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Background: The field of serious games for people with dementia (PwD) is mostly driven by game-design principals typically applied to games created by and for younger individuals. Little has been done developing serious games to help PwD maintain cognition and to support functionality. Objectives: We aimed to create a theory-based serious game for PwD, with input from a multi-disciplinary team familiar with aging, dementia, and gaming theory, as well as direct input from end users (the iterative process). Targeting enhanced self-efficacy in daily activities, the goal was to generate a game that is acceptable, accessible and engaging for PwD. Methods: The theory-driven game development was based on the following learning theories: learning in context, errorless learning, building on capacities, and acknowledging biological changes—all with the aim to boost self-efficacy. The iterative participatory process was used for game screen development with input of 34 PwD and 14 healthy community dwelling older adults, aged over 65 years. Development of game screens was informed by the bio-psychological aging related disabilities (ie, motor, visual, and perception) as well as remaining neuropsychological capacities (ie, implicit memory) of PwD. At the conclusion of the iterative development process, a prototype game with 39 screens was used for a pilot study with 24 PwD and 14 healthy community dwelling older adults. The game was played twice weekly for 10 weeks. Results: Quantitative analysis showed that the average speed of successful screen completion was significantly longer for PwD compared with healthy older adults. Both PwD and controls showed an equivalent linear increase in the speed for task completion with practice by the third session (P<.02). Most important, the rate of improved processing speed with practice was not statistically different between PwD and controls. This may imply that some form of learning occurred for PwD at a nonsignificantly different rate than for controls. Qualitative results indicate that PwD found the game engaging and fun. Healthy older adults found the game too easy. Increase in self-reported self-efficacy was documented with PwD only. Conclusions: Our study demonstrated that PwD’s speed improved with practice at the same rate as healthy older adults. This implies that when tasks are designed to match PwD’s abilities, learning ensues. In addition, this pilot study of a serious game, http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al designed for PwD, was accessible, acceptable, and enjoyable for end users. Games designed based on learning theories and input of end users and a multi-disciplinary team familiar with dementia and aging may have the potential of maintaining capacity and improving functionality of PwD. A larger longer study is needed to confirm our findings and evaluate the use of these games in assessing cognitive status and functionality. (JMIR Serious Games 2017;5(3):e16) doi: 10.2196/games.6514 KEYWORDS serious games; dementia; functionality; learning in context; speed of processing acceptable, accessible, and engaging for people with moderate Introduction and advanced dementia based on DSM-5 criteria . Our approach aims to bridge the transfer gap between “game Background designers” practice and knowledge, and neuro-psychosocial Aging in place is a desirable social and economic goal in our scientific knowledge of aging and dementia. In addition, our rapidly aging global society . Maintaining cognitive game design considers theories of learning and the impact of functionality while aging is important to achieve this goal. the “built environment” as compensatory constructs in learning. Cognitive stimulation games have been used and studied as a The overall aim of our gaming approach was to facilitate people method for maintaining healthy aging brains . The use of with moderate and advanced dementia to arrive at an increased computer games for cognitive stimulation and prevention of sense of self efficacy, which, according to recent research in cognitive decline in healthy older adults is a fast growing area neuropsychology, directly contributes to psychological, of research, sometimes referred to as “neuro-games” [3,4]. cognitive, and physical health, and thus serves as a key enabler in exercising and prolonging functionality . A budding field of research is the use of computer games for people with dementia [5-9]. With the global rise of people with Theoretical Framework for Game Screen Development dementia (PwD)  and the huge economic cost of their care, The game was designed with input from a multi-disciplinary there is an increasing desire to maintain PwD at home and not team familiar with aging and dementia and gaming theory as institutions, for as long as possible . One of the key factors well as direct input from end users (the iterative process) . in keeping PwD in their homes, as opposed to nursing homes, Each game screen was developed with the input of 34 PwD, 14 is related to their ability to maintain functionality of simple community dwelling healthy older adults (ages 65-90), an daily activities, despite their cognitive decline. Indeed, when occupational therapist, gerontologist, an MD PhD specialist in families opt for institutionalization, it is usually on the basis of technology for health, a computer engineer, and a PhD cognitive a loss of the PwD’s ability to eat independently, as well as psychologist specializing in cognitive and sensory aging. The perform activities related to personal hygiene, such as grooming complete game includes 39 screens. and toileting . The development of modalities to maintain aging in place for PwD could include computer-based games The theoretical models that form the underpinnings of our game specifically designed to accommodate functional limitations are based on a multidisciplinary model outlined in Figure 1. and build on their remaining capacities [13-15]. The key frameworks involved (1) acknowledging the physiological changes associated with aging, (2) dementia’s Serious games offer the promise of low cost interventions in neuropsychosocial induced changes, (3) applying learning the care of PwD . In addition, they require minimal theories that focus on “errorless learning,” learning in context, professional supervision (ie, by an occupational therapist) and and building on remaining capacity (implicit memory), (4) can be played with the assistance of formal or informal external compensatory mechanisms, the “built environment” caregivers. The