Development of the Training Platform "AD-GAMING" for the Improvement of Quality of Life of People with Dementia through "Serious Games"

  

    
brain Tuner 
    
Positive aspects 
    
Challenges  
    
Solutions 
  
  

    
Shadows 
    

      
Fun and interesting game. 
    
    

      
Some players were anxious to get the answer correct or unable to    complete the task in the allotted time. 
      
Can be difficult for people with visual problems. 
    
      
 
    

      
Use a projection screen to encourage group interaction. 
      
Increase the difficulty as players improved with practice. 
      
Increase the size of the silhouettes. 
      
Allow more time for people to engage with the game. 
    
  
  

    
Supermarket 
    

      
Promoted enhanced mood and concentration. 
      
Promoted satisfaction when achieved goal. 
      
The game was applicable to activities of daily living. 
      
Attractive game with an engaging design. 
      
Promoted mathematical abilities. 
      
Promoted collaborative working. 
    
    

      
Difficulties engaging with the touchscreen. 
      
A difficulty reading the banners as the writing was small. 
    
    

      
Provide players more time to interact with the technology and engage    with the game. 
      
Have the PC as a platform for the game rather than iPad. 
    
  
  

    
Brain Tuner 
    

      
Promoted mathematical abilities and cognitive stimulation. 
      
Simple and easy to follow. 
      
Applicable to activities of daily living. 
      
Engaging colours and easy to read numbers. 
    
    

      
None. 
    
    

      
Could provide rewards when objective is achieved. 
    
  
  

    
Sea Hero Quest 
    

      
Fun and adventurous game with clear objective. 
      
Promoted enhanced mood, collaboration and social interaction. 
      
Attractive and engaging game that caught people's attention. 
      
Good use of rewards at the end of each level. 
    
    

      
Sometimes difficulties moving the boat. 
      
Difficulties with the touchscreen. 
    
    

      
Have a video with the demonstration of the game next to the player as    they engage with it. This will remind them of the target. 
      
After practice players became more competent at engaging with the    game. 
    
  
  

    
Large pieces jigsaw 
    

      
Engaging colours and shapes. 
      
Enhanced sense of mood. 
      
Promoted collaborative working. 
    
    

      
Difficult to understand the objective of the game. 
      
Difficulty with the touch screen technology. 
    
    

      
PC version of the game. 
      
Clearer instructions to understand the purpose of the game or a video    outlining the objective. 
    
  
  

    
Kinesiotherapy 
    

      
Promoted physical exercise and enhanced sense of mood. 
      
Promoted collaboration. 
      
Promoted the use of memory. 
    
    

      
None. 
    
    

      
Provide a reward when objective is achieved. 
      
Clear instructions on the purpose of the game. 
    
  
  

    
Kinect sports 
    

      
Promoted physical exercise. 
      
Promoted fun and enhanced mood, particularly bowling and golf game. 
      
Promoted concentration. 
      
Engaging game with colourful graphics. 
      
Promoted reminiscence. 
      
Promoted competition and collaboration. 
      
People improved through practice. 
      
Did not require the use of a controller. 
    
    

      
Games such as tennis and football were more difficult as they were    played at a faster pace. 
      
Difficulty with positioning required when engaging with the game. 
      
On occasions more difficult using the sensor for left handed people. 
      
Some people had difficulties understanding the sensor. 
      
Difficult for people in wheelchairs. 
    
    

      
Use markings on the floor to indicate where people should stand. 
      
Provide support to navigate the instruction screens. 
    
  
  

    
Maths Run 
    

      
Fun game with colourful/engaging graphics. 
      
Promoted calculation skills. 
      
Promoted attention. 
      
Easy to understand game. 
    
    

      
Some graphics could be a little off-putting such as the fireworks. 
      
Difficulties with some of the calculations. 
    
    

      
Reward system so players are aware when they have answered a question    correctly. 
    
  
  

    
Nintendo Wii sports and balance board 
    

      
Promoted physical exercise. 
      
Promoted fun and enhanced mood. 
      
Promoted competition. 
      
Promoted sense of balance. 
      
Engaging game with colourful graphics. 
      
Promoted reminiscence. 
      
Promoted competition and collaboration. 
      
People improved through practice. 
      
Games could be played sitting down. 
    
    

      
More complicated movements that required a controller. 
      
Games such as tennis and football were more difficult as they were    played at a faster pace. 
      
Some people had difficulties understanding the sensor. 
      
The balance board could be difficult for some people to understand. 
    
    

      
Players improved with practice. 
      
Provide support to navigate the instruction screen. 
    
