95% CI [?0.30 to 11.36]) and declined in the control group (Cohen d effect size = 0.414). PP analyses also showed interaction terms for RBANS list recall subtest (b=?0.36, P=.08, 95% CI [?0.75 to 0.04]) and visuospatial domain (b=0.46, P=.08, 95% CI [?0.05 to 0.96]) that were not statistically significant. Conclusions: CCT can be implemented in community settings to improve attention and executive function among healthy older adults. Findings help to identify suitable healthy aging programs that can be implemented on a larger scale within communities. Trial Registration: ClinicalTrials.gov NCT04439591; https://clinicaltrials.gov/ct2/show/NCT04439591 UR - https://formative.jmir.org/2021/4/e25462 UR - http://dx.doi.org/10.2196/25462 UR - http://www.ncbi.nlm.nih.gov/pubmed/33904819 ID - info:doi/10.2196/25462 ER - TY - JOUR AU - Brons, Annette AU - de Schipper, Antoine AU - Mironcika, Svetlana AU - Toussaint, Huub AU - Schouten, Ben AU - Bakkes, Sander AU - Kröse, Ben PY - 2021/4/22 TI - Assessing Children?s Fine Motor Skills With Sensor-Augmented Toys: Machine Learning Approach JO - J Med Internet Res SP - e24237 VL - 23 IS - 4 KW - motor development KW - fine motor function KW - gamification KW - playful KW - motor skill assessment KW - Movement ABC (MABC) KW - machine learning KW - motor function KW - motor skills KW - toys KW - children KW - game KW - movement assessment N2 - Background: Approximately 5%-10% of elementary school children show delayed development of fine motor skills. To address these problems, detection is required. Current assessment tools are time-consuming, require a trained supervisor, and are not motivating for children. Sensor-augmented toys and machine learning have been presented as possible solutions to address this problem. Objective: This study examines whether sensor-augmented toys can be used to assess children?s fine motor skills. The objectives were to (1) predict the outcome of the fine motor skill part of the Movement Assessment Battery for Children Second Edition (fine MABC-2) and (2) study the influence of the classification model, game, type of data, and level of difficulty of the game on the prediction. Methods: Children in elementary school (n=95, age 7.8 [SD 0.7] years) performed the fine MABC-2 and played 2 games with a sensor-augmented toy called ?Futuro Cube.? The game ?roadrunner? focused on speed while the game ?maze? focused on precision. Each game had several levels of difficulty. While playing, both sensor and game data were collected. Four supervised machine learning classifiers were trained with these data to predict the fine MABC-2 outcome: k-nearest neighbor (KNN), logistic regression (LR), decision tree (DT), and support vector machine (SVM). First, we compared the performances of the games and classifiers. Subsequently, we compared the levels of difficulty and types of data for the classifier and game that performed best on accuracy and F1 score. For all statistical tests, we used ?=.05. Results: The highest achieved mean accuracy (0.76) was achieved with the DT classifier that was trained on both sensor and game data obtained from playing the easiest and the hardest level of the roadrunner game. Significant differences in performance were found in the accuracy scores between data obtained from the roadrunner and maze games (DT, P=.03; KNN, P=.01; LR, P=.02; SVM, P=.04). No significant differences in performance were found in the accuracy scores between the best performing classifier and the other 3 classifiers for both the roadrunner game (DT vs KNN, P=.42; DT vs LR, P=.35; DT vs SVM, P=.08) and the maze game (DT vs KNN, P=.15; DT vs LR, P=.62; DT vs SVM, P=.26). The accuracy of only the best performing level of difficulty (combination of the easiest and hardest level) achieved with the DT classifier trained with sensor and game data obtained from the roadrunner game was significantly better than the combination of the easiest and middle level (P=.046). Conclusions: The results of our study show that sensor-augmented toys can efficiently predict the fine MABC-2 scores for children in elementary school. Selecting the game type (focusing on speed or precision) and data type (sensor or game data) is more important for determining the performance than selecting the machine learning classifier or level of difficulty. UR - https://www.jmir.org/2021/4/e24237 UR - http://dx.doi.org/10.2196/24237 UR - http://www.ncbi.nlm.nih.gov/pubmed/33885371 ID - info:doi/10.2196/24237 ER - TY - JOUR AU - Hassandra, Mary AU - Galanis, Evangelos AU - Hatzigeorgiadis, Antonis AU - Goudas, Marios AU - Mouzakidis, Christos AU - Karathanasi, Maria Eleni AU - Petridou, Niki AU - Tsolaki, Magda AU - Zikas, Paul AU - Evangelou, Giannis AU - Papagiannakis, George AU - Bellis, George AU - Kokkotis, Christos AU - Panagiotopoulos, Rafail Spyridon AU - Giakas, Giannis AU - Theodorakis, Yannis PY - 2021/3/24 TI - ? Virtual Reality App for Physical and Cognitive Training of Older People With Mild Cognitive Impairment: Mixed Methods Feasibility Study JO - JMIR Serious Games SP - e24170 VL - 9 IS - 1 KW - virtual reality KW - elderly KW - mild cognitive impairment KW - combined physical and cognitive function KW - dual task N2 - Background: Therapeutic virtual reality (VR) has emerged as an effective treatment modality for cognitive and physical training in people with mild cognitive impairment (MCI). However, to replace existing nonpharmaceutical treatment training protocols, VR platforms need significant improvement if they are to appeal to older people with symptoms of cognitive decline and meet their specific needs. Objective: This study aims to design and test the acceptability, usability, and tolerability of an immersive VR platform that allows older people with MCI symptoms to simultaneously practice physical and cognitive skills on a dual task. Methods: On the basis of interviews with 20 older people with MCI symptoms (15 females; mean age 76.25, SD 5.03 years) and inputs from their health care providers (formative study VR1), an interdisciplinary group of experts developed a VR system called VRADA (VR Exercise App for Dementia and Alzheimer?s Patients). Using an identical training protocol, the VRADA system was first tested with a group of 30 university students (16 females; mean age 20.86, SD 1.17 years) and then with 27 older people (19 females; mean age 73.22, SD 9.26 years) who had been diagnosed with MCI (feasibility studies VR2a and VR2b). Those in the latter group attended two Hellenic Association Day Care Centers for Alzheimer?s Disease and Related Disorders. Participants in both groups were asked to perform a dual task training protocol that combined physical and cognitive exercises in two different training conditions. In condition A, participants performed a cycling task in a lab environment while being asked by the researcher to perform oral math calculations (single-digit additions and subtractions). In condition B, participants performed a cycling task in the virtual environment while performing calculations that appeared within the VR app. Participants in both groups were assessed in the same way; this included questionnaires and semistructured interviews immediately after the experiment to capture perceptions of acceptability, usability, and tolerability, and to determine which of the two training conditions each participant preferred. Results: Participants in both groups showed a significant preference for the VR condition (students: mean 0.66, SD 0.41, t29=8.74, P<.001; patients with MCI: mean 0.72, SD 0.51, t26=7.36, P<.001), as well as high acceptance scores for intended future use, attitude toward VR training, and enjoyment. System usability scale scores (82.66 for the students and 77.96 for the older group) were well above the acceptability threshold (75/100). The perceived adverse effects were minimal, indicating a satisfactory tolerability. Conclusions: The findings suggest that VRADA is an acceptable, usable, and tolerable system for physical and cognitive training of older people with MCI and university students. Randomized controlled trial studies are needed to assess the ef?cacy of VRADA as a tool to promote physical and cognitive health in patients with MCI. UR - https://games.jmir.org/2021/1/e24170 