Recommendations for the use of Serious Games in people with Alzheimer's Disease, related disorders and frailty

Outcome measurement of cognitive impairment and dementia in serious digital games: a scoping review

PURPOSE

Dementia prevalence is increasing worldwide. With the emergence of digital rehabilitation, serious digital games are a potential tool to maintain and monitor function in people living with dementia. It is unclear however whether games can measure changes in cognition. We conducted a scoping review to identify the types of outcomes measured in studies of serious digital games for people with dementia and cognitive impairment.

METHODS

We included primary research of any design including adults with cognitive impairment arising from dementia or another health condition; reported data about use of serious digital games; and included any cognitive outcome. We searched Medline (via EBSCO), PsycInfo, CINAHL, Web of Science, from inception to 4th March 2024 and extracted study characteristics.

RESULTS

We reviewed 5899 titles, including 25 full text studies. We found heterogeneity in domains and measures used: global cognition (n = 15), specific cognitive processes (n = 13), motor function (n = 5), mood (n = 6), activities of daily living (n = 5), physiological processes (n = 4) and quality of life (n = 2). Use of outcome measurement tools was inconsistent; the most frequently used measures were the Montreal Cognitive Assessment (n = 8), the Mini-Mental State Examination (n = 7), and the Trail Making Test (n = 7). Nine studies used in-game measures, most of which were related to game performance.

CONCLUSION

We found very few studies with assessment of cognition within the game. Studies of serious games for people with dementia and cognitive impairment should develop digital outcome tools based on recommendations in Core Outcome Sets, to increase consistency between studies.

Ιnnovative Health Promotion Strategies: A 6-Month Longitudinal Study on Computerized Cognitive Training for Older Adults with Minor Neurocognitive Disorders

Minor neurocognitive disorders (NCDs) represent a transitional phase between normal cognitive aging and dementia, highlighting the importance of early interventions. This study assessed the efficacy of a structured 6-month computerized cognitive training (CCT) program in stabilizing cognitive decline among older adults with minor NCDs. One hundred participants were randomly assigned to an intervention group or a non-intervention group. The intervention group underwent weekly, personalized CCT sessions using the MeMo program, which targeted memory, attention, and adaptability. Cognitive performance was measured at baseline and after six months using the Cambridge Cognitive Examination (CAMCOG). Statistical analysis showed significant cognitive decline in the non-intervention group in orientation (p = 0.032), language expression (p = 0.008), praxis (p = 0.008), and memory (p = 0.01). In contrast, the intervention group showed no significant changes, except for a minor decline in perception (p = 0.003). These results suggest that CCT may help delay cognitive deterioration in minor NCDs. However, while cognitive decline was stabilized, no significant improvement was observed. Further research is recommended to investigate the long-term benefits and the transferability of cognitive gains. The findings support the use of CCT as a non-pharmacological health promotion strategy for enhancing cognitive resilience in aging populations. The novelty of this research lies in its focus on adaptive CCT as a non-pharmacological intervention, highlighting the potential role of neuroplasticity in delaying cognitive decline and offering new insights into personalized cognitive health strategies for aging populations.

The limitations and challenges in the assessment of executive dysfunction associated with real-world functioning: The opportunity of serious games

Nowadays, there is a broad range of methods for detecting and evaluating executive dysfunction ranging from clinical interview to neuropsychological evaluation. Nevertheless, a critical issue of these assessments is the lack of correspondence of the neuropsychological test's results with real-world functioning. This paper proposes serious games as a new framework to improve the neuropsychological assessment of real-world functioning. We briefly discuss the contribution and limitations of current methods of evaluation of executive dysfunction (paper-and-pencil tests, naturalistic observation methods, and Information and Communications Technologies) to inform on daily life functioning. Then, we analyze what are the limitations of these methods to predict real-world performance: (1) A lack of appropriate instruments to investigate the complexity of real-world functioning, (2) the vast majority of neuropsychological tests assess well-structured tasks, and (3) measurement of behaviors are based on simplistic data collection and statistical analysis. This work shows how serious games offer an opportunity to develop more efficient tools to detect executive dysfunction in everyday life contexts. Serious games provide meaningful narrative stories and virtual or real environments that immerse the user in natural and social environments with social interactions. In those highly interactive game environments, the player needs to adapt his/her behavioral performance to novel and ill-structured tasks which are suited for collecting user interaction evidence. Serious games offer a novel opportunity to develop better tools to improve diagnosis of the executive dysfunction in everyday life contexts. However, more research is still needed to implement serious games in everyday clinical practice.

Effects of Serious Games in Older Adults With Mild Cognitive Impairment

OBJECTIVE

The rising prevalence of mild cognitive impairment (MCI) has spurred interest in innovative cognitive rehabilitation approaches, including serious games. This review summarizes randomized clinical trials (RCTs) exploring the impact of serious games on MCI patients.

METHODS

We conducted a comprehensive data search using key terms such as "gamification," "digital therapy," "cognition," "mild cognitive impairment," and "Alzheimer's disease." We exclusively considered published RCTs, excluding animal studies and basic research.

RESULTS

We identified eight RCTs. Four RCTs examined the effects of serious games using cognitive training for MCI patients. Notably, one study found that non-specific training (Nintendo Wii) significantly enhanced cognitive function and quality of life compared to cognition-specific computer training (CoTras). Among the remaining three RCTs, one specifically demonstrated that personalized serious game-based cognitive training yielded superior cognitive outcomes and reduced depressive symptoms. One RCT focused on serious games incorporating physical exercise, highlighting the effectiveness of kinetic-based exergaming in enhancing overall cognition. Three RCT focused on combined cognitive training and physical exercise. A double-blind RCT revealed that progressive resistance training or standalone physical exercise outperformed the combined approach in improving executive function and global cognition. Two additional RCTs reported positive outcomes, including improvements in cognitive function and electroencephalogram patterns associated with game-based interventions.

CONCLUSION

Serious games, whether focusing on cognitive training, physical exercise, or a combination of both, have potential to improve cognitive and functional outcomes in individuals with MCI. Further research and standardization of protocols are needed to better understand the full potential of serious games in MCI.

Bio-Experiential Technology to Support Persons With Dementia and Care Partners at Home (TEND): Protocol for an Intervention Development Study

BACKGROUND

Alzheimer disease and related dementias are debilitating and incurable diseases. Persons with dementia and their informal caregivers (ie, dyads) experience high rates of emotional distress and negative health outcomes. Several barriers prevent dyads from engaging in psychosocial care including cost, transportation, and a lack of treatments that target later stages of dementia and target the dyad together. Technologically informed treatment and serious gaming have been shown to be feasible and effective among persons living with dementia and their care partners. To increase access, there is a need for technologically informed psychosocial interventions which target the dyad, together in the home.

OBJECTIVE

This study aims to develop the toolkit for experiential well-being in dementia, a dyadic, "bio-experiential" intervention for persons with dementia and their caregivers. Per our conceptual model, the toolkit for experiential well-being in dementia platform aims to target sustained attention, positive emotions, and active engagement among dyads. In this paper, we outline the protocol and conceptual model for intervention development and partnership with design and development experts.

METHODS

We followed the National Institutes of Health (NIH) stage model (stage 1A) and supplemented the model with principles of user-centered design. The first step includes understanding user needs, goals, and strengths. We met this step by engaging in methodology and definition synthesis and conducting focus groups with dementia care providers (N=10) and persons with dementia and caregivers (N=11). Step 2 includes developing and refining the prototype. We will meet this step by engaging dyads in up to 20 iterations of platform β testing workshops. Step 3 includes observing user interactions with the prototype. We will meet this step by releasing the platform for feasibility testing.

RESULTS

Key takeaways from the focus groups include balancing individualization and the dyadic relationship and avoiding confusing stimuli. As of September 2023, we have completed focus groups with providers, persons with dementia, and their caregivers. Additionally, we have conducted 4 iterations of β testing workshops with dyads. Feedback from focus groups informed the β testing workshops; data have not yet been formally analyzed and will be reported in future publications.