  
  

    
Google Earth 
    

      
Fun and entertaining game with engaging colours. 
      
Promoted reminiscence. 
      
Promoted socialisation and collaboration. 
      
Enabled people to view the world. 
      
Generated ideas for future places to visit. 
    
    

      
Difficulties navigating the screen, particularly with finger dexterity    issues. 
      
Difficulty viewing the screen on the iPad. 
      
Game can be quite short. 
    
    

      
Stylus can support interaction with iPad. 
      
iPad can link to a TV screen. 
      
Practice with the iPad can improve abilities. 
      
Playing in groups to promote discussion. 
      
Provide clearer motivations on what you would like players to find.    Have a list of questions that you can set players to answer. 
    
  

Table 4: Technological games played in Phase 1.

Also, at the begging, methodology, information and tools for guiding the Co-Creation sessions were developed and agreed among partners. Partners collected and shared basis, recommendations and tools for improving active and healthy ageing through the exploitation of Assistive Technologies, to be used in the Co-Creation Working Sessions. During the Sessions partners and PwA discussed about the more relevant SGs, based on both cognitive and QoL criteria, about the key factors and tools for getting a successful transference of knowledge, and agreed on the specific characteristics of the Training Materials, Designed Experiential Activities and e-Training Platform (some interviews questions in the Box 1).

As participants engaged with the SGs, feedback data was collected through researcher’s observations and verbal feedback from the players. The data collected included: positive aspects of the games; the challenges that players faced when interacting with the SGs; and any solutions that were found to enhance the players’ experiences of engaging with the SGs. Tables 3 and 4 below include some examples of the feedback. The main categories for the description of each game (positive aspects, challenges and solutions) were according to the Guide “Using ICT in activities for people with dementia” [14].

After the Workshops the Co-Created Methodological Guide was developed, with the direct participation of end users. Its main objective was determining the key contents, methodologies and tools needed for creating and improving the critical competences of PwA and their caregivers for increasing their QoL through the exploitation of “SGs”. The Co-Created Methodological Guide also includes:

• The training program as an outline of the training process.
• The evaluation and determination of SGs to be included in the Training Program.
• Key competences related to the exploitation of SGs by PwA and critical points in which trainees should improve after the training.
• Key factors for getting successful knowledge transference to PwA in terms of training approach.
• Evaluation and determination of specifications and approach of the Training Materials and Designed Experiential Training Activities.
• Evaluation and determination of technical specifications and approach of the e-Training Platform in terms of accessibility, usability and applications to be included.

Key Findings

It is crucial to underline some of the main outcomes relevant to the environment, the technology and the professionals who take care of PwA, that are included in the Methodological Guide.

First of all, according to our results, it is important to create an environment where people feel safe to engage with the SGs. When using sensor technology such as the Nintendo Wii or the Microsoft Kinect, it is important that players have enough space to move around without fear of hitting others. The television should be positioned at eye level and the sensor can be placed above or below this. It may also be worth placing other chairs in a semi-circle around the television screen (but at a safe distance from the players) so that those not engaging with the games can still watch. This means that even if people are not playing the SGs then they can feel a sense of enjoyment from it.

When using SGs that require people to sit down to interact with them then it is important that practitioners provide a space where players can sit at a table. Arranging the tables in a circular fashion will also encourage people to socially interact as they engage with the SGs. Practitioners may also wish to consider having care partners sit and watch the SGs even if they don’t interact with them. Research has shown that this can challenge some of their views of the capabilities of PwD and is also likely to encourage socialisation between the care partner and person with dementia [15].

Between 1.5 and 2 hours is probably the optimal time for engaging people with dementia in SGs. The effectiveness of this duration for non pharmacological interventions has been well demonstrated through research findings and also from the experience of implementing non-pharmacological interventions in the GAADRD day centres during the last 10 years [16,17,7]. This duration provides enough time for PwD to play the SGs at their own pace, and provide feedback on their experience. Any shorter and people may feel rushed, and any longer and people may begin to disengage.

It is important that PwD are enabled to interact with the SGs and the technology independently. Practitioners should be aware of the support they provide to players and ensure they are not being over-controlling. For example, if users struggle to hold the weight of the tablet as well as interact with it, then practitioners should avoid taking over the game, but instead hold the tablet to enable the player to engage with the game with both hands. Similarly, practitioners should consider having their own controller when instructing PwD to use the Nintendo Wii. This way they can point to the button or carry out the action on their controller whilst instructing the player to do likewise on theirs. Of course, on occasions and with certain people (depending on their capabilities) it may be necessary to provide more support, but it is important for practitioners to be mindful that their aim is to empower PwD whilst they interact with the game.