UR - http://dx.doi.org/10.2196/24170 UR - http://www.ncbi.nlm.nih.gov/pubmed/33759797 ID - info:doi/10.2196/24170 ER - TY - JOUR AU - Krebs, Christine AU - Falkner, Michael AU - Niklaus, Joel AU - Persello, Luca AU - Klöppel, Stefan AU - Nef, Tobias AU - Urwyler, Prabitha PY - 2021/3/22 TI - Application of Eye Tracking in Puzzle Games for Adjunct Cognitive Markers: Pilot Observational Study in Older Adults JO - JMIR Serious Games SP - e24151 VL - 9 IS - 1 KW - eye tracking KW - puzzle games KW - aging KW - cognitive assessment KW - cognition, attention, executive functions, visual search, fixations N2 - Background: Recent studies suggest that computerized puzzle games are enjoyable, easy to play, and engage attentional, visuospatial, and executive functions. They may help mediate impairments seen in cognitive decline in addition to being an assessment tool. Eye tracking provides a quantitative and qualitative analysis of gaze, which is highly useful in understanding visual search behavior. Objective: The goal of the research was to test the feasibility of eye tracking during a puzzle game and develop adjunct markers for cognitive performance using eye-tracking metrics. Methods: A desktop version of the Match-3 puzzle game with 15 difficulty levels was developed using Unity 3D (Unity Technologies). The goal of the Match-3 puzzle was to find configurations (target patterns) that could be turned into a row of 3 identical game objects (tiles) by swapping 2 adjacent tiles. Difficulty levels were created by manipulating the puzzle board size (all combinations of width and height from 4 to 8) and the number of unique tiles on the puzzle board (from 4 to 8). Each level consisted of 4 boards (ie, target patterns to match) with one target pattern each. In this study, the desktop version was presented on a laptop computer setup with eye tracking. Healthy older subjects were recruited to play a full set of 15 puzzle levels. A paper-pencil?based assessment battery was administered prior to the Match-3 game. The gaze behavior of all participants was recorded during the game. Correlation analyses were performed on eye-tracking data correcting for age to examine if gaze behavior pertains to target patterns and distractor patterns and changes with puzzle board size (set size). Additionally, correlations between cognitive performance and eye movement metrics were calculated. Results: A total of 13 healthy older subjects (mean age 70.67 [SD 4.75] years; range 63 to 80 years) participated in this study. In total, 3 training and 12 test levels were played by the participants. Eye tracking recorded 672 fixations in total, 525 fixations on distractor patterns and 99 fixations on target patterns. Significant correlations were found between executive functions (Trail Making Test B) and number of fixations on distractor patterns (P=.01) and average fixations (P=.005). Conclusions: Overall, this study shows that eye tracking in puzzle games can act as a supplemental source of data for cognitive performance. The relationship between a paper-pencil test for executive functions and fixations confirms that both are related to the same cognitive processes. Therefore, eye movement metrics might be used as an adjunct marker for cognitive abilities like executive functions. However, further research is needed to evaluate the potential of the various eye movement metrics in combination with puzzle games as visual search and attentional marker. UR - https://games.jmir.org/2021/1/e24151 UR - http://dx.doi.org/10.2196/24151 UR - http://www.ncbi.nlm.nih.gov/pubmed/33749607 ID - info:doi/10.2196/24151 ER - TY - JOUR AU - Gamito, Pedro AU - Oliveira, Jorge AU - Matias, Marcelo AU - Cunha, Elsa AU - Brito, Rodrigo AU - Lopes, Ferreira Paulo AU - Deus, Alberto PY - 2021/1/29 TI - Virtual Reality Cognitive Training Among Individuals With Alcohol Use Disorder Undergoing Residential Treatment: Pilot Randomized Controlled Trial JO - J Med Internet Res SP - e18482 VL - 23 IS - 1 KW - alcohol use disorder KW - cognitive training KW - virtual reality N2 - Background: Alcohol use disorder (AUD) has been associated with diverse physical and mental morbidities. Among the main consequences of chronic and excessive alcohol use are cognitive and executive deficits. Some of these deficits may be reversed in specific cognitive and executive domains with behavioral approaches consisting of cognitive training. The advent of computer-based interventions may leverage these improvements, but randomized controlled trials (RCTs) of digital interactive-based interventions are still scarce. Objective: The aim of this study is to explore whether a cognitive training approach using VR exercises based on activities of daily living is feasible for improving the cognitive function of patients with AUD undergoing residential treatment, as well as to estimate the effect size for this intervention to power future definitive RCTs. Methods: This study consisted of a two-arm pilot RCT with a sample of 36 individuals recovering from AUD in a therapeutic community; experimental group participants received a therapist-guided, VR-based cognitive training intervention combined with treatment as usual, and control group participants received treatment as usual without cognitive training. A comprehensive neuropsychological battery of tests was used both at pre- and postassessments, including measurement of global cognition, executive functions, attention, visual memory, and cognitive flexibility. Results: In order to control for potential effects of global cognition and executive functions at baseline, these domains were controlled for in the statistical analysis for each individual outcome. Results indicate intervention effects on attention in two out of five outcomes and on cognitive flexibility in two out of six outcomes, with effect sizes in significant comparisons being larger for attention than for cognitive flexibility. Patient retention in cognitive training was high, in line with previous studies. Conclusions: Overall, the data suggest that VR-based cognitive training results in specific contributions to improving attention ability and cognitive flexibility of patients recovering from AUD. Trial Registration: ClinicalTrials.gov NCT04505345; https://clinicaltrials.gov/show/NCT04505345 UR - http://www.jmir.org/2021/1/e18482/ UR - http://dx.doi.org/10.2196/18482 UR - http://www.ncbi.nlm.nih.gov/pubmed/33512329 ID - info:doi/10.2196/18482 ER - TY - JOUR AU - Hsu, Wan-Yu AU - Rowles, William AU - Anguera, A. Joaquin AU - Zhao, Chao AU - Anderson, Annika AU - Alexander, Amber AU - Sacco, Simone AU - Henry, Roland AU - Gazzaley, Adam AU - Bove, Riley PY - 2021/1/20 TI - Application of an Adaptive, Digital, Game-Based Approach for Cognitive Assessment in Multiple Sclerosis: Observational Study JO - J Med Internet Res SP - e24356 VL - 23 IS - 1 KW - cognition KW - digital health KW - mHealth KW - multiple sclerosis KW - cognitive assessment KW - video game N2 - Background: Cognitive impairment is one of the most debilitating manifestations of multiple sclerosis. Currently, the assessment of cognition relies on a time-consuming and extensive neuropsychological examination, which is only available in some centers. Objective: To enable simpler, more accessible cognitive screening, we sought to determine the feasibility and potential assessment sensitivity of an unsupervised, adaptive, video game?based digital therapeutic to assess cognition in multiple sclerosis. Methods: A total of 100 people with multiple sclerosis (33 with cognitive impairment and 67 without cognitive impairment) and 24 adults without multiple sclerosis were tested with the tablet game (EVO Monitor) and standard measures, including the Brief International Cognitive Assessment for Multiple Sclerosis (which included the Symbol Digit Modalities Test [SDMT]) and Multiple Sclerosis Functional Composite 4 (which included the Timed 25-Foot Walk test). Patients with multiple sclerosis also underwent neurological evaluations and contributed recent structural magnetic resonance imaging scans. Group differences in EVO Monitor performance and the association between EVO Monitor performance and standard measures were investigated. Results: Participants with multiple sclerosis