CONCLUSIONS

Technological interventions, particularly "bio-experiential" technology, can be used in dementia care to support emotional health among persons with a diagnosis and caregivers. Here, we outline a collaborative intervention development process of bio-experiential technology through a research, design, and development partnership. Next, we are planning to test the platform's feasibility as well as its impact on clinical outcomes and mechanisms of action.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52799.

Virtual reality applications based on instrumental activities of daily living (iADLs) for cognitive intervention in older adults: a systematic review

BACKGROUND

In recent years, the use of virtual reality (VR) as a complementary intervention in treating cognitive impairment has significantly increased. VR applications based on instrumental activities of daily living (iADL-VR) could offer a promising approach with greater ecological validity for intervention in groups with cognitive impairments. However, the effectiveness of this approach is still debated.

OBJECTIVE

This systematic review aims to synthesize the effects of iADL-VR interventions to rehabilitate, train, or stimulate cognitive functions in healthy adults and people with mild cognitive impairment (MCI) and different types of dementia.

METHODS

A systematic search was performed in the Scopus, PubMed, IEEE Xplore, Web of Science, and APA PsycNet databases until September 2022 and repeated in April 2023. The selected studies met the search terms, were peer-reviewed, included an iADL-VR intervention, and were written in English. Descriptive, qualitative studies, reviews, cognitive assessment, non-intervention studies, those unrelated to VR or iADL, those focused on motor aspects, and non-degenerative disorders were excluded. The PEDro scale was used to assess the methodological quality of the controlled studies. To present and synthesize the results, we organized the extracted data into three tables, including PEDro scores, participant characteristics, and study characteristics.

RESULTS

Nineteen studies that met the inclusion and exclusion criteria were included. The total sample reached 590 participants, mostly women (72.67%). Approximately 30% were diagnosed with Alzheimer's disease or dementia, and 20% had mild cognitive impairment. Variables such as authors and year of publication, study design, type of intervention and VR applied, duration of the intervention, main findings, and conclusions were extracted. Regarding demographic characteristics, the sample size, age, sex, years of education, neurological diagnosis, dropouts, and the city and country where the intervention took place were recorded. Almost all studies showed improvements in some or all the outcomes after the intervention, generally greater in the iADL-VR group than in the control group.

CONCLUSION

iADL-VR interventions could be beneficial in improving the performance of cognitive functions in older adults and people with MCI and different types of dementia. The ecological component of these tasks makes them very suitable for transferring what has been learned to the real world. However, such transfer needs to be confirmed by further studies with larger and more homogeneous samples and longer follow-up periods. This review had no primary funding source and was registered with PROSPERO under registration ID: 375166.

Virtual Reality Technology in Nursing Professional Skills Training: Bibliometric Analysis

BACKGROUND

Nursing professional skills training has undergone significant transformation due to the exponential growth of computer and medical technology. The innovative use of virtual reality (VR) in nursing education has emerged as a cutting-edge technical support technique that has gained attention as a highly effective method for improving nurse training quality.

OBJECTIVE

This study aims to review the current status of VR technology in nursing professional skills training, research hotspots, and emerging trends in the last 15 years.

METHODS

The Web of Science Core Collection database was used to search for literature on VR technology in nursing professional skills training covering the period from 2006 to 2022. Biblioshiny (K-Synth Srl) was used to import and convert the records to Bibliometrix (K-Synth Srl) for analysis, and R (R Core Team) was used for descriptive bibliometric analysis. VOSviewer (Leiden University) was used to cluster co-occurring keywords, and Scimago Graphica (version 1.0.16; Scimago Lab) was used to generate a geographical visualization of published countries and regions.

RESULTS

A total of 1073 papers were analyzed, indicating a surge in research on the application of VR in nursing professional skills training in recent years, as evidenced by a positive trend in annual publication of relevant literature. The majority of studies were from the United States (n=340) and Canada (n=107), and Margaret Verkuyl was the most prolific author, leading the way with 9 publications. Furthermore, "Computerized Virtual Patients in Health Professions Education: a Systematic Review and Meta-Analysis" was the most frequently cited reference. Keywords such as education, simulation, skills, students, and care were most commonly used by researchers.

CONCLUSIONS

The bibliometric analysis provides a comprehensive overview of the use of VR in nursing professional skills training, indicating that VR-based training is an effective means of improving the skills and competencies of nursing students and professionals alike. The COVID-19 pandemic has reinforced the importance of developing VR-based distance education, despite challenges such as integrating virtual and real-world training and mitigating safety risks.

Cognitive Training With Head-Mounted Display Virtual Reality in Neurorehabilitation: Pilot Randomized Controlled Trial

BACKGROUND

Neurological rehabilitation is technologically evolving rapidly, resulting in new treatments for patients. Stroke, one of the most prevalent conditions in neurorehabilitation, has been a particular focus in recent years. However, patients often need help with physical and cognitive constraints, whereby the cognitive domain in neurorehabilitation does not technologically exploit existing potential. Usually, cognitive rehabilitation is performed with pen and paper or on a computer, which leads to limitations in preparation for activities of daily living. Technologies such as virtual reality (VR) can bridge this gap.

OBJECTIVE

This pilot study investigated the use of immersive VR in cognitive rehabilitation for patients undergoing inpatient neurorehabilitation. The goal was to determine the difference in rehabilitation effectiveness between a VR serious game that combines everyday activities with cognitive paradigms and conventional computerized cognitive training. We hypothesized the superiority of the VR serious game regarding cognitive abilities and patient-reported outcomes as well as transfer to daily life.

METHODS

We recruited 42 patients with acute brain affection from a German neurorehabilitation clinic in inpatient care with a Mini Mental Status Test score >20 to participate in this randomized controlled trial. Participants were randomly assigned to 2 groups, with 1 receiving the experimental VR treatment (n=21). VR training consisted of daily life scenarios, for example, in a kitchen, focusing on treating executive functions such as planning and problem-solving. The control group (n=21) received conventional computerized cognitive training. Each participant received a minimum of 18 treatment sessions in their respective group. Patients were tested for cognitive status, subjective health, and quality of life before and after the intervention (Alters-Konzentrations-Test, Wechsler Memory Scale-Revised, Trail Making Test A and B, Tower of London-German version, Short Form 36, European Quality of Life 5 Dimensions visual analog scale, and Fragebogen zur Erfassung der Performance in VR).

RESULTS

Repeated-measures ANOVA revealed several significant main effects in the cognitive tests: Tower of London-German version (P=.046), Trail Making Test A (P=.01), and Wechsler Memory Scale-Revised (P=.006). However, post hoc tests revealed that the VR group showed significant improvement in the planning, executive control, and problem-solving domains (P=.046, Bonferroni P=.02). In contrast, no significant improvement in the control group between t₀ and t₁ was detected (all P>.05). Furthermore, a nonsignificant trend was observed in visual speed in the VR group (P=.09, Bonferroni P=.02).

CONCLUSIONS

The results of this pilot randomized controlled trial showed that immersive VR training in cognitive rehabilitation had greater effectiveness than the standard of care in treating patients experiencing stroke in some cognitive domains . These findings support the further use and study of VR training incorporating activities of daily living in other neurological disorders involving cognitive dysfunction.

TRIAL REGISTRATION

Federal Registry of Clinical Trials of Germany (DRKS) DRKS00023605; https://drks.de/search/de/trial/DRKS00023605.

Age and sex effects on Super G performance are consistent across internet devices

There have been recent advances in the application of online games that assess motor skill acquisition/learning and its relationship to age and biological sex, both of which are associated with dementia risk. While this online motor learning assessment (called Super G), along with other computer-based cognitive tests, was originally developed to be completed on a computer, many people (including older adults) have been shown to access the internet through a mobile device. Thus, to improve the generalizability of our online motor skill learning game, it must not only be compatible with mobile devices but also yield replicable effects of various participant characteristics on performance relative to the computer-based version. It is unknown if age and sex differentially affect game performance as a function of device type (keyboard versus touchscreen control). Thus, the purpose of this study was to investigate if device type modifies the established effects of age and sex on performance. Although there was a main effect of device on performance, this effect did not alter the overall relationship between performance vs. age or sex. This establishes that Super G can now effectively be extended to both computer and mobile platforms to further test for dementia risk factors.