American Society of Occupational Therapy has theoretical constructs including design, spatial orientation frames developed computer applications for assisting individuals with all brought to bear on, and (5) improving “self-perceived” autism and dementia . However, very few of the efforts self-efficacy. In later sections, each of these topics is briefly cited have used theory-driven learning theories in the game discussed first, and then the person-centered technological development or reported on the iterative human centered design approach to the game development is presented, followed by process of game development with the end users involvement. the description of the iterative process of developing the game This paper aimed to contribute to methodology of game design screens with direct input from the end users (people with for PwD. Our goal was to create a serious game that is moderate and advanced dementia). http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al Figure 1. Multidisciplinary constructs and theories in designing serious games for people with dementia. alongside empirical evidence, support the notion that Enhancing Self Efficacy in PwD self-efficacy plays a significant role in functionality (physical The most important construct influencing our gaming strategy and cognitive) of PwD . Therefore, our highest level is aimed to enhance the self-efficacy of PwD, an important objective in our design strategy was to utilize serious games to component of executive function . A central problem that create the conditions and opportunities to rebuild and maintain PwD experience is the gradual loss of cognitive and a sense of self-efficacy, along with acknowledging the physiological capabilities in their daily lives. Indeed, not just challenges on self-efficacy arising from normal and pathological intellectual tasks but simple activities of daily living (ADL) physiological changes, as well as the PwD’s family and become more challenging. However, the literature shows (and caregivers attitudes toward this slope of decline. experiential data in our daycare centers supports) there is a gap Cognitive Changes Related to Aging and Dementia between a PwD capacity to learn and participate in daily tasks and their performance, as measured by cognitive instruments One of the main characteristics of dementia relates to cognitive . Physiological decline impacts on the PwD’s speed of impairments, specifically, changes in memory encoding and completing tasks and movement. This is often exacerbated by memory retrieval. In addition, research supports that PwD also family and caregivers who significantly and unknowingly experience a reduction in executive functions—including contribute to PwD’s choice-limitations, as related to everyday planning, working memory, and selective attention . living activities. Caregivers tend to do things for the PwD that Executive functions are central to most cognitive processes: the the PwD could do on their own. This excessive involvement ability to focus on one aspect of the environment, to ignore and over protection by caregivers tends to reduce the PwD’s other unrelated information, and to switch between them when confidence in their own abilities and competence, leading to prompted. premature disengagement by the PwD. On the other hand, Selective attention has been marked as one of the major areas adapted environments encourage independence in activity and of cognitive impairments in dementia in general and Alzheimer help to maintain one's sense of perceived self-efficacy . dementia specifically , related to a reduction in the The concept of self-efficacy has grown out of a social efficiency of inhibition , above and beyond age-related psychology construct of human agency . However, its bases changes. This impairment may be linked with changes to frontal are very old and embedded in such perennial philosophical lobe regions . These cognitive changes should be considered underpinnings as theories of determinism, choice, intentionality, during game development. For example, reduced efficiency of free will, and causality. There are 2 distinct, yet overlapping, inhibitory processes may translate to difficulties PwD will have theories that underlie the self-efficacy: (1) Motivational theories, in ignoring the irrelevant information presented on the screen which conceptualize self-efficacy in motivational terms and (2) during the game, or the information embedded in an irrelevant Cognitive theories, which conceptualize self-efficacy in terms dimension of the stimuli presented (for a further discussion see of expectancies and perceptions of control. Both theories, Lustig et al ). Several aspects of our game were designed http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al to tackle this change. For example, our design strategy was to factor, plays a large role in the performance of older adults. avoid the clutter of the screen, thus reducing the amount of Specifically, framing tasks in an engaging, relevant context can information PwD will need to inhibit. Additional factors related improve performance . For example, research by Zimerman to the dementia process were taken into consideration, such as et al  suggests that cognitive tasks, targeted originally with attention span, inhibition of initiation or perseveration, eye hand college students in mind, appear unsnagging for older adults, coordination, semantic sequencing, orientation to time and place, and may impact negatively on their ability to perform at their sustained attention, agnosia, and judgment. full capacity. This is of specific importance, as PwD are much more focused on emotional and social issues than on abstract Sensory Motor Degradation Related to Aging and problems [52-54]. While we aimed to design the serious game Dementia application in a simple “clean” fashion to facilitate sensory and Research shows that PwD do not face only cognitive deficiencies cognitive processing, we were aware of the importance of related to executive function, but also other deficiencies in designing the game screens in a visually engaging way. We auditory [31,32], visual  and other sensory systems  postulate that when performing a task in an engaging context that contribute to cognitive deficits and difficulties in daily and by choosing stimuli that relate to PwD, the resulting increase functionality . For example, Ben-David and colleagues  in perceived self-efficacy would increase executive function have recently showed that reduced performance for PwD (as and thus improve learning and performance. These relevant compared