and cognitive impairment showed worse performance in EVO Monitor compared with participants without multiple sclerosis (P=.01) and participants with multiple sclerosis without cognitive impairment (all P<.002). Regression analyses indicated that participants with a lower SDMT score showed lower performance in EVO Monitor (r=0.52, P<.001). Further exploratory analyses revealed associations between performance in EVO Monitor and walking speed (r=?0.45, P<.001) as well as brain volumetric data (left thalamic volume: r=0.47, P<.001; right thalamic volume: r=0.39, P=.002; left rostral middle frontal volume: r=0.28, P=.03; right rostral middle frontal volume: r=0.27, P=.03). Conclusions: These findings suggest that EVO Monitor, an unsupervised, video game?based digital program integrated with adaptive mechanics, is a clinically valuable approach to measuring cognitive performance in patients with multiple sclerosis. Trial Registration: ClinicalTrials.gov NCT03569618; https://clinicaltrials.gov/ct2/show/NCT03569618 UR - http://www.jmir.org/2021/1/e24356/ UR - http://dx.doi.org/10.2196/24356 UR - http://www.ncbi.nlm.nih.gov/pubmed/33470940 ID - info:doi/10.2196/24356 ER - TY - JOUR AU - Amaefule, O. Chimezie AU - Lüdtke, Stefan AU - Kirste, Thomas AU - Teipel, J. Stefan PY - 2020/10/8 TI - Effect of Spatial Disorientation in a Virtual Environment on Gait and Vital Features in Patients with Dementia: Pilot Single-Blind Randomized Control Trial JO - JMIR Serious Games SP - e18455 VL - 8 IS - 4 KW - spatial disorientation KW - activity recognition KW - wayfinding KW - wearable sensors KW - dementia KW - virtual reality KW - older adults N2 - Background: Orientation deficits are among the most devastating consequences of early dementia. Digital navigation devices could overcome these deficits if adaptable to the user?s needs (ie, provide situation-aware, proactive navigation assistance). To fulfill this task, systems need to automatically detect spatial disorientation from sensors in real time. Ideally, this would require field studies consisting of real-world navigation. However, such field studies can be challenging and are not guaranteed to cover sufficient instances of disorientation due to the large variability of real-world settings and a lack of control over the environment. Objective: Extending a foregoing field study, we aim to evaluate the feasibility of using a sophisticated virtual reality (VR) setup, which allows a more controlled observation of disorientation states and accompanying behavioral and physiological parameters in cognitively healthy older people and people with dementia. Methods: In this feasibility study, we described the experimental design and pilot outcomes of an ongoing study aimed at investigating the effect of disorientation on gait and selected physiological features in a virtual laboratory. We transferred a real-world navigation task to a treadmill-based virtual system for gait analysis. Disorientation was induced by deliberately manipulating landmarks in the VR projection. Associated responses in motion behavior and physiological parameters were recorded by sensors. Primary outcomes were variations in motion and physiological parameters, frequency of disorientation, and questionnaire-derived usability estimates (immersion and perceived control of the gait system) for our population of interest. At this time, the included participants were 9 cognitively healthy older participants [5/9 women, 4/9 men; mean age 70 years, SD 4.40; Mini?Mental State Examination (MMSE) mean 29, SD 0.70) and 4 participants with dementia (2/4 women, 2/4 men; mean age 78 years, SD 2.30 years; MMSE mean 20.50, SD 7.54). Recruitment is ongoing, with the aim of including 30 cognitively healthy older participants and 20 participants with dementia. Results: All 13 participants completed the experiment. Patients? route was adapted by shortening it relative to the original route. Average instances of disorientation were 21.40, 36.50, and 37.50 for the cognitively healthy older control, cognitively healthy older experimental participants, and participants with dementia, respectively. Questionnaire outcomes indicated that participants experienced adequate usability and immersion; 4.30 for presence, 3.73 for involvement, and 3.85 for realism of 7 possible points, indicating a good overall ability to cope with the experiment. Variations were also observed in motion and physiological parameters during instances of disorientation. Conclusions: This study presents the first feasibility outcomes of a study investigating the viability of using a sophisticated VR setup, based on an earlier real-world navigation study, to study spatial disorientation among cognitively healthy older people and people with dementia. Preliminary outcomes give confidence to the notion that our setup can be used to assess motion and physiological markers of disorientation, even in people with cognitive decline. Trial Registration: ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT04134806 UR - https://games.jmir.org/2020/4/e18455 UR - http://dx.doi.org/10.2196/18455 UR - http://www.ncbi.nlm.nih.gov/pubmed/33030436 ID - info:doi/10.2196/18455 ER - TY - JOUR AU - Frost, Emily AU - Porat, Talya AU - Malhotra, Paresh AU - Picinali, Lorenzo PY - 2020/9/30 TI - A Novel Auditory-Cognitive Training App for Delaying or Preventing the Onset of Dementia: Participatory Design With Stakeholders JO - JMIR Hum Factors SP - e19880 VL - 7 IS - 3 KW - cognitive decline KW - mobile phone KW - hearing loss N2 - Background: Multiple gaming apps exist under the dementia umbrella for skills such as navigation; however, an app to specifically investigate the role of hearing loss in the process of cognitive decline is yet to be designed. There is a demonstrable gap in the utilization of games to further the knowledge of the potential relationship between hearing loss and dementia. Objective: This study aims to identify the needs, facilitators, and barriers in designing a novel auditory-cognitive training gaming app. Methods: A participatory design approach was used to engage key stakeholders across audiology and cognitive disorder specialties. Two rounds, including paired semistructured interviews and focus groups, were completed and thematically analyzed. Results: A total of 18 stakeholders participated, and 6 themes were identified to inform the next stage of app development. These included congruence with hobbies, life getting in the way, motivational challenge, accessibility, addictive competition, and realism. Conclusions: The findings can now be implemented in the development of the app. The app will be evaluated against outcome measures of speech listening in noise, cognitive and attentional tasks, quality of life, and usability. UR - http://humanfactors.jmir.org/2020/3/e19880/ UR - http://dx.doi.org/10.2196/19880 UR - http://www.ncbi.nlm.nih.gov/pubmed/32996884 ID - info:doi/10.2196/19880 ER - TY - JOUR AU - Backx, Rosa AU - Skirrow, Caroline AU - Dente, Pasquale AU - Barnett, H. Jennifer AU - Cormack, K. Francesca PY - 2020/8/4 TI - Comparing Web-Based and Lab-Based Cognitive Assessment Using the Cambridge Neuropsychological Test Automated Battery: A Within-Subjects Counterbalanced Study JO - J Med Internet Res SP - e16792 VL - 22 IS - 8 KW - reliability KW - mobile health KW - neuropsychological tests KW - CANTAB KW - cognition N2 - Background: Computerized assessments are already used to derive accurate and reliable measures of cognitive function. Web-based cognitive assessment could improve the accessibility and flexibility of research and clinical assessment, widen participation, and promote research recruitment while simultaneously reducing costs. However, differences in context may influence task performance. Objective: This study aims to determine the comparability of an unsupervised, web-based administration of the Cambridge Neuropsychological Test Automated Battery (CANTAB) against a typical in-person lab-based assessment, using a within-subjects counterbalanced design. The study aims to test (1) reliability, quantifying the relationship between measurements across settings using correlational approaches; (2) equivalence, the extent to which test results in different settings produce similar