Feasibility and potential cognitive impact of a cognitive-motor dual-task training program using a custom exergame in older adults: A pilot study

Introduction

Dual-task training may be relevant and efficient in the context of active aging. An issue in training programs lies in enhancing the adherence of participants. This can potentially be improved using games as support. We designed and developed a custom interactive exergame in this way. The objective of this pilot study was to explore the potential use of this exergame and the feasibility of our intervention, including the level of safety and adherence. The result's trends on cognitive and motor capacities, as well as on the level of motivation for physical activity, fear of falling, and quality of life of participants, were also explored.

Methods

Older adults aged 65 years or older were recruited and realized 30 min of supervised training in groups of 4, 2-3 times a week for 12 weeks. Exercises consisted of incorporated cognitive and motor dual tasks, with an increased difficulty over the weeks. Our program's safety, engagement, attendance, and completion levels were evaluated. Participants' postural control in single-task and dual-task conditions, as well as their performances in mental inhibition, flexibility, working memory, mobility, and postural control, and their levels of motivation for physical activity, fear of falling, and quality of life were also assessed. We realized a per protocol statistical analysis with a p-value set at 0.05.

Results

Thirty-nine participants (aged 84.6 ± 8.5 years) were recruited. No adverse events, and 89% adherence, 88% attendance, and 87% completion rates were observed. A potentially significant effect of our exergame on working memory in single-task conditions and on the cognitive aspect of dual-task conditions was also observed. We observed no differences in other parameters.

Discussion

Our exergame seemed feasible and safe and was enjoyed by participants, mainly due to the gamification of our training program. Moreover, our exergame may be efficient for cognitive training in older adults, as well as for the maintenance of motor functions, motivation for physical activity, fear of falling, and quality of life levels. This constitutes the first step for our solution with interesting results that need to be further studied.

Development and Evaluation of an Artificial Intelligence–Based Cognitive Exercise Game: A Pilot Study

Recently, cognitive serious games have successfully been employed to train cognitive abilities in elderly people with mild cognitive impairment, Alzheimer’s disease, and related disorders. However, despite the continuous rehabilitation game design and its applications, the existing cognitive exercise games fall short of user interaction and personalized elements with regard to difficult levels, which leads to users leaving early and losing interests during the gameplay. In this regard, the purpose of the study was to design and develop the serious game inclusive of playful elements for user motivation, the web-based mobile application system for easy accessibility, and Artificial Intelligence– (AI–) based difficulty level adjustment system for prevention from earlier leaving out in the middle of the play so that the elderly users can feel entertaining and immersed into the cognitive game voluntarily. This study was designed as an eight-week pilot experiment with thirty-seven participants in their 60s to 80s for the game’s usability assessment purpose. Results of the study showed that the AI-based cognitive exercise game was acceptable, interesting, and motivating for the elderly people and the test results before and after the eight-week training suggest a relationship between longer the training on the game and lower cognitive assessment scores including geriatric quality of life scale, geriatric depression scale, and Korean version of mini-mental state examination (MMSE). These correlations demonstrate the potential value of serious games in clinical assessment of cognitive status for the elderly users with varying cognitive ability. Based on these results, the elderly-centered serious game with playful element can be potentially used in clinical settings, allowing the cognitive training to be more enjoyable and more medically effective. Given these promising results, a more focused study can extend to the game system or additional game tools or features to be explored that solely target the elderly by applying AI and advanced visualization devices.

Application of virtual reality for dementia management

Age is recognized as the major factors of dementia, especially in for Alzheimer’s disease (AD). Given to the aged population, the increased number of demented population has been receiving a great impact in our society. Unfortunately, so far, no cured medicines have been demonstrated to provide effective treatment in AD. The combination of pharmacological and non-pharmacological interventions has been proposed to manage dementia with potential benefits especially in decreasing caregiver’s burden and behavior, as well as psychological problems of demented patients. Recently, giving to the glorious development in digital technologies, the virtual reality, one of the non-pharmacological interventions has been used extensively in dementia managements for its strengths which can be adapted in accordance with the heterogeneous needs from demented patients and their caregivers. However, various study designs and other reasons made these results difficult to be interpreted. In this review our goal is to provide a better understanding for these points.

Available Virtual Reality-Based Tools for Executive Functions: A Systematic Review

Introduction

Executive dysfunctions constitute a significant public health problem: their high impact on everyday life makes it a priority to identify early strategies for evaluating and rehabilitating these disorders in a real-life context. The ecological limitation of traditional neuropsychological tests and several difficulties in administering tests or training in real-life scenarios have paved the way to use Virtual Reality-based tools to evaluate and rehabilitate Executive Functions (EFs) in real-life.

Objective

This work aims to conduct a systematic review to provide a detailed description of the VR-based tools currently developed for the evaluation and rehabilitation of EFs.

Methods

We systematically searched for original manuscripts regarding VR tools and EFs by looking for titles and abstracts in the PubMed, Scopus, PsycInfo, and Web of Science databases up to November 2021 that contained the following keywords “Virtual Reality” AND “Executive function^*.”

Results and Conclusion

We analyzed 301 articles, of which 100 were included. Our work shows that available VR-based tools appear promising solutions for an ecological assessment and treatment of EFs in healthy subjects and several clinical populations.

Immersive Virtual Reality Exergames for Persons Living With Dementia: User-Centered Design Study as a Multistakeholder Team During the COVID-19 Pandemic

BACKGROUND

Advancements in supporting personalized health care and well-being using virtual reality (VR) have created opportunities to use immersive games to support a healthy lifestyle for persons living with dementia and mild cognitive impairment (MCI). Collaboratively designing exercise video games (exergames) as a multistakeholder team is fundamental to creating games that are attractive, effective, and accessible.

OBJECTIVE

This research extensively explores the use of human-centered design methods that involve persons living with dementia in long-term care facilitates, exercise professionals, content developers, game designers, and researchers in the creation of VR exergames targeting physical activity promotion for persons living with dementia/MCI.

METHODS

Conceptualization, collaborative design, and playtesting activities were carried out to design VR exergames to engage persons living with dementia in exercises to promote upper limb flexibility, strength, and aerobic endurance. We involved a total of 7 persons living with dementia/MCI, 5 exercise professionals, 5 community-dwelling older adults, a VR company for content creation, and a multidisciplinary research team with game designers, engineers, and kinesiology experts.

RESULTS

An immersive VR exergame called Seas the Day was jointly designed and developed and it is freely available to be played in state-of-the-art VR headsets (Oculus Quest 1, 2). A model for the triadic interaction (health care institution, industry partner, academia) is also presented to illustrate how different stakeholders contribute to the design of VR exergames that consider/complement complex needs, preferences, and motivators of an underrepresented group of end users.

CONCLUSIONS

This study provides evidence that a collaborative multistakeholder design results in more tailored and context-aware VR games for persons living with dementia. The insights and lessons learned from this research can be used by others to co-design games, including remote engagement techniques that were used during the COVID-19 pandemic.

The VITAAL Stepping Exergame Prototype for Older Adults With Major Neurocognitive Disorder: A Usability Study

Purpose: This study investigates the usability of a stepping exergame in older adults with major neurocognitive disorder (MNCD) residing in a long-term care facility.

Materials and Methods: A mixed methods study was conducted. Participants played exergames for 30 min on one try-out session. During the exergames, the think aloud method was used, and field notes were taken by the facilitator. Following the exergames, participants completed the System Usability Scale (SUS) and a semi-structured in-depth interview about usability including their personal experiences. Audio files were transcribed and a thematic content analysis of the think aloud data, field notes and interviews were performed using NVivo 12.

Results: Twenty-two participants with MNCD were included [mean age = 84.3 ± 5.5 (70–95) years; 81.8% women; Short Physical Performance Battery score = 7.5 ± 3.2 (1–12), Montreal Cognitive Assessment score = 11.9 ± 4.4 (2–19)]. System usability was rated “ok to good” with a mean SUS score of 57.8 (SD = 12.3) with scores ranging from 37.5 to 90.0. Five main themes emerged from the thematic content analysis: (1) perceived user friendliness and acceptability of the exergames; (2) interactional experience; (3) motivational factors; (4) training modalities; and (5) risks. There were no adverse events nor dropouts.