to healthy older adults) on a task that gauges executive learning theories are discussed next. functions (the Stroop color-word test) can be partially mediated Learning Theories by dementia-related changes in color-vision . Auditory The majority of serious games, or games for health, have utilized changes can also lead to reduced cognitive performance, the important construct of entertainment as the major motivator especially in daily life activities such as communication . for game construction. In our efforts to create a game for PwD This dual sensory loss (visual and auditory) also has direct based on information and communication technology (ICT), implications on game administration. It reduces the we put emphasis on age appropriate entertainment venues as comprehension of spoken instructions and increases the effort defined by the end users themselves, and based on the concept and the amount of cognitive resources invested in speech that fun “learning in context” is a framework that induces processing, thus tapping into the already reduced pool of capacity building for all persons and especially those people resources [39-41]. Together, this cognitive and sensory with disabilities, both physical and cognitive . interaction is expressed as a part of the information degradation hypothesis . The theory postulates that as the perceptual Learning in Context system receives degraded information from the senses, it leads “Learning in context” has been defined in a variety of ways, to reduced cognitive performance. however, the basic supposition is that adult learning does not To address the above listed challenges, we considered take place in a vacuum, but within a sociocultural model, or as multisensory approaches to enhance PwD’s daily functionality, Hassin coined: learning “outside the mind” . In the such as using a variety of cues , both visual and auditory sociocultural models, learning is not something that happens, , as well as adjusting color and light setting. For example, or is just inside the head, but instead, it is shaped by the context, an estimate of 88% of the aging population have very high culture, and tools in the learning situation. Russian psychologist failure rates of discrimination in the red-green and blue-yellow LS Vygotsky was the pioneer of “learning in context”, a spectrum . These age-related physiological changes were sociocultural theory of learning, in contrast to psychological taken into consideration during the design relating to layout, and behavioral understandings of learning . His work is color and instruction delivery methods and demonstration. based on the concept that all human activities take place in a Special attention in the design of the game was paid to the cultural context with many levels of interactions, shared beliefs, linguistics/semantic challenges of PwD [46-48]. values, knowledge, skills, structured relationships, and symbol systems . These interactions and activities are mediated Finally, sensory-motor degradation was considered in the design through the use of tools, either technical (machines, computers, of the game environment. For example, during the iterative calculators) or psychological (language, counting, writing, and process, we learned from the comments of the end-users (34 strategies for learning), provided by the culture . These tools PwD and 14 healthy community dwelling older adults) and the ensure that linguistically created meanings have shared social observations of the testers that the placement of the tablet has meanings. His theories are relevant for our end-users, PwD, to be such as to allow visualization with natural light and no using technical and psychological tools to build upon the cultural screen glare from artificial light or sun. The tablet should be learning of PwD and practice skills. Thus “learning in context” placed in a comfortable position for the PwD, table height, and is a form of situated cognition —that is, learning is in a quiet environment with few distractions (again inherently social in nature. Following this approach, learning acknowledging cognitive changes). takes place in 5 sequential phases that allow scaffolding of Making the Game Engaging learning experiences (for a review, see ): (1) modeling, (2) approximating, (3) fading, (4) self-directed learning and, (5) Serious games for older adults should be engaging and fun and generalizing. further contribute to easing the personal burden of families and caregivers of PwD, as Robert and colleagues  among others, Learning in context has been linked with basic cognitive point out. The motivation to perform the task, an often-ignored constructs. Nisbett  postulated that implicit memory and http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al learning is one of the products of context learning, based on the learning. However, the deficit in explicit recall in PwD ontological assumption that interpretations of tasks are based eliminates this counterweight to error learning and renders a on a background of past experience and intellectual resources. PwD more vulnerable to its negative impact. In other words, Nisbett suggested that cognitive structures are constructed and PwD may remember the error, rather than learn the correct way developed in particular social circumstances. The significance to complete the task (ie, rather than learning that it was an error). of cognitive structures resides in their deployment in cognitive In the pertinent literature, there is an ongoing debate about the activity, such as problem-solving, transfer, and learning. benefits of erroneous [72,73] versus errorless learning on Given the cognitive, physical, and sensory challenges of aging memory creation. However, incorporating errorless learning people with dementia, we focused on the above cited literature scenarios within an active learning paradigm is a widely on learning theories to support our use of game screens, based accepted practice in rehabilitation and dementia treatment, as on contextual learning. Specifically, our game screens utilized it was found to maximize successful retrieval opportunities cultural memories and implicit memory, which are relatively [74,75]. Indeed, errorless learning is taken as an encoding more preserved for PwD. Implicit memory is one of the two method that results in superior retrospective memory compared main types of long-term memory which has recently been with erroneous learning. Neuropsychological studies indicate actively investigated as an important construct of cognitive that people with compromised explicit memory are adversely