Serious Games for Dementia Illness Detection and

Motivation: The eMotiva Experience José Luis Bayo Montón

#1, Carlos Fernandez-LLatas

#2, Juan Miguel García-Gomez

*3, Vicente Traver Salcedo

#4

#ITACA – Health and Wellbeing Technologies

Universidad Politécnica de Valencia, Spain 1jobamon@itaca.upv.es

2carfell@itaca.upv.es

4vtraver@itaca.upv.es

*ITACA - Biomedical Informatics Group

Universidad Politécnica de Valencia, Spain 3juanmig@ibime.upv.es

Abstract— The increase in age-related diseases in our society is

growing constantly as a result of medical advances, about 824.00

new cases of dementia are diagnosed each year. Different studies

show that thanks to the plasticity of the nervous system, brain

degenerative processes may be delayed, this requires an adequate

stimulation of cognitive activity. The stimulation activities in

patients with dementia, it is particularly difficult since it is

necessary to maintain the patient's motivation at all times.

The eMotiva project is an Internet tool of the future that tries to

create a synergy between doctors and people with cognitive

degeneration caused by diseases associated with dementia to

promote social inclusion as a therapeutic method for patients

through the use of digital content in response to behaviour

disorders.

This article focuses on part of the developments made within the

project, to ensure that the patient perform a series of activities

which stimulate different cognitive processes such as memory or

attention, all trying to keep the patient motivated to achieve

activities continuity and perceives that these are not a burden,

but as an activity of leisure. To achieve this, the project has used

the paradigm of serious games used as a therapeutic tool.

I. INTRODUCTION

The aging of the population is without doubt one of the

hallmarks of our time and should be classified as a success in

the health field. However, the increasing number of elderly

means that the number of diseases of the aging process itself

is increasing, as is the case of dementia. It is estimated that

there are about 5,752,754 people in Europe with dementia and

there are 824,000 new cases per year. In Spain, it affects about

550,000 people, representing 1.24% of the population. Spain

is framed in the top 5 European countries in terms of number

of cases with dementia and the third in terms of percentage

from the total population [1].

Behaviour disorders of dementia are a reality faced by the

patients, families and health professionals given the long

evolution of this disease, and the relatively rapid deterioration

that occurs, the management of behavioural symptoms is so

important or more, than to trust on the potential benefit of

treatment of cognitive symptoms. These disorders often affect

the life of care-dependent people, who may then be excluded

from society. To overcome this, we need further treatment of

the disease beyond the mere management.

The stimulation and maintenance of brain function level is

based on the plasticity of the nervous system, a term that

refers to the ability of our Central Nervous System to create

and modify neural connections throughout life to compensate

for certain losses. With proper stimulation, the brain creates

new neural connections, which helps not to lose or maintain

for more time higher functions when a disease such as

Alzheimer's begins neuronal destruction, [2]. Motivational

processes are suitable for the treatment of these patients, based

on brain plasticity, and may include exercises of attention,

orientation, memory, money management, calculation,

reasoning, and social adjustment.

Current good practices in the care of older people are based

on comprehensive approaches that include actions such as the

stimulation and maintenance of cognitive processes. It has

been shown that continuous stimulation of cognitive activity

can alleviate the degenerative process of the diseases

associated with dementia.

The eMotiva's project raises the design and the

implementation of an active and comprehensive system for

monitoring and motivation of people with dementia in

institutional residences. The implementation of the monitoring

subsystem is based on pattern recognition in time series, to

detect behaviour patterns associated to disorders, and personal

motivation is based on the technologies of motivation. B.J.

Fogg [3] defines persuasive technology or motivating as a

system designed to change attitudes or behaviours of people.

II. OBJETIVES

The primary goal of administered therapies in dementia is

stimulate mental abilities of the affected, maintain their

autonomy and their social relations. In general, therapies

administered to patients with dementia affect that patients at

levels cognitive, functional (Activities of Daily Living) and /

or behavioural.

Based on this, eMotiva poses a motivation system that

seeks to promote skills in people with dementia at a cognitive

level, to encourage mobility and promote a state of relaxation.

The objective is defined as the creation of innovative

multimedia motivation tools, which enables influence on the

attitudes or behaviour of people with dementia to alleviate

their disease process.

III. MATERIALS AND METHODS

Within the treatments in dementia we can distinguish two

types of therapy: drug therapy and nonpharmacological

therapy, both compatible to be developed simultaneously.

The nonpharmacological therapy is defined as "a non-

chemical intervention, theoretically supported, focused and

replicable, made over the patient or caregiver and potentially

able to obtain a relevant benefit” [4]. Recent publications

confirm that nonpharmacological therapies have several

positive clinical effects: improve domains such as cognition,

behaviour or mood, and reduce caregiver burden, avoid or

postpone entry into old people’s homes, and can reduce the

cost care economic [5].

In this line are raised the motivational systems within the

project eMotiva, aimed at developing nonpharmacological

therapies focused on Alzheimer's patient.

As a motivational tool, it is proposed a software with a

games format, focused on two lines: one line on the cognitive

stimulation of the person with dementia, and other line on

physical stimulation and relaxation.