Conclusion: Participants evaluated the usability of the exergames positively. The results indicate that the stepping exergame is usable in older adults with MNCD.

Dissecting Digital Card Games to Yield Digital Biomarkers for the Assessment of Mild Cognitive Impairment: Methodological Approach and Exploratory Study

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

The effectiveness and safety of serious games in improving cognitive abilities among elderly people with cognitive impairment: A systematic review and meta-analysis (Preprint)

Background

Cognitive impairment is a mental disorder that commonly affects elderly people. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological intervention for improving cognitive abilities. The effectiveness and safety of serious games for improving cognitive abilities have been investigated by several systematic reviews; however, they are limited by design and methodological weaknesses.

Objective

This study aims to assess the effectiveness and safety of serious games for improving cognitive abilities among elderly people with cognitive impairment.

Methods

A systematic review of randomized controlled trials (RCTs) was conducted. The following 8 electronic databases were searched: MEDLINE, Embase, CINAHL, PsycINFO, ACM Digital Library, IEEE Xplore, Scopus, and Google Scholar. We also screened reference lists of the included studies and relevant reviews, as well as checked studies citing our included studies. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. We used a narrative and statistical approach, as appropriate, to synthesize the results of the included studies.

Results

Fifteen studies met the eligibility criteria among 466 citations retrieved. Of those, 14 RCTs were eventually included in the meta-analysis. We found that, regardless of their type, serious games were more effective than no intervention (P=.04) and conventional exercises (P=.002) for improving global cognition among elderly people with cognitive impairment. Further, a subgroup analysis showed that cognitive training games were more effective than no intervention (P=.05) and conventional exercises (P<.001) for improving global cognition among elderly people with cognitive impairment. Another subgroup analysis demonstrated that exergames (a category of serious games that includes physical exercises) are as effective as no intervention and conventional exercises (P=.38) for improving global cognition among elderly people with cognitive impairment. Although some studies found adverse events from using serious games, the number of adverse events (ie, falls and exacerbations of pre-existing arthritis symptoms) was comparable between the serious game and control groups.

Conclusions

Serious games and specifically cognitive training games have the potential to improve global cognition among elderly people with cognitive impairment. However, our findings remain inconclusive because the quality of evidence in all meta-analyses was very low, mainly due to the risk of bias raised in the majority of the included studies, high heterogeneity of the evidence, and imprecision of total effect sizes. Therefore, psychologists, psychiatrists, and patients should consider offering serious games as a complement and not a substitute to existing interventions until further more robust evidence is available. Further studies are needed to assess the effect of exergames, the safety of serious games, and their long-term effects.

Diagnostic Validity of the Smart Aging Serious Game: An Innovative Tool for Digital Phenotyping of Mild Neurocognitive Disorder

BACKGROUND

The Smart Aging Serious Game (SASG) is an ecologically-based digital platform used in mild neurocognitive disorders. Considering the higher risk of developing dementia for mild cognitive impairment (MCI) and vascular cognitive impairment (VCI), their digital phenotyping is crucial. A new understanding of MCI and VCI aided by digital phenotyping with SASG will challenge current differential diagnosis and open the perspective of tailoring more personalized interventions.

OBJECTIVE

To confirm the validity of SASG in detecting MCI from healthy controls (HC) and to evaluate its diagnostic validity in differentiating between VCI and HC.

METHODS

161 subjects (74 HC: 37 males, 75.47±2.66 mean age; 60 MCI: 26 males, 74.20±5.02; 27 VCI: 13 males, 74.22±3.43) underwent a SASG session and a neuropsychological assessment (Montreal Cognitive Assessment (MoCA), Free and Cued Selective Reminding Test, Trail Making Test). A multi-modal statistical approach was used: receiver operating characteristic (ROC) curves comparison, random forest (RF), and logistic regression (LR) analysis.

RESULTS

SASG well captured the specific cognitive profiles of MCI and VCI, in line with the standard neuropsychological measures. ROC analyses revealed high diagnostic sensitivity and specificity of SASG and MoCA (AUCs > 0.800) in detecting VCI versus HC and MCI versus HC conditions. An acceptable to excellent classification accuracy was found for MCI and VCI (HC versus VCI; RF: 90%, LR: 91%. HC versus MCI; RF: 75%; LR: 87%).

CONCLUSION

SASG allows the early assessment of cognitive impairment through ecological tasks and potentially in a self-administered way. These features make this platform suitable for being considered a useful digital phenotyping tool, allowing a non-invasive and valid neuropsychological evaluation, with evident implications for future digital-health trails and rehabilitation.

Physical Training In-Game Metrics for Cognitive Assessment: Evidence from Extended Trials with the Fitforall Exergaming Platform

Conventional clinical cognitive assessment has its limitations, as evidenced by the environmental shortcomings of various neuropsychological tests conducted away from an older person’s everyday environment. Recent research activities have focused on transferring screening tests to computerized forms, as well as on developing short screening tests for screening large populations for cognitive impairment. The purpose of this study was to present an exergaming platform, which was widely trialed (116 participants) to collect in-game metrics (built-in game performance measures). The potential correlation between in-game metrics and cognition was investigated in-depth by scrutinizing different in-game metrics. The predictive value of high-resolution monitoring games was assessed by correlating it with classical neuropsychological tests; the area under the curve (AUC) in the receiver operating characteristic (ROC) analysis was calculated to determine the sensitivity and specificity of the method for detecting mild cognitive impairment (MCI). Classification accuracy was calculated to be 73.53% when distinguishing between MCI and normal subjects, and 70.69% when subjects with mild dementia were also involved. The results revealed evidence that careful design of serious games, with respect to in-game metrics, could potentially contribute to the early and unobtrusive detection of cognitive decline.

Using Patient and Public Involvement to Elicit Opinion on Cognitive Training Games and Assessment Technologies for Dementia (Preprint)

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 φ 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 φ coefficients were observed between several coding themes between categories, including a relatively strong positive φ 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

A double-blind randomized controlled trial of the efficacy of cognitive training delivered using two different methods in mild cognitive impairment in Parkinson's disease: preliminary report of benefits associated with the use of a computerized tool

BACKGROUND

The effectiveness of computer-based cognitive training (CCT) remains controversial, especially in older adults with neurodegenerative diseases.

AIMS

To evaluate the efficacy of CCT in patients with Parkinson's disease and mild cognitive impairment (PD-MCI).

METHODS

In this randomized controlled trial, 53 patients were randomized to receive CCT delivered by means of CoRe software, traditional paper-and-pencil cognitive training (PCT), or an unstructured activity intervention (CG). In each group, the intervention lasted 3 consecutive weeks (4 individual face-to-face sessions/week). Neuropsychological assessment was administered at baseline (T0) and post-intervention (T1). Outcome measures at T0 and T1 were compared within and between groups. The Montreal Overall Cognitive Assessment (MoCA) was taken as the primary outcome measure.

RESULTS

Unlike the PCT group and the CG, the patients receiving CCT showed significant medium/large effect size improvements in MoCA performance, global cognition, executive functions, and attention/processing speed. No baseline individual/demographic variables were associated with greater gains from the intervention, although a negative correlation with baseline MoCA performance was found.

CONCLUSION

CCT proved effective in PD-MCI patients when compared with traditional PCT. Further follow-up assessments are being conducted to verify the retention of the gains and the potential ability of the tool to delay conversion to PD-dementia. Trial registration number (ClinicalTrials.gov): NCT04111640 (30th September 2019).

Digital therapeutics in neurology

Digital therapeutics (DTx) is a section of digital health defined by the DTx Alliance as “delivering evidence-based therapeutic interventions to patients that are driven by software to prevent, manage, or treat a medical disorder or disease. They are used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes”. Chronic disabling diseases could greatly benefit from DTx. In this narrative review, we provide an overview of DTx in the care of patients with neurological dysfunctions.

