INTRODUCTION

Nearly six million (5,935,635) seniors, aged 65 and over, live in Canada, representing 16.9% of the total population, which is expected to grow to 26% by 2036 [1]. This population is likely to experience cognitive decline with aging. Recent studies show that serious mobile games can potentially improve cognition in older adults [2, 3] . A serious game is one designed for a primary purpose other than pure entertainment [4]. The premise for this research lies on the idea that the aging brain is able to retain considerable plasticity [5] that can be fostered by playing computer games. These brain games are believed to improve cognitive functions such as executive functions, memory, attention and processing speed.

Older adults with dementia need to engage in meaningful activities that provide happiness, purpose and wellbeing to their lives. However, as one’s dementia progresses to later stages, an individual may find it difficult to engage in typical daily activities. If engaging and simple enough, serious mobile games may provide a meaningful activity to seniors with dementia who may participate on a regular basis and in playful ways This may have a positive impact on their cognitive skills, affect (emotions), and mood.

Most research that examine the benefits of interventions using computer games has been conducted with healthy older adults [6, 5]. Only a handful of studies have investigated how these games can be used as interventions for mitigating the progress of cognitive decline [7, 8, 9], and how playing these games may positively impact social engagement [10].  Despite the potential of brain training using mobile serious games for improving cognitive functions in older adults, the scientific evidence for the beneficial effects of these games on cognitive function, affect, and occupational engagement of older adults living with dementia is scarce.

We have developed a collection of serious mobile games, i.e., Whack-A-Mole (WAM), Word Search, Bejeweled, and Mahjong, sharing a common back end, for the assessment and intervention of visuomotor, cognitive and mental health conditions. They are appropriate for cognitively healthy older adults as well as those with up to moderate dementia. These touch-screen enabled computer games contain few rules and use a simple interface. As gameplay improves, each game becomes progressively more difficult. The software embedded in the suite of games captures gameplay data in an anonymized file.

The objective of this paper is to present on how playing one of our serious mobile game (i.e., Word Search) improves specific cognitive functions, engagement, affect, and occupational engagement in an older adult with dementia.

METHODS

Design and setting

This is a single case design (n=1), organized around three phases: baseline, intervention, and follow-up. The study was approved by the Research Ethics Board of the University of Alberta. Potential participants and/or their caregivers were given recruitment flyers that contained researchers’ contact details. Informed written consent was obtained from the participant’s Substitute Decision Maker (husband) and assent was obtained from the participant. Her husband was with her in the same room during the sessions. The study was conducted at the Alzheimer Society in Edmonton, Canada.

Participant

The participant was a 74 years old woman, diagnosed with Alzheimer disease. Her educational level was college diploma.

Variables and measures

The independent variable of the study is the “type of intervention”. We compared two interventions: a traditional paper-based word-search activity vs. playing a mobile and web-based word-search game. The dependent variables of this study are the occupational engagement of the participant, her affect, specific mental functions, and perception of the intervention. 

Occupational engagement: Engagement is a critical element when individuals take part in play and leisure occupations because a person who is playing is deeply immersed in the activity. The theoretical foundation of engagement relies on Flow Theory [11]. We measured engagement using a self-report engagement measure scale (a 4-point self-reported Likert scale, with 8 questions) that has been shown to have good internal consistency (Cronbach Alpha = 0.88) [12]. Engagement was measured after each session across all phases of the study.

Affect: Positive and negative affect are the emotional components of subjective well-being [13]. Affect was measured using the Positive and Negative Affect Scale (PANAS), which has been validated for use with older adults [13]. Affect was measured after each session across all phases of the study and the Delta PANAS was computed as the difference between the positive and negative affect scores.

Specific mental functions: Specific mental functions are part of the functions of the brain such as such as attention functions, memory functions, psychomotor functions, emotional functions, perceptual functions, thought functions, higher-level cognitive functions, mental functions of language, calculation functions, mental function of sequencing complex movements and experience of self and time functions [14]. We assessed the participant’s visual-search ability, scanning ability, speed of processing, mental flexibility, and executive function using the Trail Making Test A and B [15]; we further assessed their attention, concentration, executive function, memory, language, visuoconstructional skills, conceptual thinking, calculation ability, and orientation through the Montreal Cognitive Assessment (MOCA) [16]. Specific mental functions were measured at the beginning of the study and at the end of each phase.

Materials

This study is designed around the word-search activity. In this activity the player is challenged to find hidden words among letters in a grid. For the traditional paper-and-pencil word search, we prepared 16 levels of the activity. During the intervention, we used a mobile and web-based version of the word-search game in which the user is given to one minute to find all words hidden in a grid. As the level of the game increases, the length of the words (number of letters) and the complexity of the vocabulary also increases. This mobile game has 15 levels and provides immediate visual and audio feedback to the player regarding success on finding the words. The game was played on a 10-inch Android tablet.

Procedures

Baseline phase (1.5 weeks – 3 sessions): The participant was asked to play traditional paper-and-pencil based word search twice per week for sessions of 30 minutes.