function and overlooked to the usually measured explicit affected by errors made during learning, and that implicit memory. Implicit memory includes procedural learning (eg, memory is sufficient to produce an errorless learning advantage skills and habits), priming, and classical conditioning. These for PwD . This is perhaps due to the fact that erroneous learning processes do not require conscious recollection of learning demands greater frontal/executive contributions . information, instead learning is expressed through performance It is important to highlight the fact that there is something lost or behavior . Indeed, implicit memory or specifically in an “errorless learning” approach. Psychological research in non-declarative memory is acquired and used without the need learning and memory identifies the opportunity to engage in (or ability) to verbally describe the process. For example, in difficult (hence error-prone) as very important in successful procedural memory when tying one’s shoe or riding a bike, learning, most specifically for retrieval of learnt information processes are learned and conducted without consciously (for a review, see ). However, working with PwD, we aim thinking about the actions. It is a type of indirect, unintentional at compensatory learning approaches in an attempt to improve manifestation of prior experience . function by recruiting relatively intact neurocognitive processes Explicit memory, on the other hand, refers to the conscious, to fill the role of impaired ones. Thus, it is assumed that new intentional recollection of factual information, previous learning is stronger and more durable if mistakes are eliminated experiences and concepts. While the literature documents well during training. Performance becomes automated through an age-related decline in explicit memory, numerous studies imitative learning and repetitive practice of perfect task have shown that implicit memory is spared in older adults execution . [65-67]. Even mild cognitively impaired older adults  and In summary, all other factors being equal, it appears that there people with Alzheimer disease  showed some form of is ample evidence to suggest that errorless learning procedures preserved implicit memory. This capacity can be utilized for are likely to improve retrieval in people with memory reinforcing scaffolding learning theories. The aim of our game impairments relative to erroneous methods . is to focus on practical activities in an entertaining, visually captivating and age appropriate presentation based on Cueing, Priming, and Semantic Considerations scaffolding learning theories . In addition to errorless learning in PwD, the procedure of cueing or priming and semantic structuring of instructions are important Errorless Learning elements in cognitive functioning especially in semantic Within the framework of situated cognition learning in context, dementia. Priming is an implicit memory effect in which errorless learning methodology and cueing offers an important exposure to one stimulus (ie, perceptual pattern) influences the path to present the task so that a PwD overcomes inhibitions response to another stimulus . The literature generally and limitations arising from low perceived self-efficacy. suggests that performance on implicit memory tasks, such as Errorless learning is “a teaching technique whereby people are repetition priming, deteriorates in AD. However, these prevented, as far as possible, from making mistakes while they AD-related impairments were not found for all priming tasks. are learning a new skill or acquiring new information” . Indeed, in a longitudinal study using different priming tasks, Major ways of achieving errorless learning are to use various only conceptual priming task (category- exemplar) was cues, to complete the task collaboratively with the PwD, adjust significantly impacted by AD neuropathology. Priming tasks the expectations of both client and designer, and make the task that involves perceptual processing (word-identification, as doable as possible to the PwD. This approach assumes that picture-naming, or word-stem completion tests) were not new learning is stronger and more durable if mistakes are necessarily associated with a decline in AD [82,83] eliminated during training. Performance becomes automated through imitative learning and repetitive practice of perfect task Consequently, we chose in our game the use of visual-spatial execution. Errorless learning is not suited for all populations. cueing or priming . Visual-spatial cueing represents a form With neurologically intact individuals, conscious or explicit of learning in context [85,86]. Using context to facilitate object memory of having made an error minimizes the impact of error recognition has gained importance in design, acknowledging http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 5 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al both the role context plays in object recognition in human visual technology for older adults, Rogers and Fink  explain that processing (Gestalt theory) and the striking algorithmic successful performance depends on demands imposed by the improvements that “visual context” has provided . Based environment relative to capabilities of the individual on the learning theories presented, we opted to use encouraging (environmental press). This model illustrates the range and type prompts when an error occurred. This method minimizes of variables that must be considered when developing erroneous learning. Thus, it increases the impact of self-efficacy, technology for older adults. As described in this introduction, building on the remaining capacities of a person to learn how our design methodology has taken many variables into to play the game successfully. consideration in order to develop a game best suited to PwD. Special attention in the design of the game was given to the Technology Considerations linguistics and semantic challenges of PwD, (for example, see In our overall strategy, we focused on person-centered [88,89]). These principles were incorporated in our game design technology, including the following 2 central guidelines: the by structuring the instructions in short simple sentences, for Human Centered Design (HCD) and the Iterative Process example, “Please drag the ball to the boy.” The modality of [95,96]. instructions delivery was also considered, in view of limitations The definition is outlined in the International Standardization in sustained attention, possible visual and auditory degradation, Organization (ISO) standard