overall results; and (3) agreement, by quantifying acceptable limits to bias and differences between measurement environments. Methods: A total of 51 healthy adults (32 women and 19 men; mean age 36.8, SD 15.6 years) completed 2 testing sessions, which were completed on average 1 week apart (SD 4.5 days). Assessments included equivalent tests of emotion recognition (emotion recognition task [ERT]), visual recognition (pattern recognition memory [PRM]), episodic memory (paired associate learning [PAL]), working memory and spatial planning (spatial working memory [SWM] and one touch stockings of Cambridge), and sustained attention (rapid visual information processing [RVP]). Participants were randomly allocated to one of the two groups, either assessed in-person in the laboratory first (n=33) or with unsupervised web-based assessments on their personal computing systems first (n=18). Performance indices (errors, correct trials, and response sensitivity) and median reaction times were extracted. Intraclass and bivariate correlations examined intersetting reliability, linear mixed models and Bayesian paired sample t tests tested for equivalence, and Bland-Altman plots examined agreement. Results: Intraclass correlation (ICC) coefficients ranged from ?=0.23-0.67, with high correlations in 3 performance indices (from PAL, SWM, and RVP tasks; ??0.60). High ICC values were also seen for reaction time measures from 2 tasks (PRM and ERT tasks; ??0.60). However, reaction times were slower during web-based assessments, which undermined both equivalence and agreement for reaction time measures. Performance indices did not differ between assessment settings and generally showed satisfactory agreement. Conclusions: Our findings support the comparability of CANTAB performance indices (errors, correct trials, and response sensitivity) in unsupervised, web-based assessments with in-person and laboratory tests. Reaction times are not as easily translatable from in-person to web-based testing, likely due to variations in computer hardware. The results underline the importance of examining more than one index to ascertain comparability, as high correlations can present in the context of systematic differences, which are a product of differences between measurement environments. Further work is now needed to examine web-based assessments in clinical populations and in larger samples to improve sensitivity for detecting subtler differences between test settings. UR - https://www.jmir.org/2020/8/e16792 UR - http://dx.doi.org/10.2196/16792 UR - http://www.ncbi.nlm.nih.gov/pubmed/32749999 ID - info:doi/10.2196/16792 ER - TY - JOUR AU - Masurovsky, Alexander PY - 2020/6/26 TI - Controlling for Placebo Effects in Computerized Cognitive Training Studies With Healthy Older Adults From 2016-2018: Systematic Review JO - JMIR Serious Games SP - e14030 VL - 8 IS - 2 KW - computerized cognitive training KW - brain training KW - placebo KW - active control KW - elderly KW - older adults N2 - Background: Computerized cognitive training has been proposed as a potential solution to age-related cognitive decline. However, published findings from evaluation studies of cognitive training games, including metastudies and systematic reviews, provide evidence both for and against transferability from trained tasks to untrained cognitive ability. There continues to be no consensus on this issue from the scientific community. Some researchers have proposed that the number of results supporting the efficacy of cognitive training may be inflated due to placebo effects. It has been suggested that placebo effects need to be better controlled by using an active control and measuring participant expectations for improvement in outcome measures. Objective: This review examined placebo control methodology for recent evaluation studies of computerized cognitive training programs with older adult subjects, specifically looking for the use of an active control and measurement of expectations. Methods: Data were extracted from PubMed. Evaluation studies of computerized cognitive training with older adult subjects (age ?50 years) published between 2016 and 2018 were included. Methods sections of studies were searched for (1) control type (active or passive) and subtype (active: active-ingredient or similar-form; passive: no-contact or passive-task); (2) if expectations were measured, how were they measured, and whether they were used in analysis; and (3) whether researchers acknowledged a lack of active control and lack of expectation measurement as limitations (where appropriate). Results: Of the 19 eligible studies, 4 (21%) measured expectations, and 9 (47%) included an active control condition, all of which were of the similar-form type. The majority of the studies (10/19, 53%) used only a passive control. Of the 9 studies that found results supporting the efficacy of cognitive training, 5 were for far transfer effects. Regarding the limitations, due to practical considerations, the search was limited to one source (PubMed) and to search results only. The search terms may have been too restrictive. Recruitment methods were not analyzed, although this aspect of research may play a critical role in systematically forming groups with different expectations for improvement. The population was limited to healthy older adults, while evaluation studies include other populations and cognitive training types, which may exhibit better or worse placebo control than the studies examined in this review. Conclusions: Poor placebo control was present in 47% (9/19) of the reviewed studies; however, the studies still published results supporting the effectiveness of cognitive training programs. Of these positive results, 5 were for far transfer effects, which form the basis for broad claims by cognitive training game makers about the scientific validity of their product. For a minimum level of placebo control, future evaluation studies should use a similar-form active control and administer a questionnaire to participants at the end of the training period about their own perceptions of improvement. Researchers are encouraged to think of more methods for the valid measure of expectations at other time points in the training. UR - http://games.jmir.org/2020/2/e14030/ UR - http://dx.doi.org/10.2196/14030 UR - http://www.ncbi.nlm.nih.gov/pubmed/32589159 ID - info:doi/10.2196/14030 ER - TY - JOUR AU - Templeton, Michael John AU - Poellabauer, Christian AU - Schneider, Sandra PY - 2020/6/24 TI - Enhancement of Neurocognitive Assessments Using Smartphone Capabilities: Systematic Review JO - JMIR Mhealth Uhealth SP - e15517 VL - 8 IS - 6 KW - mobile phone KW - mobile health KW - neurocognitive tests KW - neurodegenerative disease KW - neurocognitive disorders N2 - Background: Comprehensive exams such as the Dean-Woodcock Neuropsychological Assessment System, the Global Deterioration Scale, and the Boston Diagnostic Aphasia Examination are the gold standard for doctors and clinicians in the preliminary assessment and monitoring of neurocognitive function in conditions such as neurodegenerative diseases and acquired brain injuries (ABIs). In recent years, there has been an increased focus on implementing these exams on mobile devices to benefit from their configurable built-in sensors, in addition to scoring, interpretation, and storage capabilities. As smartphones become more accepted in health care among both users and clinicians, the ability to use device information (eg, device position, screen interactions, and app usage) for subject monitoring also increases. Sensor-based assessments (eg, functional gait using a mobile device?s accelerometer and/or gyroscope or collection of speech samples using recordings from the device?s microphone) include the potential for enhanced information for diagnoses of neurological conditions; mapping the development of these conditions over time; and monitoring efficient, evidence-based rehabilitation programs. Objective: This paper provides an overview of neurocognitive conditions and relevant functions of interest, analysis of recent results using smartphone and/or tablet built-in sensor information for the assessment of these different neurocognitive conditions, and how human-device interactions