Intervention phase (8 weeks - 16 sessions): The intervention started with one 15-minute training session on how to use the word-search mobile game. Once the participant understood how to play the game, she was asked to play the game twice per week for 30 minutes.

Follow up phase (1.5 weeks – 3 sessions): We withdrew the intervention. The participant was asked again to play traditional paper-and-pencil word search twice per week for sessions of 30 minutes.

A research assistant conducted all sessions. We encouraged the participant to play independently. The research assistant provided support to participant as needed.

Analysis

The PANAS and the engagement scale were analyzed according to the guidelines for single-case design research using both experimental and applied criteria. Visual and statistical analysis were conducted. Statistical analysis was conducted using the 2-standard deviation band method. Serial dependence of the data was assessed before performing any comparison between phases. Regarding specific mental functions, comparisons of the participant’s scores in TMT A and B and MOCA with her own scores were performed.

RESULTS

The participant completed the study. Figures 1 and 2 shows the results for the variables affect (Delta PANAS score minimum value= -40, Maximum value= 40) and engagement (self-reported sum of all scores, minimum value= 8, maximum value= 32).

Figures 1 and 2 are plot graphs showing the series of data in each of the study phases (Baseline, Intervention and Follow-Up). The dashed lines are the upper and lower limits calculated based on the baseline data. No data point at the intervention phase fell outside these limits showing that there was not a significant difference between the baseline scores and the intervention for affect or for engagement. However, the mean at the intervention was slightly higher than that at the baseline, for both variables. The mean at the follow-up was lower than that at the baseline for Delta PANAS variable, while it was higher at the follow-up than at the baseline for the Engagement variable (i.e. Delta PANAS mean at baseline = 28.67; Intervention = 29.27 and follow-up= 26.67. Engagement mean at baseline = 27.33; Intervention = 27.87 and follow-up= 27.67). Both variables exhibit a decreasing trend after the sixth intervention session.

The participant’s MOCA score at each measurement point were as follows: at the beginning of the study = 8, after the baseline = 11, at the end of the intervention = 13, at the end of the follow-up = 8. The participant’s TMT A plus B score (i.e. the sum of the seconds spent in each test) at each measurement point were: after the baseline = 995 sec.; at the end of the intervention = 942 sec.; and at the end of the follow-up = 839 sec.

Series of data had no autocorrelation at the baseline nor at the intervention. Scores for the intervention session No. 16 and the TMT scores at the beginning of the study were missing data.

DISCUSSION

This study aimed to investigate the effect of a technology intervention using a word-search mobile game on the cognitive function, affect and engagement in one older woman with dementia. In doing so, we measured cognitive skills at four times during the study. The results showed that the MOCA reached highest scores during the intervention. This may indicate that playing the mobile game affected the cognitive functions measured through the MOCA (i.e., attention, concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation).

The time spent by the participant in doing the trails during the test TMT A and B was shorter at the intervention compared with the baseline. Her time in this test at the end of the study was shorter than at both baseline and intervention. One explanation for this may be that playing word search either using the mobile version or the traditional paper and pencil version, might have helped the participant to practice the cognitive functions measured by the TMT A and B (i.e., visual search, scanning, speed of processing, mental flexibility, and executive functions) in similar ways. Another possible explanation is that, playing the mobile game helped the participant to improve such cognitive functions and some carry over effects were observed during the follow-up (phase in which we withdrew the intervention) causing that the scores were the highest at this last phase.

There was no significant difference between the affect and engagement at the intervention compared with the baseline. However, the results of this single case design provide hints about the possible benefits of brain training using mobile and computer games. First, the score in both scales were located at their highest third, showing that the participant was in general having a good time (engaged and good emotions) during the whole study. Second, both variables increased during the intervention phase compared with the baseline. This means that the participant perceived slightly more positive affect and engagement during the play experience using the mobile game. Third, the trend of data showed that: 1) the affect had an increasing trend during the first six intervention sessions with the mobile game, and 2) both variables (affect and engagement) had a decreasing trend after the sixth intervention session. It may be due to the participant was reaching higher levels that posed bigger challenges, making her fell less skillful and successful at playing. The Flow Theory indicates that when the challenge is very superior to the individual skills, the engagement might decrease [11]. Another possible explanation is that the participant started to feel bored because she played the same game during the whole intervention. However, she told us at every session that she had a good time.

CONCLUSION

This single case design study compared the affect and engagement of an older woman with dementia during sessions with a mobile word-search game and sessions with a paper-and-pencil version of the same activity. Results show that the mobile version was not statistically significantly more engaging, nor did it produced more positive affect (emotions) for the participant. However, the participant’s cognitive functions scores were better at the end of the intervention compared with the baseline. This result suggests that playing word-search mobile game regularly may be used to improve or at least maintain cognitive function in older adults with dementia. This result should be interpreted with caution because. Analysis of more participants is ongoing which will allow us to draw conclusions that are more definitive.