A Gamification Framework for Cognitive Assessment and Cognitive Training: Qualitative Study

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.

Efficacy of serious exergames in improving neuropsychiatric symptoms in neurocognitive disorders: Results of the X-TORP cluster randomized trial

INTRODUCTION

The aim of this study was to evaluate the efficacy of a serious exergame in improving the neuropsychiatric symptoms of patients with neurocognitive disorders.

METHODS

X-Torp is a serious exergame combining motor and cognitive activities. Ninety-one subjects (mean age = 81.7 years, mean Mini-Mental State Examination = 18.3) were recruited in 16 centers. Centers were randomized into intervention and control centers. Subjects underwent assessment for cognitive and behavioral symptoms at baseline (BL), the end of the intervention (W12), and 12 weeks after the end of the intervention (W24).

RESULTS

The comparison of neuropsychiatric symptoms between BL and W12 and W24 showed that subjects of the intervention group improved in apathy between BL and W12. Mixed analysis (time BL, W12, W24 x group) indicated a significant increase in apathy and neuropsychiatric symptoms in the control subjects.

DISCUSSION

The use of X-Torp improved neuropsychiatric symptoms, particularly apathy. Future studies should more consistently use behavioral and neuropsychiatric symptoms as outcome measures.

Usability and User Experience of Cognitive Intervention Technologies for Elderly People With MCI or Dementia: A Systematic Review

Introduction

Incorporating technology in cognitive interventions represents an innovation, making them more accessible, flexible, and cost-effective. This will not be feasible without adequate user-technology fit. Bearing in mind the importance of developing cognitive interventions whose technology is appropriate for elderly people with cognitive impairment, the objective of this systematic review was to find evidence about usability and user experience (UX) measurements and features of stimulation, training, and cognitive rehabilitation technologies for older adults with mild cognitive impairment (MCI) or dementia.

Method

The Medline, PubMed, Scopus, ScienceDirect, and PsycINFO databases were searched for literature published in the last 10 years (2009–2019), and three researchers independently reviewed potentially eligible studies, following specific inclusion criteria. A systematic review of the studies was conducted, presenting a qualitative synthesis of usability and UX measures with their outcomes, study characteristics and features of the cognitive intervention technologies.

Results

Ten studies were selected: five were cognitive stimulation and five were cognitive training. Most of them (60%) were computer-based programs with a serious game format. Efficiency and effectiveness were the most frequent measurements used for collecting objective usability data, showing that elderly people with cognitive impairment require more time (45%) and help (40%) but can complete tasks (60%). Regarding UX or subjective usability data, questionnaires and scales were the most used methods, reporting positive experience despite certain difficulties with the interface in five studies.

Conclusion

Measuring usability and UX in cognitive intervention technologies for older adults with MCI or dementia provides an integrated view that can contribute to their development according to the needs and characteristics of the target population. More research is required to include this population group in usability and UX studies, as well as standardized tools and consensus on the relationship of these terms to guarantee the future effectiveness of cognitive intervention technologies.

Review registration

This review was registered in the PROSPERO (CRD42020158147) International Register of Systematic Review Protocols.

Do Older and Young Adults Learn to Integrate Geometry While Navigating in an Environment of a Serious Game?

We evaluated the outcomes of an intervention using a serious game designed to be played on iPads for improving spatial reorientation by training users to integrate geometry of the environment, instead of relying solely on featural cues. Using data logged online through a clinical study of using this game, the effect of training among 16 older adults (69.3 ± 6.4 years, 4 males), who played the game repeatedly (self-administered) over a period of 8 weeks, was investigated. The game contains a hexagonal room with 3 objects, textured walls, and grids on the floor, which are removed one by one as the participant played the game. In each level, the room also rotates such that the viewpoint of the user is different from that of the previous level. Participants cannot play a higher level unless they make no mistake during the trials of the lower test level. In addition to data of older adults available from that clinical trial, we recruited 16 young adults (27.3 ± 5.6 years, 4 males) to play the game for 5 sessions and compared their results with those of the older adults. We evaluated the error type made in each test level and the scores for each session among older adults. Further, we compared the frequency of each error type between young and older adults during the test levels that a landmark adjacent to the target was removed over the first 5 sessions. The results of older adults’ performance suggest they learned to make fewer mistakes over the sessions. Also, both young and older adults learned to integrate the geometrical cues rather than relying on the landmark cue adjacent to the target to find the target. Overall, the results indicate the designed hexagonal room game can enhance spatial cognition among all age groups of adults.

Telerehabilitation for Geriatrics

Advancements in medical science and technology, along with global increases in life expectancy, are changing the way health care services are delivered to the aging society. Telerehabilitation refers to rehabilitation services involving evaluation and treatment. It is an attractive option for older adults who may have multiple comorbidities. Limited access to in-person services and the concern about potential exposure to severe acute respiratory syndrome coronavirus-2 during this pandemic accelerated the implementation of telerehabilitation. This article review the scope, need, and implementation of telehealth and telerehabilitation in the aging population from the perspective of clinicians, patients, and caregivers.

Serious video games and virtual reality for prevention and neurorehabilitation of cognitive decline because of aging and neurodegeneration

PURPOSE OF REVIEW

Cognitive decline because of aging and neurodegeneration has become increasingly prevalent. This calls for the implementation of efficacious, motivating, standardized and widely available cognitive interventions for the elderly. In this context, serious video games and virtual reality may represent promising approaches. Here, we review recent research on their potential for cognitive prevention and neurorehabilitation of age-related cognitive decline and mild cognitive impairment (MCI).

RECENT FINDINGS

The majority of currently available data in this evolving domain lacks the methodological quality to draw reliable conclusions on the potential of novel technology for cognitive training in older people. However, single well designed randomized controlled trials have reported promising effects of cognitive interventions involving serious video games and virtual reality. The cognitive benefits of exergames promoting physical exercise with and without combined cognitive training remain unclear.

SUMMARY

The immersion into stimulating and motivating environments along with training content based on neuroscientific and neuropsychological models may represent a significant advance as compared with conventional computerized cognitive training. Additional research with sound methodology including sufficient sample sizes, active control groups and meaningful outcome measures of everyday function is needed to elucidate the potential of serious video games and virtual reality in multifactorial neurorehabilitation of cognitive decline in aging and neurodegeneration.

Focusing on Emotional and Social Intelligence Stimulation of People With Dementia by Playing a Serious Game—Proof of Concept Study

Context: Dementia is one of the top five chronic diseases, which has an overwhelming impact on patients' life quality, family, and caregivers. Currently, research relating to people with dementia (PwD) focuses on the deterioration of cognitive abilities. A more innovative approach, and the one taken by this paper, is focusing on methods to maintain and improve functionality, communication and quality of life of PwD by building on remaining capacities in the yet unexplored domain of emotional and social intelligence (ESI). The use of serious games for PwD (SG4D) aimed at building social and emotional capacity is a budding field of research.

Objectives: Proof of concept that the, low cost, easy to deploy SG4D, called “My Brain Works” (MBW), co-designed with PwD, enhances ESI, based on the Bar-On ESI model.

Methods: 27 PwD, clients at MELABEV dementia day center, participated in a mixed methods 12 weeks pilot, proof of concept study using a tablet SG4D co-designed with PwD. Quantitative performance data was collected automatically by the tablet during game sessions. In this paper we focus on the analysis of the qualitative and quantitative data related to ESI, observed by 10 different researchers, during each game session.

Results: Quantitative data revealed: both the PwD with high and low MoCA scores had similar average ESI scores. Qualitative analysis revealed that the PwD demonstrated 9 sub-components of the Bar-On ESI Model.

Conclusion: While there is no drug to stop cognitive decline associated with dementia, interventions related to ESI, on the other hand, may improve functioning and quality of life. Despite declines in cognitive abilities, our study shows that a tablet based SG4D can stimulate their ESI and evoke responses in self-awareness, empathy, social and communication capacities. Using SG4D to exercise and maintain social skills is an area that may be promising in the future and may help counter the negative effects of social isolation and loneliness. Such games, while not focusing on cognitive improvement, may also impact on cognitive functioning and help bridge the gap between caregiver and PwD. More research is needed with larger sample sizes.