and the assessment and monitoring of these neurocognitive functions can be enhanced for both the patient and health care provider. Methods: This survey presents a review of current mobile technological capabilities to enhance the assessment of various neurocognitive conditions, including both neurodegenerative diseases and ABIs. It explores how device features can be configured for assessments as well as the enhanced capability and data monitoring that will arise due to the addition of these features. It also recognizes the challenges that will be apparent with the transfer of these current assessments to mobile devices. Results: Built-in sensor information on mobile devices is found to provide information that can enhance neurocognitive assessment and monitoring across all functional categories. Configurations of positional sensors (eg, accelerometer, gyroscope, and GPS), media sensors (eg, microphone and camera), inherent sensors (eg, device timer), and participatory user-device interactions (eg, screen interactions, metadata input, app usage, and device lock and unlock) are all helpful for assessing these functions for the purposes of training, monitoring, diagnosis, or rehabilitation. Conclusions: This survey discusses some of the many opportunities and challenges of implementing configured built-in sensors on mobile devices to enhance assessments and monitoring of neurocognitive functions as well as disease progression across neurodegenerative and acquired neurological conditions. UR - http://mhealth.jmir.org/2020/6/e15517/ UR - http://dx.doi.org/10.2196/15517 UR - http://www.ncbi.nlm.nih.gov/pubmed/32442150 ID - info:doi/10.2196/15517 ER - TY - JOUR AU - Bonnechère, Bruno AU - Bier, Jean-Christophe AU - Van Hove, Olivier AU - Sheldon, Sally AU - Samadoulougou, Sékou AU - Kirakoya-Samadoulougou, Fati AU - Klass, Malgorzata PY - 2020/6/12 TI - Age-Associated Capacity to Progress When Playing Cognitive Mobile Games: Ecological Retrospective Observational Study JO - JMIR Serious Games SP - e17121 VL - 8 IS - 2 KW - cognitive performance KW - brain training KW - cognitive monitoring KW - mobile games KW - aging KW - serious games N2 - Background: The decline of cognitive function is an important issue related to aging. Over the last few years, numerous mobile apps have been developed to challenge the brain with cognitive exercises; however, little is currently known about how age influences capacity for performance improvement when playing cognitive mobile games. Objective: The objective of this study was to analyze the score data of cognitive mobile games over a period of 100 gaming sessions to determine age-related learning ability for new cognitive tasks by measuring the level of score improvement achieved by participants of different ages. Methods: Scores from 9000 individuals of different ages for 7 cognitive mobile games over 100 gaming sessions were analyzed. Scores from the first session were compared between age groups using one-way analysis of variance. Mixed models were subsequently used to investigate the progression of scores over 100 sessions. Results: Statistically significant differences were found between age groups for the initial scores of 6 of the 7 games (linear trend, P<.001). Cognitive mobile game scores increased for all participants (P<.001) suggesting that all participants were able to improve their performance. The rate of improvement was, however, strongly influenced by the age of the participant with slower progression for older participants (P<.001). Conclusions: This study provides evidence to support two interesting insights?cognitive mobile game scores appear to be sensitive to the changes in cognitive ability that occur with advancing age; therefore, these games could be a convenient way to monitor cognitive function over long-term follow-up, and users who train with the cognitive mobile games improve regardless of age. UR - http://games.jmir.org/2020/2/e17121/ UR - http://dx.doi.org/10.2196/17121 UR - http://www.ncbi.nlm.nih.gov/pubmed/32530432 ID - info:doi/10.2196/17121 ER - TY - JOUR AU - Hafiz, Pegah AU - Bardram, Eyvind Jakob PY - 2020/6/1 TI - The Ubiquitous Cognitive Assessment Tool for Smartwatches: Design, Implementation, and Evaluation Study JO - JMIR Mhealth Uhealth SP - e17506 VL - 8 IS - 6 KW - cognition KW - memory KW - response time KW - attention KW - Stroop task KW - wearable devices KW - mobile phone N2 - Background: Cognitive functioning plays a significant role in individuals? mental health, since fluctuations in memory, attention, and executive functions influence their daily task performance. Existing digital cognitive assessment tools cannot be administered in the wild and their test sets are not brief enough to capture frequent fluctuations throughout the day. The ubiquitous availability of mobile and wearable devices may allow their incorporation into a suitable platform for real-world cognitive assessment. Objective: The aims of this study were threefold: (1) to evaluate a smartwatch-based tool for the assessment of cognitive performance, (2) to investigate the usability of this tool, and (3) to understand participants? perceptions regarding the application of a smartwatch in cognitive assessment. Methods: We built the Ubiquitous Cognitive Assessment Tool (UbiCAT) on a smartwatch-based platform. UbiCAT implements three cognitive tests?an Arrow test, a Letter test, and a Color test?adapted from the two-choice reaction-time, N-back, and Stroop tests, respectively. These tests were designed together with domain experts. We evaluated the UbiCAT test measures against standard computer-based tests with 21 healthy adults by applying statistical analyses significant at the 95% level. Usability testing for each UbiCAT app was performed using the Mobile App Rating Scale (MARS) questionnaire. The NASA-TLX (Task Load Index) questionnaire was used to measure cognitive workload during the N-back test. Participants rated perceived discomfort of wearing a smartwatch during the tests using a 7-point Likert scale. Upon finishing the experiment, an interview was conducted with each participant. The interviews were transcribed and semantic analysis was performed to group the findings. Results: Pearson correlation analysis between the total correct responses obtained from the UbiCAT and the computer-based tests revealed a significant strong correlation (r=.78, P<.001). One-way analysis of variance (ANOVA) showed a significant effect of the N-back difficulty level on the participants' performance measures. The study also demonstrated usability ratings above 4 out of 5 in terms of aesthetics, functionality, and information. Low discomfort (<3 out of 7) was reported by our participants after using the UbiCAT. Seven themes were extracted from the transcripts of the interviews conducted with our participants. Conclusions: UbiCAT is a smartwatch-based tool that assesses three key cognitive domains. Usability ratings showed that participants were engaged with the UbiCAT tests and did not feel any discomfort. The majority of the participants were interested in using the UbiCAT, although some preferred computer-based tests, which might be due to the widespread use of personal computers. The UbiCAT can be administered in the wild with mentally ill patients to assess their attention, working memory, and executive function. UR - https://mhealth.jmir.org/2020/6/e17506 UR - http://dx.doi.org/10.2196/17506 UR - http://www.ncbi.nlm.nih.gov/pubmed/32478664 ID - info:doi/10.2196/17506 ER - TY - JOUR AU - Tacchino, Andrea AU - Veldkamp, Renee AU - Coninx, Karin AU - Brulmans, Jens AU - Palmaers, Steven AU - Hämäläinen, Päivi AU - D'hooge, Mieke AU - Vanzeir, Ellen AU - Kalron, Alon AU - Brichetto, Giampaolo AU - Feys, Peter AU - Baert, Ilse PY - 2020/4/16 TI - Design, Development, and Testing of an App for Dual-Task Assessment and Training Regarding Cognitive-Motor Interference (CMI-APP) in People With Multiple Sclerosis: Multicenter Pilot Study JO - JMIR Mhealth Uhealth SP - e15344 VL - 8 IS - 4 KW - tablet KW - mobile device KW - cognitive rehabilitation KW - cognitive impairment KW - dual-task training KW - cognitive-motor interference KW - dual-task cost KW - adherence KW - multiple sclerosis KW - walking N2 - Background: Dual tasking constitutes a large portion of most activities of daily living; in real-lifesituations, people need to not only maintain balance and mobility skills, but also perform other cognitive or motor tasks at the same time. Interest toward dual-task training (DTT) is increasing as traditional interventions may not prepare patients to adequately face the challenges of most activities of daily living. These usually involve simultaneous cognitive and motor tasks, and they often show a decline in performance. Cognitive-motor interference (CMI) has been investigated in different neurological populations, but limited evidence is present for people with multiple sclerosis (MS). The use of computerized tools is mandatory to allow the application of more standardized assessment and rehabilitation intervention protocols and easier implementation of multicenter and multilanguage studies. Objective: To describe the design and development of CMI-APP, an adaptive and interactive technology tablet-based app, and to present the preliminary results of a multicenter pilot study involving people with MS performed in several European centers for evaluating the feasibility of and adherence to a rehabilitation program based on CMI-APP. Methods: CMI-APP includes user-friendly interfaces for personal data input and management, assessment of CMI, and DTT. A dedicated team developed CMI-APP for Android tablets above API level 14 (version 4.0), using C# as the programming language and Unity and Visual Studio as development tools. Three cognitive assessment tests for working memory, information processing speed, and sustained attention and four motor assessment tests for walking at different difficulty levels were implemented. Dual cognitive-motor tasks were performed by combining single cognitive and motor tasks. CMI-APP implements exercises for DTT involving the following 12 cognitive functions: sustained attention, text comprehension, verbal fluency, auditory discrimination, visual discrimination, working memory, information processing speed, auditory memory, visual memory, verbal analog reasoning, visual analog reasoning, and visual spatial planning, which can be performed during walking or stepping on the spot. Fifteen people with MS (mean age 52.6, SD 8.6 years; mean disease duration 9.4, SD 8.4 years; mean Expanded Disability Status Scale score 3.6, SD 1.1) underwent DTT (20 sessions). Adherence to the rehabilitation program was evaluated according to the percentage of performed sessions, perceived exertion during the training (Borg 15-point Ratings of Perceived Exertion [RPE] Scale), and subjective experience of the training (Intrinsic Motivation Inventory [IMI]). Results: The adherence rate was 91%. DTT was perceived as ?somewhat difficult? (mean RPE Scale score 12.6, SD 1.9). IMI revealed that participants enjoyed the training and felt that it was valuable and, to some extent, important, without feelings of pressure. They felt competent, although they did not always feel they could choose the exercises, probably because the therapist chose the exercises and many exercises had few difficulty levels. Conclusions: CMI-APP is safe, highly usable, motivating, and well accepted for DTT by people with MS. The findings are fundamental for the preparation of future large-sample studies examining CMI and the effectiveness of DTT interventions with CMI-APP in people with MS. UR - http://mhealth.jmir.org/2020/4/e15344/ UR - http://dx.doi.org/10.2196/15344 UR - http://www.ncbi.nlm.nih.gov/pubmed/32343258 ID - info:doi/10.2196/15344 ER - TY - JOUR AU - Khalili-Mahani, Najmeh AU - Assadi, Atousa AU - Li, Kate AU - Mirgholami, Mahsa AU - Rivard, Marie-Eve AU - Benali, Habib AU - Sawchuk, Kim AU - De Schutter, Bob PY - 2020/3/26 TI - Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study JO - JMIR Ment Health SP - e12388 VL - 7 IS - 3 KW - silver gaming KW - serious games KW - stress KW - cognitive training KW - brain training games KW - exercise games KW - ICT N2 - Background: The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants? motivations to adopt these technologies. Objective: This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework. Methods: A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S1-BrainGame, S2-CarRace, and S3-Exergame). Each session included an identical sequence of activities (t1-Baseline, t2-Picture encode, t3-Play, t4-Stroop test, t5-Play, and t6-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session×activity or session×activity×cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session×group effects on the scores of the postgame appraisal questionnaire. Results: Session×activity effects were significant on all ambulatory measures (?210>20; P<.001) other than cortisol (P=.37). Compared with S1 and S2, S3 was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S1, we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S3. The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense (?21>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group. Conclusions: Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed. UR - http://mental.jmir.org/2020/3/e12388/ UR - http://dx.doi.org/10.2196/12388 UR - http://www.ncbi.nlm.nih.gov/pubmed/32213474 ID - info:doi/10.2196/12388 ER - TY - JOUR AU - Bang, Changbae AU - Nam, Yelin AU - Ko, Jae Eun AU - Lee, Wooseong AU - Kim, Byungjae AU - Choi, Yejin AU - Park, Rang Yu PY - 2019/10/24 TI - A Serious Game?Derived Index for Detecting Children With Heterogeneous Developmental Disabilities: Randomized Controlled Trial JO - JMIR Serious Games SP - e14924 VL - 7 IS - 4 KW - serious game KW - developmental disabilities KW - mobile game KW - cognitive screening tool KW - machine learning N2 - Background: Developmental disabilities are a set of heterogeneous delays or difficulties in one or more areas of neuropsychological development. Considering that childhood is an essential stage of brain development and developmental delays lead to personal or social burdens, the early detection of childhood developmental disabilities is important. However, early screening for developmental disabilities has been a challenge because of the fear of positive results, expensive tests, differences in diagnosis depending on examiners? abilities, and difficulty in diagnosis arising from the need for long-term follow-up observation. Objective: This study aimed to assess the feasibility of using a serious game?derived index to identify heterogeneous developmental disabilities. This study also examines the correlation between the game-derived index and existing neuropsychological test results. Methods: The randomized controlled trial involved 48 children with either normal development or developmental disabilities. In this clinical trial, we used 19 features (6 from the Korean-Wechsler Preschool and Primary Scale of Intelligence, 8 from the Psychoeducational Profile Revised, 2 from the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, and 3 from the Pediatric Evaluation of Disability Inventory) from neuropsychological tests and 9 (7 game scores, path accuracy, and completion rate) from the serious game, DoBrain. The following analysis was conducted based on participants? baseline information and neuropsychological test and game-derived index data for one week: (1) we compared the baseline information between the normal development and developmental disabilities groups; (2) then we measured the correlation between the game-derived index and the neuropsychological test scores for each group; and (3) we built a classifier based on the game-derived index with a Gaussian process method and then compared the area under the curve (AUC) with a model based on neuropsychological test results. Results: A total of 16 children (normal development=9; developmental disabilities=7) were analyzed after selection. Their developmental abilities were assessed before they started to play the serious games, and statistically significant differences were found in both groups. Specifically, the normal development group was more developed than the developmental disabilities group in terms of social function, gross motor function, full-scale IQ, and visual motor imitation, in that order. Similarly, the normal development group obtained a higher