In order to ensure that the games are in line with the work

methodology of residential institutions, in-depth interviews

there have been conducted with medical personnel of the

Asociación de Familiares de enfermos de Alzheimer (AFA)

and the Boni Mediero's residence in Salamanca, and the staff

of San Sebastian's residential centre in La Pobla de Vallbona

(Valencia).

A. Devices

When designing and developing systems to encourage or

persuade older people, we must take into account the barriers

that they encounter in adopting and using new technologies.

Martijn H. Vastenburg et al. [6], indicate the complexity and

learning as well as lack of perceived benefit, as key factors to

consider when developing systems of motivation for older

people, as users may find the cost of adopting new technology

more than the expected benefit. In these cases they suggest to

increase the direct benefit that the technology produces to

increase the benefit perceived by the user.

To break the barrier of learning and simplify the use of

games, it was decided to use natural interaction techniques

based on the use of touchscreens as interface with the

computer, eliminating the use of keyboards and mice, in

particular it has been chosen an All-in-one PC which includes

the computer and a touch screen in a compact and nice design,

reducing the psychological barrier of dealing with a computer.

Figure 1 - All-in-one PC, MSI Wind Top

In those games that require physical interaction it has been

chosen to use the Wiimote remote control, this device can

measure acceleration in three axes of movement, offering

information from the user movements. We have chosen this

controller instead of one made to order or another brand, for

its low cost and for being shown its usefulness and ease of use

in existing developments in other studies.

Figure 2 - Wiimote remote control

B. Software Technology

For the development of games there have been used two

different software development technologies. In the

immersive type games there have been used the Microsoft

XNA technology, which is a set of tools for developing games

with high graphics capabilities and performance, for both the

Xbox console and computers running Windows. The second

technology used for non-immersive games is Windows

Presentation Foundation (WPF), this technology is not

specifically designed for games, but it offers a large

infrastructure and graphics power with animation, video and

audio capabilities. This puts it on the ability to develop non-

immersive games with high graphics performance and

interaction, reducing the development time compared with the

technologies specially designed for games and 3D

environments such as XNA.

IV. RESULTS

Within the project there are several game environments that

can be divided according to their objective into: cognitive

stimulation environments and physical stimulation

environments.

The cognitive stimulation games seek to work the areas

such as attention, memory or executive functions, being

cognitive areas the most affected at the beginning of dementia.

These games are presented in a touchscreen environment,

allowing users to interact with the game in a simple and

intuitive way, and are fully configurable as they allow

defining different scenarios playing with their parameters,

such as difficulty or number of items involved in the game.

On the other hand, with the aim of stimulating physically,

we propose a virtual paradise which seeks to encourage the

abandonment of the idle, transmit peace and quiet to the

player.

All in line with the conclusions drawn from interviews with

medical personnel, where the main lines were: The use of

simple equipment, easy to use and intuitive; Development of

games that incorporate visual or auditory stimuli to improve

memory, strengthen the patient's daily life activities, allowing

customization of the games to the needs and abilities of the

patient, and finally not forgetting the fun as the engine of

motivation for encouraging the use of games.

A. Rowing

1) Description:

The game is based on a realistic graphical model that

allows users to immerse themselves in a tropical paradise and

interact with it.

The game features several scenarios where the user can

move slowly interacting with the game using the Wiimote

remote control.

The figure shows a tropical paradise with an island in the

background, a sunny day and clear water, this scenario intends

to convey peace and quiet to the user.

Figure 3 - Rowing (screen capture)

2) How to play:

To play you need a screen and a Wiimote. The remote

control is taken as an oar and using gentle circular motion, the

camera is moved around the stage following a predefined path.

B. Follow the sequence

1) Description:

The screen shows a series of tiles and the user has to click

on them in a particular order. This order may be numeric or

size.

Figure 4 - Follow the sequence (screen capture)

2) How to play:

At the beginning of the game, the tiles are displayed, and

the player must click on the appropriate order. In the case of

numbered tiles, each tile carries within it a number, starting

with 1 and ending in the number of tiles that you have on the

board. The player must to click the tiles in increased

numerical order.

If we play by size, on the board appear tiles of various sizes,

but this time without a number. In this case, the player must

click the tiles beginning with the smallest and ending with the

largest.

If the appropriate tile is clicked, it turns green, indicating

that is the correct. If is wrong, on top of the screen is displays

a message encouraging you to try again, and is counted as a

mistake. Once all the tiles are lit, it is indicated in the same

part of the screen that the game is over and scores are stored.

If you click on a green tile also counts as a mistake.

You can configure how tiles appear on the board, having

three distributions. In the first distribution tiles are arranged in

a straight line. In the second, the tiles are aligned along a line

by decreasing size. In the third, the tiles are randomly

distributed across the board. So the game has defined six

levels of difficulty, which cover all combinations of tile types

and distributions on the board.

C. Dress the doll

1) Description:

The screen shows a doll and a set of clothes. The user

should dress the doll with the appropriate ones.