Exergaming for people with major neurocognitive disorder: a qualitative study

PURPOSE

This study investigated the experiences of participation in a standing balance exergame program amongst people with major neurocognitive disorder (MNCD) within residential care settings.

MATERIALS AND METHODS

A qualitative descriptive study was conducted in participants with MNCD recruited from two residential settings. Participants exergamed for 15 min, three times per week for 8 weeks. Semi-structured interviews were conducted in all participants of the trial after 4 and 8 weeks. Audio files were transcribed and subsequently a thematic content analysis was performed using NVivo 12. Activity logs including adherence and attrition rates were kept.

RESULTS

Thirty-one participants with MNCD participated (median age = 85 (67-93) years; 77.4% women; Mini-Mental State Examination score = 19 (10-25)). Four broad themes emerged: (1) cognitive effects; (2) physical effects; (3) psychosocial effects and (4) motivators. The tailored exergame program was perceived as enjoyable. It stimulated participants' attention, concentration, reaction time, and memory. Participants reported improvements in balance, flexibility, and gait. Exergaming made participants energetic and calm. The attrition rate was 0% and the mean attendance rate was 79.3%.

CONCLUSIONS

The results indicate that standing balance exergaming is feasible, beneficial, and engaging in people with MNCD.Implications for rehabilitationExergames present a personalised intervention for engaging people with major neurocognitive disorder in physical activity.An exergame intervention is feasible and highly appreciated in this population.Exergames should be adapted to the individuals' needs and possibilities in order to enhance motivation and learning.

Telemedicine and Virtual Reality for Cognitive Rehabilitation: A Roadmap for the COVID-19 Pandemic

The current COVID-19 pandemic presents unprecedented new challenges to public health and medical care delivery. To control viral transmission, social distancing measures have been implemented all over the world, interrupting the access to routine medical care for many individuals with neurological diseases. Cognitive disorders are common in many neurological conditions, e.g., stroke, traumatic brain injury, Alzheimer's disease, and other types of dementia, Parkinson's disease and parkinsonian syndromes, and multiple sclerosis, and should be addressed by cognitive rehabilitation interventions. To be effective, cognitive rehabilitation programs must be intensive and prolonged over time; however, the current virus containment measures are hampering their implementation. Moreover, the reduced access to cognitive rehabilitation might worsen the relationship between the patient and the healthcare professional. Urgent measures to address issues connected to COVID-19 pandemic are, therefore, needed. Remote communication technologies are increasingly regarded as potential effective options to support health care interventions, including neurorehabilitation and cognitive rehabilitation. Among them, telemedicine, virtual reality, augmented reality, and serious games could be in the forefront of these efforts. We will briefly review current evidence-based recommendations on the efficacy of cognitive rehabilitation and offer a perspective on the role of tele- and virtual rehabilitation to achieve adequate cognitive stimulation in the era of social distancing related to COVID-19 pandemic. In particular, we will discuss issues related to their diffusion and propose a roadmap to address them. Methodological and technological improvements might lead to a paradigm shift to promote the delivery of cognitive rehabilitation to people with reduced mobility and in remote regions.

User Experience of Interactive Technologies for People With Dementia: Comparative Observational Study

Background

Serious games (SGs) are used as complementary approaches to stimulate patients with dementia. However, many of the SGs use out-of-the-shelf technologies that may not always be suitable for such populations, as they can lead to negative behaviors, such as anxiety, fatigue, and even cybersickness.

Objective

This study aims to evaluate how patients with dementia interact and accept 5 out-of-the-shelf technologies while completing 10 virtual reality tasks.

Methods

A total of 12 participants diagnosed with dementia (mean age 75.08 [SD 8.07] years, mean Mini-Mental State Examination score 17.33 [SD 5.79], and mean schooling 5.55 [SD 3.30]) at a health care center in Portugal were invited to participate in this study. A within-subject experimental design was used to allow all participants to interact with all technologies, such as HTC VIVE, head-mounted display (HMD), tablet, mouse, augmented reality (AR), leap motion (LM), and a combination of HMD with LM. Participants’ performance was quantified through behavioral and verbal responses, which were captured through video recordings and written notes.

Results

The findings of this study revealed that the user experience using technology was dependent on the patient profile; the patients had a better user experience when they use technologies with direct interaction configuration as opposed to indirect interaction configuration in terms of assistance required (P=.01) and comprehension (P=.01); the participants did not trigger any emotional responses when using any of the technologies; the participants’ performance was task-dependent; the most cost-effective technology was the mouse, whereas the least cost-effective was AR; and all the technologies, except for one (HMD with LM), were not exposed to external hazards.

Conclusions

Most participants were able to perform tasks using out-of-the-shelf technologies. However, there is no perfect technology, as they are not explicitly designed to address the needs and skills of people with dementia. Here, we propose a set of guidelines that aim to help health professionals and engineers maximize user experience when using such technologies for the population with dementia.

The Use of a Virtual Reality Platform for the Assessment of the Memory Decline and the Hippocampal Neural Injury in Subjects with Mild Cognitive Impairment: The Validity of Smart Aging Serious Game (SASG)

Due to the lack of pharmacological treatment for dementia, timely detection of subjects at risk can be of seminal importance for preemptive rehabilitation interventions. The aim of the study was to determine the usability of the smart aging serious game (SASG), a virtual reality platform, in assessing the cognitive profile of an amnestic mild cognitive impairment (aMCI) population, its validity in discriminating aMCI from healthy controls (HC), and in detecting hippocampal degeneration, a biomarker of clinical progression towards dementia. Thirty-six aMCI and 107 HC subjects were recruited and administered the SASG together with a neuropsychological evaluation. All aMCI and 30 HC subjects performed also an MRI for hippocampal volume measurement. Results showed good usability of the SASG despite the low familiarity with technology in both groups. ROC curve analyses showed similar discriminating abilities for SASG and gold standard tests, and a greater discrimination ability compared to non-specific neuropsychological tests. Finally, linear regression analysis revealed that the SASG outperformed the Montreal cognitive assessment test (MoCA) in the ability to detect neuronal degeneration in the hippocampus on the right side. These data show that SASG is an ecological task, that can be considered a digital biomarker providing objective and clinically meaningful data about the cognitive profile of aMCI subjects.

Utilisabilité des jeux vidéo sérieux avec activités physiques et cognitives dans le vieillissement normal, la maladie d’Alzheimer et les maladies apparentées

La prise en charge non-pharmacologique de la maladie d’Alzheimer et des maladies apparentées (MA) représente un enjeu de santé majeur chez les personnes âgées . L’environnement Enrichi (EE), combinaison de stimulations cognitive, physique et d’engagement social en contexte émotionnel positif, apparaît comme une méthode efficace pour lutter contre la progression d’une MA . La principale difficulté est de proposer aux patients un EE adapté et motivant. Les serious games peuvent aider dans ce sens . Xtorp est un Serious exerGame (à activité physique, SeG) d’action/aventure développé pour KinectTM. Le joueur pilote un sous-marin (Fig. 1). Il doit devenir Amiral 5 étoiles en collectant de l’expérience au cours de batailles et missions. Dix patients (MA stade léger) et 8 témoins ont suivi un programme d’entrainement avec le jeu durant 1 mois, réparties en 12 séances. Les performances au jeu, les émotions perçues (PANAS) et l’intensité d’effort physique induite par le jeu ont été étudiées. Tous les participants ont terminé au moins une fois Xtorp. Les patients ont une capacité de jeu inférieure aux témoins (temps total de jeu et vitesse de progression patents : 420 minutes et 185 points d’expérience/minute, témoins : 489 minutes et 287 points d’expérience/minute). Les patients et les témoins n’ont quasiment ressenti que des émotions positives, légèrement plus fortes pour les témoins (PANAS positifs patients : 27/50, témoins, 36/50 ; PANAS négatifs patients : 12/50, témoins 11/50). Enfin, le jeu a été stimulant physiquement mais à un moindre degré chez les patients (fréquence cardiaque de réserve moyenne et pic par séance patients : 33 % et 53 %, témoins : 44 % et 62 %). En conclusion Xtorp est un EE utilisable, motivant qui permet de réaliser une activité physique potentiellement modérée chez des patients présentant des troubles cognitifs.