score on the game-derived index than the developmental disabilities group. In the correlation analysis between the game-derived index and the neuropsychological tests, the normal development group showed greater correlation with more variables than the developmental disabilities group. The game-derived index?based model had an AUC=0.9, a similar detection value as the neuropsychological test?based model?s AUC=0.86. Conclusions: A game-derived index based on serious games can detect children with heterogenous developmental disabilities. This suggests that serious games can be used as a potential screening tool for developmental disabilities. Trial Registration: Clinical Research Information Service KCT0003247; https://cris.nih.go.kr/cris/en/search/search_result_st01 .jsp?seq=12365 UR - http://games.jmir.org/2019/4/e14924/ UR - http://dx.doi.org/10.2196/14924 UR - http://www.ncbi.nlm.nih.gov/pubmed/31651408 ID - info:doi/10.2196/14924 ER - TY - JOUR AU - Ravindran, Vijay AU - Osgood, Monica AU - Sazawal, Vibha AU - Solorzano, Rita AU - Turnacioglu, Sinan PY - 2019/9/30 TI - Virtual Reality Support for Joint Attention Using the Floreo Joint Attention Module: Usability and Feasibility Pilot Study JO - JMIR Pediatr Parent SP - e14429 VL - 2 IS - 2 KW - autism spectrum disorder KW - interpersonal skills KW - virtual reality, instructional N2 - Background: Advances in virtual reality (VR) technology offer new opportunities to design supports for the core behaviors associated with autism spectrum disorder (ASD) that promote progress toward optimal outcomes. Floreo has developed a novel mobile VR platform that pairs a user receiving instruction on target skills with an adult monitor. Objective: The primary objective of this pilot study was to explore the feasibility of using Floreo?s Joint Attention Module in school-aged children with autism in a special education setting. A secondary objective was to explore a novel joint attention measure designed for use with school-aged children and to observe whether there was a suggestion of change in joint attention skills from preintervention to postintervention. Methods: A total of 12 participants (age range: 9 to 16 years) received training with the Joint Attention Module for 14 sessions over 5 weeks. Results: No serious side effects were reported, and no participants dropped out of the study because of undesirable side effects. On the basis of monitor data, 95.4% (126/132) of the time participants tolerated the headset, 95.4% (126/132) of the time participants seemed to enjoy using Floreo?s platform, and 95.5% (128/134) of the time the VR experience was reported as valuable. In addition, scoring of the joint attention measure suggested a positive change in participant skills related to the total number of interactions, use of eye contact, and initiation of interactions. Conclusions: The study results suggest that Floreo?s Joint Attention Module is safe and well tolerated by students with ASD, and preliminary data also suggest that its use is related to improvements in fundamental joint attention skills. UR - http://pediatrics.jmir.org/2019/2/e14429/ UR - http://dx.doi.org/10.2196/14429 UR - http://www.ncbi.nlm.nih.gov/pubmed/31573921 ID - info:doi/10.2196/14429 ER - TY - JOUR AU - Chua, Loon Sean Ing AU - Tan, Chuan Ngiap AU - Wong, Teen Wei AU - Allen Jr, Carson John AU - Quah, Min Joanne Hui AU - Malhotra, Rahul AU - Østbye, Truls PY - 2019/08/01 TI - Virtual Reality for Screening of Cognitive Function in Older Persons: Comparative Study JO - J Med Internet Res SP - e14821 VL - 21 IS - 8 KW - virtual reality KW - feasibility studies KW - mental status and dementia tests KW - technology KW - video games KW - dementia KW - cognitive dysfunction N2 - Background: The prevalence of dementia, which presents as cognitive decline in one or more cognitive domains affecting function, is increasing worldwide. Traditional cognitive screening tools for dementia have their limitations, with emphasis on memory and, to a lesser extent, on the cognitive domain of executive function. The use of virtual reality (VR) in screening for cognitive function in older persons is promising, but evidence for its use is sparse. Objective: The primary aim was to examine the feasibility and acceptability of using VR to screen for cognitive impairment in older persons in a primary care setting. The secondary aim was to assess the module?s ability to discriminate between cognitively intact and cognitively impaired participants. Methods: A comparative study was conducted at a public primary care clinic in Singapore, where persons aged 65-85 years were recruited based on a cut-off score of 26 on the Montreal Cognitive Assessment (MoCA) scale. They participated in a VR module for assessment of their learning and memory, perceptual-motor function, and executive function. Each participant was evaluated by the total performance score (range: 0-700) upon completion of the study. A questionnaire was also administered to assess their perception of and attitude toward VR. Results: A total of 37 participants in Group 1 (cognitively intact; MoCA score?26) and 23 participants in Group 2 (cognitively impaired; MoCA score<26) were assessed. The mean time to completion of the study was 19.1 (SD 3.6) minutes in Group 1 and 20.4 (3.4) minutes in Group 2. Mean feedback scores ranged from 3.80 to 4.48 (max=5) in favor of VR. The total performance score in Group 1 (552.0, SD 57.2) was higher than that in Group 2 (476.1, SD 61.9; P<.001) and exhibited a moderate positive correlation with scores from other cognitive screening tools: Abbreviated Mental Test (0.312), Mini-Mental State Examination (0.373), and MoCA (0.427). A receiver operating characteristic curve analysis for the relationship between the total performance score and the presence of cognitive impairment showed an area under curve of 0.821 (95% CI 0.714-0.928). Conclusions: We demonstrated the feasibility of using a VR-based screening tool for cognitive function in older persons in primary care, who were largely in favor of this tool. UR - https://www.jmir.org/2019/8/e14821/ UR - http://dx.doi.org/10.2196/14821 UR - http://www.ncbi.nlm.nih.gov/pubmed/31373274 ID - info:doi/10.2196/14821 ER - TY - JOUR AU - Chesham, Alvin AU - Gerber, Moreno Stephan AU - Schütz, Narayan AU - Saner, Hugo AU - Gutbrod, Klemens AU - Müri, Martin René AU - Nef, Tobias AU - Urwyler, Prabitha PY - 2019/05/09 TI - Search and Match Task: Development of a Taskified Match-3 Puzzle Game to Assess and Practice Visual Search JO - JMIR Serious Games SP - e13620 VL - 7 IS - 2 KW - match-three puzzle games KW - video games KW - task difficulty KW - attention KW - pattern recognition, visual KW - aging KW - neuropsychological tests N2 - Background: Visual search declines with aging, dementia, and brain injury and is linked to limitations in everyday activities. Recent studies suggest that visual search can be improved with practice using computerized visual search tasks and puzzle video games. For practical use, it is important that visual search ability can be assessed and practiced in a controlled and adaptive way. However, commercial puzzle video games make it hard to control task difficulty, and there are little means to collect performance data. Objective: The aim of this study was to develop and initially validate the search and match task (SMT) that combines an enjoyable tile-matching match-3 puzzle video game with features of the visual search paradigm (taskified game). The SMT was designed as a single-target visual search task that allows control over task difficulty variables and collection of performance data. Methods: The SMT is played on a grid-based (width × height) puzzle board, filled with different types of colored polygons. A wide range of difficulty levels was generated by combinations of 3 task variables over a range from 4 to 8 including height and width of the puzzle board (set size) and the numbers of tile types (distractor heterogeneity). For each difficulty level, large numbers of playable trials were pregenerated using Python. Each trial consists of 4 consecutive puzzle boards, where the goal of the task is to find a target tile configuration (search) on the puzzle board and swap 2 adjacent tiles to create a line