Figure 5 - Dress the doll (screen capture)

2) How to play:

The screen shows a figure that can be male or female, and

many different clothing. The player must drag each piece of

clothing to the area where it belongs. When it is close enough,

the garment is adjusted automatically, and a message reports

that it has been placed properly. When the article does not

approach to the area corresponding to it, nothing happens, so

you cannot put an item out of place.

The silhouette can be male or female, depending on the

difficulty. If male, the clothes are four: shoes, tie, shirt and

trousers. Therefore, at least four elements appear on the screen,

without the dummy. If the figure is female, there are a jacket,

a handbag, high heels, a skirt and a mobile, a total of five

pieces.

You can bring up one set of items or two sets of items for

each silhouette. That is, in the case of man, can be configured

to appear a set of trousers, shirt, tie and shoes in yellow colour,

and other set in blue colour, and the same for the female

figure, although in this case the colours are black and blue.

In the first degree of difficulty, only appears one set of

clothes, and the player simply has to drag each garment into

his place, so that you cannot make mistakes. However, when

there are two pieces of each garment, we can control that the

player must dress the silhouette in a particular colour or select

the clothes in the same colour.

D. Link sounds with elements

1) Description:

This game, as well as visual and tactile, incorporates sound

elements. Various elements are presented on the screen, each

one with a distinctive sound. The user must connect the sound

you hear with its visual representation.

Figure 6 - Link sounds with elements (screen capture)

2) How to play:

To start the game, the user must click on the button labelled

"Play Sound" that appears on the left side of the board. When

clicked, it plays an audio associated with any of the items

represented on the board. Having heard the sound, you must

click on the element of the board related to that sound,

clicking on another element is counted as a mistake, and on

top of the screen tells the player to try again. If correct, is also

indicated with a message. The elements that have already been

clicked count as a mistake if you click them again and sound

does not change until you get right which element it belongs.

The sounds can be heard as often as necessary. When you

click on the correct item, the sound changes to the next item,

and when all have been clicked correctly, indicates that the

game is finished and data is saved. The sounds order is

random and the way the figures are placed on the board is

random too, so every game is different.

The elements vary in type and number to increase the

complexity, taking from musical instruments or animals, to

fragments of songs that must be associated with the interpreter.

E. Grouping objects

1) Description:

Various objects appear on the screen related in some way

and the user will have to separate them into two groups

according to their relationship.

Figure 7 - Grouping objects (screen capture)

2) How to play:

The game is to group shapes according to their shape or

colour. It features a configurable number of elements on the

board that the player must drag to a defined area, in which to

group the items based on certain criteria.

When starting the game, in the central part appear the

figures, distributed randomly. In the upper left corner

indicates the way they should be grouped. The areas where the

figures must be carried are green and yellow boxes that are in

the ends of the board. When the figures are close enough to

these boxes will automatically move on them. Once placed, a

figure cannot be moved again. When all have been placed, it

will display a message in the middle of the board indicating

that the game has ended.

You can vary the difficulty of the game using the number

of elements and the number of colours of them.

V. CONCLUSIONS

The developed games aim to raise enough motivation for

users to feel connected to their internal dynamics, which

include playful and entertaining aspects, with a high value of

auditory stimulation, visual and incorporating progressive

levels of difficulty.

On the one hand, we must emphasize the importance of

those games where, as in the Rowing game, it interacts with

the movement itself, recreations where the user is moving to

increase physical activity and, as a therapeutic tool, aims to

improve motor skills. In addition, the overall atmosphere of

the game tries to generate an atmosphere of calm and

animosity to involve the player emotionally, which will

increase their motivation to perform the task. Emotions are an

important part of motor learning, a means of reinforcement or

for avoidance of behaviours, are useful to produce a

significant motivation to prevent apathy, inactivity or

passivity.

On the other hand, the other games try to stimulate different

areas of cognition such as memory, attention or executive

functions, as well as stimulate visual and auditory perception.

The cognitive stimulation has its biological basis in

neuroplasticity or plasticity of the nervous system as

mentioned in the introduction. On this basis, frequent

interaction with a game environment rich in stimuli, can be

considered positive in maintaining cognitive abilities in

people with dementia. Each game presents a challenge and an

attempt to improve day by day, which can have effects on

people's emotional interaction. So the games are presented as

elements that can promote motivation.

After an initial presentation of the games to the medical

staff, the first assessments are agree that these appear to

comply with the guidelines of simplicity, the inclusion of

different requested elements of cognitive stimulation and

capacity to be included easily in their daily activities with the

patient.

F. Future lines of work:

The path or line of work ahead is clearly marked and goes

through to make a gaming implementation of motivation in

the centres that are part of the project. To carry out

subsequently a randomized controlled study, in subjects with

Alzheimer-type dementia, in its later stages. The study will

have ten weeks of duration, during which patients will have

thirty play sessions, it will try to assess the status of the

patient before the study and at its conclusion, comparing their

evolution against a control group, to try to validate the

theoretical conclusions initially mentioned in this article and

proposed in the eMotiva's project.

ACKNOWLEDGMENT

Authors thank the eMotiva consortium for their

contribution to this work.

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