When first engaging PwD with SGs, practitioners would be advised to begin by using simple games and to attempt to tailor these to the interests of the players. Research has shown that PwD are more likely to interact with activities if they are tailored to their personal interests [18]. It is important that practitioners find out this information prior to running SGs sessions with PwD. Where applicable, it is also beneficial to keep the volume high on the SG. Often the music is fun and engaging, and this is likely to encourage people to interact with the game.

Easier SGs tends to be those games that have slower graphics, have relatively straight-forward goals and do not require complicated movement and button combinations. It is important that practitioners assess the difficulty level of the games before engaging PwD. If a game is too hard for a person, then they are likely not to return to it and this may discourage them from attempting to play any other SGs in the future. Most SGs offer difficultly settings and so it is important for practitioners to ensure that these are set to the easiest level at the beginning; they can always be adjusted as players improve.

Practitioners may find that some PwD are more confident at engaging with the SGs than others. In these instances, practitioners would be advised to encourage the more confident people to play the game first and enable those who are less confident to watch. This is likely to reassure those who were initially apprehensive and so inspire them to also play the SGs. It may also be possible for practitioners to pair up the more confident players with those that are less confident, and so encourage them to work together to engage with the SGs. Encouraging players to engage with group-based SGs is a good way to promote social connections and conversations.

It is important that practitioners regularly collect feedback on the appropriateness and fun factor of the SGs from PwD and their care partners. This feedback can be used to inform future sessions and decisions on other SGs that users may wish to play. Quantitative measures (such as questionnaires on QoL or well-being) can be used, although these are often not subtle enough to pick up on ‘in-the-moment’ benefits for PwD. As such, the best way to obtain feedback on the SGs is to ask those people playing the games and watch them as they interact with them. This qualitative data will ensure that practitioners can continue to engage PwD in SGs that will appeal to them and therefore likely to bring them benefits.

When engaging in feedback discussions, practitioners would be advised not to focus solely on those members who are more outgoing or loud. Whilst the information they provide will be important it may not be representative of the whole group. It is essential that practitioners also look to include the quieter members in the conversations as well. Practitioners would also be advised to adjust their approach when engaging PwD for feedback. Some may respond better in a group situation where as others may be better in a one-to-one situation.

Phase 2: Development of the online platform and training documents

The final SGs that had been selected are Shapes, Word scramble, Hangman, Pixels, Sea Hero Quest, Math Run, Google Earth, Wii Sports, Match pairs, Bingo, Matchstick Math, Tactile disks, Motoric tree, SixStix, Kinect sports, Kinesiotherapy, Supermarket, Virtual Garden, Dual Task, Number balance, Word games, Large pieces jigsaw, 3 D Flash Chess, Maze games, Brain tuner, Driving and parking cars games. The main criteria were to include at least five games from each country, which are well developed, tested, available and focused on the 8 cognitive dimensions. Furthermore, there is also literature evidence that these SGs are effective and usable for PwA [7,15,19,20-23]. For example, Padala et al. [24] in their research used a relatively large number of participants (N=22) and had a high number and frequency of gaming sessions (5 sessions per week for 8 weeks/participant), showing that the PwD could benefit from WiiFit in acquiring better balance and gait, compared to a walking program.

Training Materials addressed to PwA, families and professionals for facilitating the exploitation of SGs were developed including:

• Basics for improving the cognitive situation and global QoL of PwA through the exploitation of SG.
• The available SGs which focused on cognitive symptoms and the improvement of the QoL of PwA.
• Guidelines for evaluation of personal needs and criteria for proper SGs selection.
• Guidelines for playing the selected SGs depending on the cognitive symptoms to be focused on, conditions of PwA, participation of professionals or families, use in assistive centers or domestic environments, etc.
• Basic and easy-to-understand guidelines to develop digital and technological skills directly related with the exploitation of ICT-Serious Games.
• Adapted Training Materials developed in different modules adapted to the target stakeholders (PwA, families and professionals) and roles (trainers and trainees), including text-based information, presentations, videos, games and exercises.

Phase 3: Evaluation of the online training platform and training documents

Each partner undertook workshops within their respective countries throughout April-July 2018. The workshops aimed to introduce the SGs platform to dementia practitioners (formal and informal caregivers) whilst recording observations of how they navigated through the platform, as well as their opinions about the benefits and limitations of the platform. Each of the workshops focused on one of the 8 dimensions that make up the SGs platform: memory, attention, orientation, calculation, praxis, language, perception and executive function.

