Paper José Luis Bayo - Serious Games For Dementia illness Detection and Motivation: The eMotiva Experience
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 1 email@example.com 2 firstname.lastname@example.org 4 email@example.com * ITACA - Biomedical Informatics Group Universidad Politécnica de Valencia, Spain 3 firstname.lastname@example.orgAbstract— The increase in age-related diseases in our society is from society. To overcome this, we need further treatment ofgrowing constantly as a result of medical advances, about 824.00 the disease beyond the mere management.new cases of dementia are diagnosed each year. Different studies The stimulation and maintenance of brain function level isshow that thanks to the plasticity of the nervous system, brain based on the plasticity of the nervous system, a term thatdegenerative processes may be delayed, this requires an adequate refers to the ability of our Central Nervous System to createstimulation of cognitive activity. The stimulation activities inpatients with dementia, it is particularly difficult since it is and modify neural connections throughout life to compensatenecessary to maintain the patients motivation at all times. for certain losses. With proper stimulation, the brain createsThe eMotiva project is an Internet tool of the future that tries to new neural connections, which helps not to lose or maintaincreate a synergy between doctors and people with cognitive for more time higher functions when a disease such asdegeneration caused by diseases associated with dementia to Alzheimers begins neuronal destruction, . Motivationalpromote social inclusion as a therapeutic method for patients processes are suitable for the treatment of these patients, basedthrough the use of digital content in response to behaviour on brain plasticity, and may include exercises of attention,disorders. orientation, memory, money management, calculation,This article focuses on part of the developments made within the reasoning, and social adjustment.project, to ensure that the patient perform a series of activitieswhich stimulate different cognitive processes such as memory or Current good practices in the care of older people are basedattention, all trying to keep the patient motivated to achieve on comprehensive approaches that include actions such as theactivities continuity and perceives that these are not a burden, stimulation and maintenance of cognitive processes. It hasbut as an activity of leisure. To achieve this, the project has used been shown that continuous stimulation of cognitive activitythe paradigm of serious games used as a therapeutic tool. can alleviate the degenerative process of the diseases associated with dementia. I. INTRODUCTION The eMotivas project raises the design and the The aging of the population is without doubt one of the implementation of an active and comprehensive system forhallmarks of our time and should be classified as a success in monitoring and motivation of people with dementia inthe health field. However, the increasing number of elderly institutional residences. The implementation of the monitoringmeans that the number of diseases of the aging process itself subsystem is based on pattern recognition in time series, tois increasing, as is the case of dementia. It is estimated that detect behaviour patterns associated to disorders, and personalthere are about 5,752,754 people in Europe with dementia and motivation is based on the technologies of motivation. B.J.there are 824,000 new cases per year. In Spain, it affects about Fogg  defines persuasive technology or motivating as a550,000 people, representing 1.24% of the population. Spain system designed to change attitudes or behaviours of people.is framed in the top 5 European countries in terms of numberof cases with dementia and the third in terms of percentage II. OBJETIVESfrom the total population . The primary goal of administered therapies in dementia is Behaviour disorders of dementia are a reality faced by the stimulate mental abilities of the affected, maintain theirpatients, families and health professionals given the long autonomy and their social relations. In general, therapiesevolution of this disease, and the relatively rapid deterioration administered to patients with dementia affect that patients atthat occurs, the management of behavioural symptoms is so levels cognitive, functional (Activities of Daily Living) and /important or more, than to trust on the potential benefit of or behavioural.treatment of cognitive symptoms. These disorders often affect Based on this, eMotiva poses a motivation system thatthe life of care-dependent people, who may then be excluded 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 innovativemultimedia motivation tools, which enables influence on theattitudes or behaviour of people with dementia to alleviatetheir disease process. III. MATERIALS AND METHODS Within the treatments in dementia we can distinguish twotypes of therapy: drug therapy and nonpharmacologicaltherapy, both compatible to be developed simultaneously. The nonpharmacological therapy is defined as "a non-chemical intervention, theoretically supported, focused andreplicable, made over the patient or caregiver and potentiallyable to obtain a relevant benefit” . Recent publicationsconfirm that nonpharmacological therapies have severalpositive clinical effects: improve domains such as cognition, Figure 1 - All-in-one PC, MSI Wind Topbehaviour or mood, and reduce caregiver burden, avoid orpostpone entry into old people’s homes, and can reduce the In those games that require physical interaction it has beencost care economic . chosen to use the Wiimote remote control, this device can In this line are raised the motivational systems within the measure acceleration in three axes of movement, offeringproject eMotiva, aimed at developing nonpharmacological information from the user movements. We have chosen thistherapies focused