Human Centered Design for and cultural nuances of language. Therefore, in our game, Interactive Systems: ISO 9241-210 . The HCD ISO instructions are provided in writing for each game screen, as guidelines are as follows: (1) Understand and specify the context well as vocal spoken instructions adapted to the culture of our of use, (2) Specify the user requirements, (3) Produce design target population. Every instruction for each game screen was solutions, and (4) Evaluate. We embedded this process within tested with the end-users, (34 PwD and 14 healthy community the iterative design process, where end-users (34 PwD and 14 dwelling older adults) various times during the iterative healthy community dwelling elders) were involved directly in development process. Game screens were adapted and corrected the creation and clarification of each game screen. The iterative, for the final prototype game based on the verbal feedback of human centered approach  is the strategy we chose to follow the end-users, as well as their ability to understand the for development of each game screen, as research shows that instructions and succeed at the game as observed by the testers. PwD, despite cognitive decline, can (and should) provide insight Interaction of the Different Elements and Built and user feedback that improves usability and human experience Environment . We adopted modern viewpoints on cognitive performance in For example, at first we planned to use laptops, because we aging that consider the full context rather than focus on thought the portability would be convenient and the screen size performance alone. In these views, all the elements of the model would be appropriate for older adults. However, during the interact to shape performance. This complex interplay guides iterative development process, we learned from the end-users us in our design of the game and in our focus on human-centered and observations of the testers that tablets were preferable, technology, as discussed in the next section. For example, therefor the game development was switched from laptops to sensory changes were noted to affect performance on cognitive tablets. Tablets are easily mobile and can be easily disassociated tasks in older age (sensory degradation hypothesis ), where from the keypad—a technology that often appears intimidating reduced performance was linked with reduced acuity. Game to PwD. Moreover, tablets use a touch screen and/or a stylus, engagement will clearly also be affected by sensory changes, an object resembling a pen, an element likely to be culturally as reduced sensory input leads to more effortful processing, more familiar to PwD then a keyboard. As we live in a society potentially reducing engagement . In other words, the game where technology is ubiquitous, our theoretical presupposition is less engaging if one cannot see it clearly. Learning in context is that self-efficacy of PwD would be enhanced by their is chosen to overcome cognitive changes in dementia, by using successful use of tablet technology [99,100]. the most preserved intellectual abilities and knowledge . Similarly, the choice of cueing and priming is designed Game Framing Methodology considering visual sensory changes, and cognitive changes in Broadly speaking, we developed a matrix based on the dementia. Likewise, instructions and their presentation were aforementioned theoretical frameworks that guided the creation designed considering learning in context, along with cognitive of every game screen. A brief summary of these variables is  and sensory changes. depicted in Table 1. The aim was to create a fun and engaging game environment that is, on one hand challenging enough to This interplay can be exemplified in the variety of elements that provide an exercising and learning effect, while on the other are best classified as “built environment.” Built environment hand, specifically adapted to assist in exercising key cognitive encompasses the design parameters related to the technological strengths a PwD has available (such as implicit memory), while (machine) and screen design characteristics, as well as the providing assistive mechanisms to help overcome extraneous physical environment within which the prototype game was limitations (that would impede the accomplishing of tasks). pilot tested. In describing their CREATE model on designing http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 6 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al Table 1. Examples of variables taken into consideration for game screen frames. Challenges Variables Solutions Sensory degradation Visual Avoid blue or yellow combination, script choice Spatial placement of fields of action Center of screen Learning “Learning in context” visual elements Culturally relevant Cuing Placing correct answer center screen, reminder by reading instructions over Feedback Positively framed, immediate, errorless, and entertaining Cognitive changes Semantics Simple action oriented instruction Uncluttered (inhibition) No unnecessary information Technology complexity Each time the game is played, it is preceded by practice exercises related to tablet use (ie, touch and drag functions). The practice exercises aren’t included in the analytics of the game session We identified a set of functional simple daily tasks that are performance data (ie, speed of initial interaction with the game essential and culturally relevant to daily life. Each task was then screen, speed of successful screen completion, and number of divided into subtasks, utilizing an occupational therapy screens completed successfully). methodology, primarily adapted from neuro-rehabilitation . One sample game frame is presented in Figure 2. In this frame, Each subtask was further clarified in terms of the main key the PwD was instructed to follow written and oral instructions cognitive skills it reflects. While it is of course not possible to to find, drag, and move items on the tablet touch screen. Table untangle different cognitive skills during task performance, it 2 describes the other various actions or tasks the PwD were is possible to identify the main cognitive skills around which asked to do in other game screens. It also lists the skills targeted the game screen is designed, that is, executive function, eye by all of the game screens. hand coordination, working memory, and prolonged attention . At the end of the iterative development stage, we had developed a prototype of a tablet-based game for PwD with 39 game Each game screen was person-centered , and was designed screens. The