of 3 identical tiles (match). For each puzzle board, there is exactly 1 possible match (single target search). In a user study with 28 young adults (aged 18 to 31 years), 13 older (aged 64 to 79 years) and 11 oldest (aged 86 to 98 years) adults played the long (young and older adults) or short version (oldest adults) of the difficulty levels of the SMT. Participants rated their perception and the usability of the task and completed neuropsychological tests that measure cognitive domains engaged by the puzzle game. Results: Results from the user study indicate that the target search time is associated with set size, distractor heterogeneity, and age. Results further indicate that search performance is associated with general cognitive ability, selective and divided attention, visual search, and visuospatial and pattern recognition ability. Conclusions: Overall, this study shows that an everyday puzzle game?based task can be experimentally controlled, is enjoyable and user-friendly, and permits data collection to assess visual search and cognitive abilities. Further research is needed to evaluate the potential of the SMT game to assess and practice visual search ability in an enjoyable and adaptive way. A PsychoPy version of the SMT is freely available for researchers. UR - http://games.jmir.org/2019/2/e13620/ UR - http://dx.doi.org/10.2196/13620 UR - http://www.ncbi.nlm.nih.gov/pubmed/31094325 ID - info:doi/10.2196/13620 ER - TY - JOUR AU - van de Weijer, CF Sjors AU - Kuijf, L. Mark AU - de Vries, M. Nienke AU - Bloem, R. Bastiaan AU - Duits, A. Annelien PY - 2019/05/07 TI - Do-It-Yourself Gamified Cognitive Training: Viewpoint JO - JMIR Serious Games SP - e12130 VL - 7 IS - 2 KW - cognitive remediation KW - Parkinson disease KW - video games UR - http://games.jmir.org/2019/2/e12130/ UR - http://dx.doi.org/10.2196/12130 UR - http://www.ncbi.nlm.nih.gov/pubmed/31066713 ID - info:doi/10.2196/12130 ER - TY - JOUR AU - Mandryk, Lee Regan AU - Birk, Valentin Max PY - 2019/04/23 TI - The Potential of Game-Based Digital Biomarkers for Modeling Mental Health JO - JMIR Ment Health SP - e13485 VL - 6 IS - 4 KW - digital games KW - digital phenotyping KW - mental health KW - computational modeling KW - big data KW - video games KW - biomarkers N2 - Background: Assessment for mental health is performed by experts using interview techniques, questionnaires, and test batteries and following standardized manuals; however, there would be myriad benefits if behavioral correlates could predict mental health and be used for population screening or prevalence estimations. A variety of digital sources of data (eg, online search data and social media posts) have been previously proposed as candidates for digital biomarkers in the context of mental health. Playing games on computers, gaming consoles, or mobile devices (ie, digital gaming) has become a leading leisure activity of choice and yields rich data from a variety of sources. Objective: In this paper, we argue that game-based data from commercial off-the-shelf games have the potential to be used as a digital biomarker to assess and model mental health and health decline. Although there is great potential in games developed specifically for mental health assessment (eg, Sea Hero Quest), we focus on data gathered ?in-the-wild? from playing commercial off-the-shelf games designed primarily for entertainment. Methods: We argue that the activity traces left behind by natural interactions with digital games can be modeled using computational approaches for big data. To support our argument, we present an investigation of existing data sources, a categorization of observable traits from game data, and examples of potentially useful game-based digital biomarkers derived from activity traces. Results: Our investigation reveals different types of data that are generated from play and the sources from which these data can be accessed. Based on these insights, we describe five categories of digital biomarkers that can be derived from game-based data, including behavior, cognitive performance, motor performance, social behavior, and affect. For each type of biomarker, we describe the data type, the game-based sources from which it can be derived, its importance for mental health modeling, and any existing statistical associations with mental health that have been demonstrated in prior work. We end with a discussion on the limitations and potential of data from commercial off-the-shelf games for use as a digital biomarker of mental health. Conclusions: When people play commercial digital games, they produce significant volumes of high-resolution data that are not only related to play frequency, but also include performance data reflecting low-level cognitive and motor processing; text-based data that are indicative of the affective state; social data that reveal networks of relationships; content choice data that imply preferred genres; and contextual data that divulge where, when, and with whom the players are playing. These data provide a source for digital biomarkers that may indicate mental health. Produced by engaged human behavior, game data have the potential to be leveraged for population screening or prevalence estimations, leading to at-scale, nonintrusive assessment of mental health. UR - http://mental.jmir.org/2019/4/e13485/ UR - http://dx.doi.org/10.2196/13485 UR - http://www.ncbi.nlm.nih.gov/pubmed/31012857 ID - info:doi/10.2196/13485 ER - TY - JOUR AU - Fielenbach, Sandra AU - Donkers, CL Franc AU - Spreen, Marinus AU - Bogaerts, Stefan PY - 2018/12/11 TI - Effects of a Theta/Sensorimotor Rhythm Neurofeedback Training Protocol on Measures of Impulsivity, Drug Craving, and Substance Abuse in Forensic Psychiatric Patients With Substance Abuse: Randomized Controlled Trial JO - JMIR Ment Health SP - e10845 VL - 5 IS - 4 KW - neurofeedback KW - impulsivity KW - substance use disorder KW - offenders KW - drug craving N2 - Background: Forensic psychiatric patients are often diagnosed with psychiatric disorders characterized by high levels of impulsivity as well as comorbid substance use disorders (SUD). The combination of psychiatric disorders and SUD increases the risk of future violence. Chronic substance abuse can lead to a structural state of disinhibition, resulting in more drug taking and eventually loss of control over drug intake. When treating SUD, it is crucial to address high levels of impulsivity and lack of inhibitory control. Objective: This study set out to investigate the effects of a theta/sensorimotor rhythm (SMR) neurofeedback training protocol on levels of impulsivity, levels of drug craving, and actual drug intake in a population of forensic psychiatric patients with a diagnosis of SUD. Methods: A total of 21 participants received 20 sessions of theta/SMR neurofeedback training in combination with treatment-as-usual (TAU). Results of the intervention were compared with results from 21 participants who received TAU only. Results: SMR magnitude showed a significant (P=.02) increase post training for patients in the neurofeedback training group, whereas theta magnitude did not change (P=.71). Levels of drug craving as well as scores on the motor subscale of the Barratt Impulsivity Scale-11 decreased equally for patients in the neurofeedback training group and the TAU group. Other measures of impulsivity as well as drug intake did not change posttreatment (P>.05). Therefore, neurofeedback+TAU was not more effective than TAU only. Conclusions: This study demonstrated evidence that forensic psychiatric patients are able to increase SMR magnitude over the course of neurofeedback training. However, at the group level, the increase in SMR activity was not related to any of the included impulsivity or drug craving measures. Further research should focus on which patients will be able to benefit from neurofeedback training at an early stage of the employed training sessions. Trial Registration: Dutch National Trial Register: NTR5386; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5386 (Archived by WebCite at http://www.webcitation.org/6nXLQuoLl). UR - http://mental.jmir.org/2018/4/e10845/ UR - http://dx.doi.org/10.2196/10845 UR - http://www.ncbi.nlm.nih.gov/pubmed/30538087 ID - info:doi/10.2196/10845 ER -