Recommendations for the Nonpharmacological Treatment of Apathy in Brain Disorders

Apathy is a common neuropsychiatric syndrome observed across many neurocognitive and psychiatric disorders. Although there are currently no definitive standard therapies for the treatment of apathy, nonpharmacological treatment (NPT) is often considered to be at the forefront of clinical management. However, guidelines on how to select, prescribe, and administer NPT in clinical practice are lacking. Furthermore, although new Information and Communication Technologies (ICT) are beginning to be employed in NPT, their role is still unclear. The objective of the present work is to provide recommendations for the use of NPT for apathy, and to discuss the role of ICT in this domain, based on opinions gathered from experts in the field. The expert panel included 20 researchers and healthcare professionals working on brain disorders and apathy. Following a standard Delphi methodology, experts answered questions via several rounds of web-surveys, and then discussed the results in a plenary meeting. The experts suggested that NPT are useful to consider as therapy for people presenting with different neurocognitive and psychiatric diseases at all stages, with evidence of apathy across domains. The presence of a therapist and/or a caregiver is important in delivering NPT effectively, but parts of the treatment may be performed by the patient alone. NPT can be delivered both in clinical settings and at home. However, while remote treatment delivery may be cost and time-effective, it should be considered with caution, and tailored based on the patient's cognitive and physical profile and living conditions.

Efficacy of a Web App for Cognitive Training (MeMo) Regarding Cognitive and Behavioral Performance in People With Neurocognitive Disorders: Randomized Controlled Trial

BACKGROUND

Cognitive and behavioral symptoms are the clinical hallmarks of neurocognitive disorders. Cognitive training may be offered to reduce the risks of cognitive decline and dementia and to reduce behavioral symptoms, such as apathy. Information and communication technology approaches, including serious games, can be useful in improving the playful aspect of computerized cognitive training and providing motivating solutions in elderly patients.

OBJECTIVE

The objective of this study was to assess the effectiveness of employing the MeMo (Memory Motivation) Web app with regard to cognitive and behavioral symptoms in patients with neurocognitive disorders.

METHODS

MeMo is a Web app that can be used on any Web browser (computer or tablet). The training activities proposed in MeMo are divided into the following two parts: memory and mental flexibility/attention. The study included 46 individuals (mean age 79.4 years) with a diagnosis of neurocognitive disorders at the Institut Claude Pompidou Memory Center in Nice. This randomized controlled study compared the evolution of cognition and behavior between patients not using MeMo (control group) and patients using MeMo (MeMo group) for 12 weeks (four sessions per week). Patients underwent memory and attention tests, as well as an apathy assessment at baseline, week 12 (end of the training period), and week 24 (12 weeks after the end of the training sessions). In addition, to assess the impact of high and low game uses, the MeMo group was divided into patients who used MeMo according to the instructions (about once every 2 days; active MeMo group) and those who used it less (nonactive MeMo group).

RESULTS

When comparing cognitive and behavioral scores among baseline, week 12, and week 24, mixed model analysis for each cognitive and behavioral score indicated no significant interaction between testing time and group. On comparing the active MeMo group (n=9) and nonactive MeMo group (n=13), there were significant differences in two attention tests (Trial Making Test A [P=.045] and correct Digit Symbol Substitution Test items [P=.045]) and in the Apathy Inventory (AI) (P=.02). Mixed analysis (time: baseline, week 12, and week 24 × number of active days) indicated only one significant interaction for the AI score (P=.01), with a significant increase in apathy in the nonactive MeMo group.

CONCLUSIONS

This study indicates that the cognitive and behavioral efficacies of MeMo, a Web-based training app, can be observed only with regular use of the app. Improvements were observed in attention and motivation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04142801; https://clinicaltrials.gov/ct2/show/NCT04142801.

Quality of life in people with dementia living in nursing homes: validation of an eight-item version of the QUALIDEM for intensive longitudinal assessment

Purpose

Our aim was to examine whether quality of life which was repeatedly assessed over time is related with the comprehensive assessment of quality of life (QoL) and thereby to validate a brief QoL assessment.

Method

This longitudinal study used a comprehensive assessment of quality of life at baseline (QUALIDEM; 37 items) to validate an eight-item version of QUALIDEM to assess momentary quality of life which was repeatedly administered using a tablet device after baseline. In all, 150 people with dementia from 10 long-term facilities participated. Momentary quality of life and comprehensive quality of life, age, gender, activities of daily living (Barthel Index), Functional assessment staging (FAST), and Geriatric Depression (GDS) have been assessed.

Results

Comprehensive and momentary quality of life showed good internal consistency with Cronbach’s alpha of .86 and .88 to .93, respectively. For multiple associations of momentary quality of life with the comprehensive quality of life, momentary quality of life was significantly related to comprehensive quality of life (B = .14, CI .08/.20) and GDS (B = − .13, CI − .19/− .06). More specifically, the comprehensive QUALIDEM subscales ‘positive affect’, ‘negative affect’, ‘restlessness’, and ‘social relationships’ showed significant positive associations with momentary quality of life (p < .001).

Conclusion

We found that momentary quality of life, reliably assessed by tablet, was associated with comprehensive measures of quality of life and depressive symptoms in people with dementia. Broader use of tablet-based assessments within frequent QoL measurements may enhance time management of nursing staff and may improve the care quality and communication between staff and people with dementia.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02418-4) contains supplementary material, which is available to authorized users.

Game-based interventions for neuropsychological assessment, training and rehabilitation: Which game-elements to use? A systematic review

Game-based interventions (GBI) have been used to promote health-related outcomes, including cognitive functions. Criteria for game-elements (GE) selection are insufficiently characterized in terms of their adequacy to patients' clinical conditions or targeted cognitive outcomes. This study aimed to identify GE applied in GBI for cognitive assessment, training or rehabilitation. A systematic review of literature was conducted. Papers involving video games were included if: (1) presenting empirical and original data; (2) using video games for cognitive intervention; and (3) considering attention, working memory or inhibitory control as outcomes of interest. Ninety-one papers were included. A significant difference between the number of GE reported in the assessed papers and those composing video games was found (p < .001). The two most frequently used GE were: score system (79.2% of the interventions using video games; for assessment, 43.8%; for training, 93.5%; and for rehabilitation, 83.3%) and narrative context (79.2% of interventions; for assessment, 93.8%; for training, 73.9% and for rehabilitation, 66.7%). Usability assessment was significantly associated with six of the seven GE analyzed (p-values between p ≤ 0.001 and p. = 027). The use of GE that act as extrinsic motivation promotors (e.g., numeric feedback system) may jeopardize patients' long-term adherence to interventions, mainly if associated with progressive difficulty-increase of gaming experience. Lack of precise description of GE and absence of a theoretical framework supporting GE selection are important limitations of the available clinical literature.

The Multidisciplinary Approach to Alzheimer's Disease and Dementia. A Narrative Review of Non-Pharmacological Treatment

Background: Alzheimer's disease (AD) and dementia are chronic diseases with progressive deterioration of cognition, function, and behavior leading to severe disability and death. The prevalence of AD and dementia is constantly increasing because of the progressive aging of the population. These conditions represent a considerable challenge to patients, their family and caregivers, and the health system, because of the considerable need for resources allocation. There is no disease modifying intervention for AD and dementia, and the symptomatic pharmacological treatments has limited efficacy and considerable side effects. Non-pharmacological treatment (NPT), which includes a wide range of approaches and techniques, may play a role in the treatment of AD and dementia. Aim: To review, with a narrative approach, current evidence on main NPTs for AD and dementia. Methods: PubMed and the Cochrane database of systematic reviews were searched for studies written in English and published from 2000 to 2018. The bibliography of the main articles was checked to detect other relevant papers. Results: The role of NPT has been largely explored in AD and dementia. The main NPT types, which were reviewed here, include exercise and motor rehabilitation, cognitive rehabilitation, NPT for behavioral and psychological symptoms of dementia, occupational therapy, psychological therapy, complementary and alternative medicine, and new technologies, including information and communication technologies, assistive technology and domotics, virtual reality, gaming, and telemedicine. We also summarized the role of NPT to address caregivers' burden. Conclusions: Although NPT is often applied in the multidisciplinary approach to AD and dementia, supporting evidence for their use is still preliminary. Some studies showed statistically significant effect of NPT on some outcomes, but their clinical significance is uncertain. Well-designed randomized controlled trials with innovative designs are needed to explore the efficacy of NPT in AD and dementia. Further studies are required to offer robust neurobiological grounds for the effect of NPT, and to examine its cost-efficacy profile in patients with dementia.