prototype was used for the proof of concept pilot in such a way that a measurement instrument collected game study that we report on next. Table 2. Game screens: game types and skills involved. A list of the nine major game types used in the study, with all relevant physical and cognitive skills targeted. Game types Physical, cognitive skills targeted Skills targeted on all games 1. Identify, find and touch Gnosis Eye hand coordination, language skills (reading, 2. Identify, find and drag Association, gnosis comprehension), under- standing and following 3. Identify, find, touch alternating correct answers Mental rigidity instructions, praxis, 4. Find, sort and drag Gnosis memory, sustained atten- tion, and object recogni- 5. Time orientation Recognition, abstraction, association, match activity with time of day tion. 6. Space orientation Recognition, gnosis 7. Hold release action Inhibition, basic math skills 8. Drag things on screen into a sequence Logic, executive functions 9. Language exercises Word finding, letter recognition, gnosis, semantic sequencing http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 7 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al Figure 2. Sample game frame. 6 different testers. All testers had past experience working with Goals the PwD population: occupational therapist, gerontologist, social The aim of our research was to answer the following questions: worker, pre-med student, occupational therapist student, and (1) Are serious computer games acceptable accessible and activity worker. Only 2 of the 6 were involved in the engaging for people with moderate and advanced dementia? (2) development of the game. Are people with moderate and advanced dementia able to use Testers’ main task was to observe the sessions and manually a tablet? and (3) Can PwD improve the speed of performing a record their observations related to the PwD’s interaction with task with practice, indicating their ability to learn? the game for each game frame. They also recorded unsolicited, unprompted spontaneous verbal comments made by the PwD Methods while using the game. Also, testers assisted PwD to maintain their attention on the game throughout the session by prompting Procedure them to refocus, when this was called for. Finally, testers were A pilot study for proof of concept was conducted to answer the instructed to assist with any technological issues that might above questions. The game was played with the PwD and a arrive. tester present in a quiet room, located in the MELABEV dementia day center, Jerusalem, Israel. MELABEV has four Each game session was between 20-30 minutes, a recommended day-care centers attended by approximately 500 PwDs, ranging time for therapy sessions with PwD. All sessions took place at from people with moderate cognitive impairment (MCI) to approximately the same time of day in a quiet room. In every advanced dementia. MELABEV’s professional staff routinely game session, each PwD had the opportunity to play the uses computer games on a one-to-one basis for cognitive complete game of 39 game screens. Each game screen was stimulation gaming , as well as reminiscence therapy at played in the following way. If they were successful, they the computer . Primary family caregivers who enroll the received a success message (audibly and visually) relevant to PwD in the day care program consent to the participation of the activity performed. If the PwD did not succeed at first, they their family member with these kinds of technology, as well as were cued (audibly and visually). The cueing procedure repeated all other activities in the day care center. 3 times, and then, even if the person didn't complete the screen successfully, the game advanced to the next screen. Success or Meaningful informed consent for people with dementia is failure, as well as other variables were recorded internally by challenging. Thus, for our pilot study, we utilized the the tablet. participatory consent process —each time a game was presented, the participant was asked by the tester if she agreed Participants to participate in the gaming session. Upon agreement, the PwD Out of about 200 PwD from two of MELABEV’s day care voluntarily got up and was guided to the designated space the centers with moderate to advanced dementia, 24 persons were computer room, to play the game. If the PwD did not agree to found to fit the inclusion criteria and participated in the pilot participate, he/she remained in the regular activity room, did study (age range: 65 years – 90 years, 15 women, and 9 men). not go to the computer room and did not use the game that time, The PwD included had cognitive assessment scores (as tested with no consequences what so ever to the services they received by the Montreal Cognitive Assessment MoCA) as low as 6/30 in the center. If at any time during the game session, the PwD  or a Mini-Mental State Examination (MMSE) as low as said or acted as if they didn't want to continue, the game session 10/30 . We excluded patients with aggression, delusional was terminated and they were taken back to the regular activity behavior, a history of alcohol or substance abuse, depression, room. severe auditory, and visual or motor deficits, as assessed by the professional staff at MELABEV. During the 10 week pilot study, the PwD played the prototype game 1-2 times a week under supervision of testers. There were http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 8 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al Fourteen healthy community dwelling older adults (age range: trend for session (ie, session 1 > 2 > 3) was found across both 65 years – 90 years; 11 women, 3 men) also volunteered to groups, F =6.1, P=.02, η =.23, denoting an increase in speed 1, 20 p participate in this process. Game sessions took place in their with practice. Clearly, a main effect for group membership was homes at the time that was convenient for them. These older noted, with significantly slower performance for PwD than for adults served as an age-matched control group and could controls, F =23.3, P<.001, η = .54, but the linear trend did 1, 20 p verbalize their opinions relating to the games accessibility and not interact significantly with group membership, F =1.1, 1,20 acceptability better than PwD. P>.3. In other words, the rate of improved speed with practice Analysis for PwD and healthy controls was not statistically different. A mixed methods approach was utilized for evaluation . Finally, the average number of game screens completed correctly Quantitative data for each participant was