Forty six (46) workshops were undertaken across the 5 countries, with 254 participants taking part in the evaluation. The participants included 163 informal care partners, 75 health professionals and 15 PwD. The majority of the participants were female (204) and their age ranged from between 20 years old to 82 years old (Table 2).

A synthesis of the data collected from all partners has been outlined below. This includes feedback from informal care partners and dementia practitioners. The findings have been separated into three main themes: Benefits of the Serious Games Platform, Aesthetics of the Platform, and Accessibility of the Platform. The strengths and limitations, as identified by participants, have been outlined below alongside recommendations to consider during the development of the online platform.

Benefits from serious games platform:

• Care partners and dementia practitioners warmly welcomed the SGs platform and felt that they would use it regularly within their practice to enable them to prepare activities that would be welcomed by PwD. They appreciated the fact that the platform provided them with both ICT and non-ICT games that they could use within their practice. Care partners also felt that they would use it within their homes with their grandchildren and so break down intergenerational barriers.
• Care partners and dementia practitioners highlighted the need to provide the benefits of SGs within the platform as this began to challenge their perceptions of using them with PwD.
• It was also considered beneficial that the platform provided a range of diverse games (and alternative games) and offered them a detailed understanding of the games and how they could be used with PwD in both a one-to-one scenario and in a group setting. They also appreciated information that outlined how the games could be adapted to the interests and capabilities of the PwD they are working with.
• The platform has good value in aiding social inclusion of PwD by giving ideas on how to be more inclusive and build relationships through ideas (and adaptations of games) health professionals might not have thought of.
• Care partners and dementia practitioners felt that the additional information about the psychological benefits of the SGs was beneficial because it provided some gravitas and scientific purpose to their activities.
• Both care partners and dementia practitioners reported that the collaborative space would be useful to them and that they would probably use this feature of the platform.
• The help/tutorial tab was considered very useful and easy to use. It provided good information on using the SG platform.

Aesthetics of the platform:

• A common theme was that the grey background and lack of pictures made this exciting platform seem less appealing and more difficult to navigate.
• Although most of the practitioners and care partners found the information about dementia interesting, some disliked the large blocks of text. The initial text at each game (in blue italics) was considered hard to read.
• Practitioners felt that due to time pressures in their job, they would not realistically have the time to read large blocks of text such as those present at the “General Materials” section. As such, this information was deemed secondary in importance to the information provided on the games themselves. Care partners had more time to absorb the information on the platform and so this was not considered as big problem for them.
• Suggestions for improvement from experts and caregivers:
• Improve direct access to the platform from the home page. The buttons should be clearly visible.
• Modify the color design of the platform. Some more specific suggestions are: add extra pictures, more images or a subtle colored background.
• Present the information in the “General Materials” section (about dementia, the cognitive areas and the serious games’ strategies) in a more accessible format e.g. concise bullet points that are broken up with pictures, or a series of short video clips on each of the cognitive areas. Another suggestion might be to offer the information in dropdown tabs or linkable chapters so that it looks less daunting, but people can select certain information to read if they are interested.

Accessibility of the Platform:

• Some practitioners stated that they may benefit from an option to search for games according to PwD’s interests, in accordance with the person-centred manner that they are accustomed to working in, rather than purely searching in relation to cognitive dimensions or the cognitive deficits of PwD. These interests could include gardening, sports, arts, reminiscence and travelling, card games, word games, driving games etc. Many practitioners also wished to search for games according to difficulty levels (e.g. easy, medium and difficult).
• Barrier reported by care partners and dementia practitioners was the lack of technological devices that they owned at home. This would prevent them from using these devices outside of a work setting.
• More physical exercise games could be provided on the SGs platform as this would mean that they could be played at home and care partners wouldn’t need to purchase additional technological equipment.
• A frequent barrier was that some practitioners and many of the care partners did not understand the meaning of some of the psychological terms commonly used within the training platform and this made them hesitant to select these options in the search function. These words included ‘gnosis’, ‘Kinesiotherapy’, ‘Executive Functions’, ‘calculus’ and ‘Praxis’. Also, some practitioners felt that the term ‘physical’ games indicated that these games involved some level of physical exercise, rather than just being a non-ICT game.
• Simplifying some of the language into layman’s terms to remove the academic barrier would make the platform more accessible. This is also likely to improve the accessibility for informal care partners who may have limited understanding of psychological terms. Also, changing ‘physical’ games to ‘non-computerized’ or ‘non-digital’ games (and use of the term digital rather than ICT) could aid comprehension by non-specialists.