Motor-cognitive effects of a computerized game-based training method in people with dementia: a randomized controlled trial

OBJECTIVES

To examine the effects of a computerized, game-based training on motor-cognitive performances, the transfer of training effects on untrained tasks, and the sustainability of training gains in people with dementia.

METHOD

Ninety-nine individuals with a mean age of 82.9 (5.8) and dementia participated in a 10-week randomized controlled trial with three-month follow-up. The intervention group (IG) received a motor-cognitive training on (Physiomat®) including concurrent dual-tasks of balance control with cognitive demands (Physiomat®-Trail Making Tasks (PTMTs)). The control group (CG) performed non-specific, low-intensity exercises. Duration and accuracy at different complexity levels of trained and untrained PTMTs and the number of successfully performed tasks (PTMT score) were assessed.

RESULTS

Physiomat® training significantly improved the duration and accuracy at almost all complexity levels of trained (P ≤ 0.001-0.047, η_p² = 0.065-0.589) and untrained PTMTs (P < 0.001-0.005, η_p² = 0.073-0.459). Significant effects were also found for the PTMT score of trained (P < 0.001, η_p² = 0.211) and untrained PTMTs (P < 0.001, η_p² = 0.184). Training gains were partly sustained at follow-up.

CONCLUSION

Physiomat® is feasible and has the potential to sustainably improve motor-cognitive performances in people with dementia.

Creating New Technologies for Companionable Agents to Support Isolated Older Adults

This article reports on the development of capabilities for (on-screen) virtual agents and robots to support isolated older adults in their homes. A real-time architecture was developed to use a virtual agent or a robot interchangeably to interact via dialog and gesture with a human user. Users could interact with either agent on 12 different activities, some of which included on-screen games, and forms to complete. The article reports on a pre-study that guided the choice of interaction activities. A month-long study with 44 adults between the ages of 55 and 91 assessed differences in the use of the robot and virtual agent.

Mobile and wearable technologies in healthcare for the ageing population

The 16th World Congress on Medical and Health Informatics (MedInfo 2017) was held August 21-25, 2017, in Hangzhou, China. It provided a valuable platform for sharing the latest medical and health informatics research and related applications to the scientists, medical practitioners, entrepreneurs, and educators as well as students. During this event, on August 23, 2017, an important related topic was presented in a panel discussion entitled "Wearable technologies: Advancing the healthcare in ageing population" by panelists Shabbir Syed-Abdul, Panagiotis Bamidis, Chun-Por Wong, and Xinxin Zhu. Recent advances in health technologies, focusing on the aging population, their benefits and challenges were discussed, and these topics are summarized in this paper. The need for technology to improve of the life of older population, influential and beneficial technologies, for delivering these technologies to patients are described in this paper.

Combining qualitative and quantitative methods to analyze serious games outcomes: A pilot study for a new cognitive screening tool

Computer games for a serious purpose - so called serious games can provide additional information for the screening and diagnosis of cognitive impairment. Moreover, they have the advantage of being an ecological tool by involving daily living tasks. However, there is a need for better comprehensive designs regarding the acceptance of this technology, as the target population is older adults that are not used to interact with novel technologies. Moreover given the complexity of the diagnosis and the need for precise assessment, an evaluation of the best approach to analyze the performance data is required. The present study examines the usability of a new screening tool and proposes several new outlines for data analysis.

Recommendations for the Design of Serious Games in Neurodegenerative Diseases

The use of Serious Games (SG) in the health domain is expanding. In the field of Neurodegenerative Diseases (ND) such as Alzheimer’s Disease, SG are currently employed to provide alternative solutions for patients’ treatment, stimulation, and rehabilitation. The design of SG for people with ND implies collaborations between professionals in ND and professionals in SG design. As the field is quite young, professionals specialized in both ND and SG are still rare, and recommendations for the design of SG for people with ND are still missing. This perspective paper aims to provide recommendations in terms of ergonomic choices for the design of SG aiming at stimulating people with ND, starting from the existing SG already tested in this population: “MINWii”, “Kitchen and Cooking”, and “X-Torp”. We propose to rely on nine ergonomic criteria: eight ergonomic criteria inspired by works in the domain of office automation: Compatibility, Guidance, Workload, Adaptability, Consistency, Significance of codes, Explicit control and Error management; and one ergonomic criterion related to videogame: the game rules. Perspectives derived from this proposal are also discussed.

System Development Guidelines From a Review of Motion-Based Technology for People With Dementia or MCI

As the population ages and the number of people living with dementia or mild cognitive impairment (MCI) continues to increase, it is critical to identify creative and innovative ways to support and improve their quality of life. Motion-based technology has shown significant potential for people living with dementia or MCI by providing opportunities for cognitive stimulation, physical activity and participation in meaningful leisure activities, while simultaneously functioning as a useful tool for research and development of interventions. However, many of the current systems created using motion-based technology have not been designed specifically for people with dementia or MCI. Additionally, the usability and accessibility of these systems for these populations has not been thoroughly considered. This paper presents a set of system development guidelines derived from a review of the state of the art of motion-based technologies for people with dementia or MCI. These guidelines highlight three overarching domains of consideration for systems targeting people with dementia or MCI: (i) cognitive, (ii) physical, and (iii) social. We present the guidelines in terms of relevant design and use considerations within these domains and the emergent design themes within each domain. Our hope is that these guidelines will aid in designing motion-based software to meet the needs of people with dementia or MCI such that the potential of these technologies can be realized.

Smart Aging Platform for Evaluating Cognitive Functions in Aging: A Comparison with the MoCA in a Normal Population

Background: Smart Aging is a Serious games (SGs) platform in a 3D virtual environment in which users perform a set of screening tests that address various cognitive skills. The tests are structured as 5 tasks of activities of daily life in a familiar environment. The main goal of the present study is to compare a cognitive evaluation made with Smart Aging with those of a classic standardized screening test, the Montreal Cognitive Assessment (MoCA).

Methods: One thousand one-hundred thirty-one healthy adults aged between 50 and 80 (M = 64.3 ± 8.3) were enrolled in the study. They received a cognitive evaluation with the MoCA and the Smart Aging platform. Participants were grouped according to their MoCA global and specific cognitive domain (i.e., memory, executive functions, working memory, visual spatial elaboration, language, and orientation) scores and we explored differences among these groups in the Smart Aging indices.

Results: One thousand eighty-six older adults (M = 64.0 ± 8.0) successfully completed the study and were stratified according to their MoCA score: Group 1 with MoCA < 27 (n = 360); Group 2 with 27 ≥ MoCA < 29 (n = 453); and Group 3 with MoCA ≥ 29 (n = 273). MoCA groups significantly differed in most of the Smart Aging indices considered, in particular as concerns accuracy (ps < 0.001) and time (ps < 0.001) for completing most of the platform tasks. Group 1 was outperformed by the other two Groups and was slower than them in these tasks, which were those supposed to assess memory and executive functions. In addition, significant differences across groups also emerged when considering the single cognitive domains of the MoCA and the corresponding performances in each Smart Aging task. In particular, this platform seems to be a good proxy for assessing memory, executive functions, working memory, and visual spatial processes.

Conclusion: These findings demonstrate the validity of Smart Aging for assessing cognitive functions in normal aging. Future studies will validate this platform also in the clinical aging populations.