recorded automatically by PwD per game session was 13.4 out of 22, representing 61% by the tablet platform, collecting game performance data on of the game frames. speed of successful screen completion and task completion rate. In sum, these results may suggest that the tasks were well These data were analyzed using a mixed-model designed for the PwD group that is challenging enough to repeated-measure ANOVA (analysis of variance). encourage improved performance, but not too challenging as Qualitative data included the observations of the 6 testers from to frustrate learning. For our control group, it appears that the each game session they participated in, as well as the tasks were easy and they quickly reached a ceiling of spontaneous comments from participants during the game performance. Most importantly, it appears that when tasks are session. The testers recorded their observations and the designed with PwD in mind, the rate of improvement in participant’s comments relating to each game screen in an Excel performance with practice (ie, learning) is not significantly document immediately after each game session. The Excel different than the rate for healthy age-matched controls. (Microsoft) document was analyzed for themes using grounded Qualitative analysis of the PwD spontaneous comments (eg, theory by 2 researchers and a research assistant, each one expressed while playing the game), as recorded manually by separately. Analysis was then discussed as a group between the testers, reveal the following major themes in accessibility, 3 researchers until consensus about common themes was acceptability, engagement, and self-efficacy. reached. A list of 10 themes emerged. One of the major themes relates to self-efficacy of PwD and is discussed in this paper. First, it appears that the PwD were able to interact with the Other themes will be discussed in a future paper. tablet and the game was acceptable to them and they even enjoyed playing it as indicated by the following: Results “Thanks for choosing me to play the game.” C. “I will recommend it to all my friends.” G. Participants “It was lovely.” C. Of the 24 PwD who began the pilot study, 12 (50%) dropped out during the study. Reasons for dropping out included: rapid The enjoyment was not dependent on cognitive ability or on deterioration of physical and/or cognitive condition, vision getting the correct answer. This was even the case with PwD deterioration, did not attend day care center due to illness, who performed poorly on the game. For example, one woman institutionalization, death, preference of other programs going would sing along with the game with a smile on her face even on in the activity room, lack of interest in the game, and found when she did not get the correct answer. Healthy older adults, the game to be too easy. Of those that dropped out 3 (12.5%) on the other hand, found the game too easy, and on the most were game related (too easy, didn’t interest them) and 9 (37.5%) part not highly engaging. were aging or dementia related. In addition, we have some preliminary qualitative indicators Analysis that PwD’s self-efficacy was improved. Quotes from the PwD expressed a sense of self-worth and an increase in their As expected, quantitative analysis showed that the average speed self-esteem with the use of the game as the testers heard quotes of successful screen completion was significantly longer for such as PwD compared with healthy older adults, t =4.4, P<.001 (see Figure 3), with an average of 45.5 (SE 5.1) and 17.4 (SE 1.1) “I did it!” M. seconds/game frame for PwD and healthy controls, respectively. “Now I know what utensil goes with what” M. Note that, as expected, performance was much more varied Increase in self-reported self-efficacy was found and seen with across PwD than across controls. PwD only, and not reported by the healthy community dwelling Next, Figure 4 presents the average speed for successful screen older adults. completion for the first 3 sessions, separately for PwD and The PwD were able to remember certain game components, controls. To test whether performance improved with practice both those that were easy for them and those that were more to the same extent for the two groups, a mixed-model difficult, as demonstrated from this spontaneous comment from repeated-measures ANOVA was conducted. Speed of screen a PwD to the tester accompanying him: “I can play the game, completion was the dependent variable, session (1, 2, or 3) except for one that is a bit harder.” C. served as the within participants variable and group (PwD vs controls) as the between participant variable. A significant linear http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al We observed learning and special learning techniques used by working on it.” C. He expressed the fact that he was thinking the PwD in order to progress in the game. For example, one and interacting with the tablet. tester overheard the PwD speak to the tablet, which asked him Testers observed that auditory cueing improved PwD’s for the answer for a second time saying, “I know, I know, I am performance and engagement with the game. Figure 3. Average speed in seconds of successful screen completion for people with dementia and controls. Figure 4. Average speed in seconds of successful screen completion for people with dementia and controls as a function of practice in the first three sessions. Although it is generally assumed that PwD cannot learn new Discussion information and skills, our exploratory data show that some of those who used the game learned how to do many of its Relevance of Our Findings activities. Future research will test exactly what is learned in The field of serious games for PwD is in its infancy. Our paper the game, and more importantly, if there is a transfer of reporting on a research and development project aims to add knowledge from the game to real life scenarios over time. much needed initial knowledge in this area. In relation to our There are several additional key themes that emerged in this original research questions, we learned that: (1) serious computer pilot study that may be useful for clinical intervention and future games can be acceptable and accessible to PwD; (2) people with game design. First, from the observations of the occupational moderate and advanced dementia are able to use a tablet; and therapists it appears that PwD can use a tablet better than a (3) PwD improved in their speed of successful screen completion laptop. It was found to be easier for them to manipulate , with practice, at a non-significantly different