Discussion

The data collected from all these workshops demonstrated that the practitioners and care partners found the SGs training platform useful and were excited about the prospect of using it to support the well-being of PwD. These results are in accordance with a huge amount of research in the field of SGs and PwD [7,12,15,19-23,25].

However, at present, there were some issues with the presentation of the information on the platform as well as its accessibility, which they felt needed to be addressed before they could successfully adopt it within their daily practice. They were predominantly focused on ensuring the website was more colorful and engaging, the language was user-friendly with less psychological jargon, and the search function for the games was more person-centered (so the activities could be better tailored towards the interests of PwD) and more prominently displayed. Chi, H., et al [12] in an assessment analysis for mHealth apps and on-line Smart Thinker suite of SGs for PwD underlined the need for SGs to be user-friendly, simple to understand, easy to play and easily accessible on home computers.

According to our results, although practitioners may wish to use SGs with PwD and their care partners, it is important they first explore whether there is an interest for this. If PwD and their care partners have no interest in learning about the technology or engaging with it, then any SGs initiative is likely to fail from the very start. It is advisable that practitioners approach their intended audience, prior to purchasing any technology, to establish whether this is something that would be of interest. Mayer M. and Zach J. [26] found that using simple games specifically customized for PwD ease the process of eliciting user needs, enhance the interest of these people and realistic prototypes allow design evaluations with PwD early on.

However, it is also important to consider that a lot of PwD and care partners will be unaware of the technology available for them to use, and consequently may also be fearful of it [23]. In these situations, it is advisable that practitioners bring some of the technology they intend to use along with them to these preliminary meetings and use it as part of a “taster session”. During this “taster session” practitioners can display the technology and SGs they are interested in using and explain some of their benefits.

The participants at the validation pointed the positive aspects of both the platform and the contents. They underlined that there is a good balance of contents and many useful and practical information. The platform is accessible and easy to use. Participants also suggested the topics that could be improved or changed. For example, for them is important the platform to have more user-friendly language and less technical jargon and more images and videos to increase the attractiveness of the contents. They underline that it is crucial to ensure the correct functioning of all the links and references and provide them in national languages and to improve some design aspects (colors, buttons, and information layout).

Using the results of this validation, and the internal revision of the contents, the consortium discussed a list of improvements. Most of the suggestions have been implemented at the platform, while others have been rejected due to technical reasons or because they have not been considered a priority. Some of the suggestions rejected have been added to future revisions of the platform, as stated at the exploitation plan. For example, according to the feedback of the phase 3, in the final version of the platform, audios to the video tutorials, practical activities to all the games and introductory texts to the Main platform page were added. Improvements to the direct access to the platform from the home page like button clearly visible and sub menus were implemented. The consortium also added moderators of each partner for the national Forums and put on the games and the general materials a box sentence inviting to use the collaborative space. These changes will improve the usefulness of the platform. Finally, some improvements in the search of games like the dropdown list at the search criteria, to avoid that the users think that more than one search option is possible were also important to be changed.

In conclude, it is crucial to underline that involving PwD as co-designers in the development of technology is deemed challenging, but not impossible. However, even with the update and expansion in the current project, specific insights in appropriate research methods and materials is still lacking [27]. Extensive reports on the methodology and evaluation of the experiences of involvement of the PwD themselves are generally missing. This makes appreciation of the active involvement of PwD and creates co-design difficulties within this combined field. Future research and projects should therefore continue to concentrate on and characterize how methodologies and materials could be collected, designed and implemented.

Conclusion

AD-GAMING is an innovative platform for increasing the technological skills of PwD, their families and caregivers, through the use SGs and focuses on improving their quality of life. Many research show that SGs can offer benefits to PwD and their families, but there are still a range of barriers. The results of this project show that this training platform can be a solution to such issues and difficulties. This program, aims also to enhance the equity and the inclusion of PwD, as it allows them to be an active part of their communities through gaming with their families and peers.

Acknowledgments

The authors would like to thank the project team, Alzheimer’s Valencia, Bournemouth University Ageing and Dementia Research Centre (ADRC), Alzheimer’s Slovenia, Alzheimer’s Romania, Greek Association of Alzheimer Disease and Related Disorders (GAADRD) and the Institute of Biomechanics of Valencia (IBV).

Disclosure Statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported by the Erasmus+ EU program under Grant 2016-1-ES01-KA204-025313

Ethics Approval

School of Psychology, Faculty of Science and Technology, Bournemouth University Talbot Campus, Fern Barrow, Poole, Dorset, BH12 5BB.

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