rate than healthy as they can adjust it and hold it with minimal difficulties. Indeed, older adults, implying some form of significant learning the touch screen response mode is easier than a mouse or occurred (see Figure 4). keyboard . Second, the testers observed that auditory From qualitative analysis of PwD spontaneous comments, we cueing improves PwD’s performance, supporting some of the learned that PwD enjoyed using the game. Our findings are findings in the literature [113-115]. consistent with previous research suggesting that technology Finally, it was encouraging to see that even people with can be empowering and satisfying to participants . dementia, who at the outset were hesitant to play the game, also http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 10 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al had a positive interaction with the technology. Specifically, previous studies and recommendations and focuses primarily PwD who initially said that “this is not for me” because “I don’t on facilitating activities of daily living and providing positive know anything about tablets,” reported enjoying the game after experiences for PwD. This area has not been hitherto sufficiently their initial trial session and learning how to interact with it. researched. Limitations Conclusion and Future Work This initial exploration has several limitations. The sample size Based on both qualitative and quantitative analyses, our pilot, was small, the duration was rather short, and not all the testers proof of concept study demonstrates that our game was involved in the pilot were independent from the game acceptable, accessible, enjoyable, and engaging for PwD. We development process. We also acknowledge that, in this stage, believe that this type of game set may be useful in creating it is not possible to point out which of the factors considered activities for people with moderate to advanced dementia. These during the development had the most effect on the results. types of serious games may provide meaningful activities for the dyad—PwD and the caregivers of PwD. Such games may Comparison With Prior Work also be a good way to assess cognitive status of PwD in a Mccallum and Boletsis  in their literature review of nonthreatening way [119-123]. Future work should also consider dementia-related serious games reported a proliferation of cultural and language aspects that may affect performance and cognitive training, exercise, and social games targeting dementia engagement (for a discussion, see ), as well as aspects of as well as its various symptoms. They conclude that serious the testers themselves . games for dementia have a real effect on PwD, but the field is The significant improved speed for task completion may also still “unchartered.” Robert and colleagues  recommend suggest that the theoretical methodology used in constructing that serious games, adapted specifically for PwD, may constitute the game screens is suitable for PwD as it utilizes their an important tool to maintain autonomy. Kenigsberg and remaining capacities - implicit memory and stimulates learning. colleagues  elaborate saying that “by providing pleasurable Our future goal is to expand the game activities based on our activities and person empowerment, these games are a way to holistic theory driven matrix. We aim to add more game screens enter the homes of PwD through technology, to structure and be able to study the transferability effect from game screens collaborative care knowledge related to dementia and to educate to functionality in real life scenarios. We plan to develop a stakeholders so they can cope with critical situations in everyday training manual for professional and family caregivers related life.” Establishing links between behavioral disorders and their to how to use the game and deploy the package in a large causes could help a personal or virtual coach in developing a practical trial with PwD living in the community setting. Finally, care plan and lifestyle training. They close by stating, that the to test the game’s efficacy, we wish to evaluate, through a role of technology in improving sensory impairments and randomized trial, the trajectories of functionality in people with facilitating activities of daily living and providing positive moderate to advanced dementia and the impact of playing the experiences is underexplored. Our work is based on these game on this trajectory. Acknowledgments We would like to thank the Israeli Ministry of Economy, Office of the Chief scientist, and the Israeli Ministry of Immigrant Absorption, new immigrant Scientists for helping to fund this research. We would also like to thank our medical student, Ayala Farkash, and our occupational therapy student, Sari Reichman, for help with this research. Conflicts of Interest None declared. References 1. Krumeich A, Meershoek A. Health in global context; beyond the social determinants of health? 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Am J Alzheimers Dis Other Demen 2017 Feb;32(1):41-50 [FREE Full text] [doi: 10.1177/1533317516680899] [Medline: 27899433] Abbreviations ADL: activities of daily living HCD: human centered design ISO: international standardization organization ICT: information and communication technology MCI: moderate cognitive impairment MOCA: Montreal Cognitive Assessment MMSE: mini mental state examination http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 16 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Tziraki et al PwD: people with dementia Edited by G Eysenbach; submitted 21.08.16; peer-reviewed by S Ballesteros, L Quinlan, C Smits; comments to author 05.12.16; revised version received 26.03.17; accepted 26.05.17; published 31.07.17 Please cite as: Tziraki C, Berenbaum R, Gross D, Abikhzer J, Ben-David BM JMIR Serious Games 2017;5(3):e16 URL: http://games.jmir.org/2017/3/e16/ doi: 10.2196/games.6514 PMID: 28760730 ©Chariklia Tziraki, Rakel Berenbaum, Daniel Gross, Judith Abikhzer, Boaz M Ben-David. Originally published in JMIR Serious Games (http://games.jmir.org), 31.07.2017. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on http://games.jmir.org, as well as this copyright and license information must be included. http://games.jmir.org/2017/3/e16/ JMIR Serious Games 2017 | vol. 5 | iss. 3 | e16 | p. 17 (page number not for citation purposes) XSL FO RenderX
JMIR Serious Games – JMIR Publications
Published: Jul 31, 2017
Keywords: serious games; dementia; functionality; learning in context; speed of processing
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