on Alzheimers patient. controller instead of one made to order or another brand, for As a motivational tool, it is proposed a software with a its low cost and for being shown its usefulness and ease of usegames format, focused on two lines: one line on the cognitive in existing developments in other studies.stimulation of the person with dementia, and other line onphysical stimulation and relaxation. In order to ensure that the games are in line with the workmethodology of residential institutions, in-depth interviewsthere have been conducted with medical personnel of theAsociación de Familiares de enfermos de Alzheimer (AFA)and the Boni Medieros residence in Salamanca, and the staffof San Sebastians residential centre in La Pobla de Vallbona(Valencia).A. Devices Figure 2 - Wiimote remote control When designing and developing systems to encourage orpersuade older people, we must take into account the barriers B. Software Technologythat they encounter in adopting and using new technologies. For the development of games there have been used twoMartijn H. Vastenburg et al. , indicate the complexity and different software development technologies. In thelearning as well as lack of perceived benefit, as key factors to immersive type games there have been used the Microsoftconsider when developing systems of motivation for older XNA technology, which is a set of tools for developing gamespeople, as users may find the cost of adopting new technology with high graphics capabilities and performance, for both themore than the expected benefit. In these cases they suggest to Xbox console and computers running Windows. The secondincrease the direct benefit that the technology produces to technology used for non-immersive games is Windowsincrease the benefit perceived by the user. Presentation Foundation (WPF), this technology is not To break the barrier of learning and simplify the use of specifically designed for games, but it offers a largegames, it was decided to use natural interaction techniques infrastructure and graphics power with animation, video andbased on the use of touchscreens as interface with the audio capabilities. This puts it on the ability to develop non-computer, eliminating the use of keyboards and mice, in immersive games with high graphics performance andparticular it has been chosen an All-in-one PC which includes interaction, reducing the development time compared with thethe computer and a touch screen in a compact and nice design, technologies specially designed for games and 3Dreducing the psychological barrier of dealing with a computer. 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 The screen shows a series of tiles and the user has to clicksuch as attention, memory or executive functions, being on them in a particular order. This order may be numeric orcognitive areas the most affected at the beginning of dementia. size.These games are presented in a touchscreen environment,allowing users to interact with the game in a simple andintuitive way, and are fully configurable as they allowdefining 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 theabandonment of the idle, transmit peace and quiet to theplayer. All in line with the conclusions drawn from interviews withmedical personnel, where the main lines were: The use ofsimple equipment, easy to use and intuitive; Development ofgames that incorporate visual or auditory stimuli to improve Figure 4 - Follow the sequence (screen capture)memory, strengthen the patients daily life activities, allowingcustomization of the games to the needs and abilities of thepatient, and finally not forgetting the fun as the engine of 2) How to play:motivation for encouraging the use of games. At the beginning of the game, the tiles are displayed, andA. Rowing the player must click on the appropriate order. In the case of numbered tiles, each tile carries within it a number, starting 1) Description: with 1 and ending in the number of tiles that you have on the The game is based on a realistic graphical model that board. The player must to click the tiles in increasedallows users to immerse themselves in a tropical paradise and numerical order.interact with it. If we play by size, on the board appear tiles of various sizes, The game features several scenarios where the user can but this time without a number. In this case, the player mustmove slowly interacting with the game using the Wiimote click the tiles beginning with the smallest and ending with theremote control. largest. The figure shows a tropical paradise with an island in the If the appropriate tile is clicked, it turns green, indicatingbackground, a sunny day and clear water, this scenario intends that is the correct. If is wrong, on top of the screen is displaysto convey peace and quiet to the user. 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 Figure 3 - Rowing (screen capture) should dress the doll with the appropriate ones. 2) How to play: To play you need a screen and a Wiimote. The remotecontrol is taken as an oar and using gentle circular motion, thecamera is moved around the stage following a predefined path.B. Follow the sequence 1) Description:
Figure 5 - Dress the doll (screen capture) Figure 6 - Link sounds with elements (screen capture) 2) How to play: 2) How to play: The screen shows a figure that can be male or female, and To start the game, the user must click on the button labelledmany different clothing. The player must drag each piece of "Play Sound" that appears on the left side of the board. Whenclothing to the area where it belongs. When it is close enough, clicked, it plays an audio associated with any of the itemsthe garment is adjusted automatically, and a message reports represented on the board. Having heard the sound, you mustthat it has been placed properly. When the article does not click on the element of the board related to that sound,approach to the area corresponding to it, nothing happens, so clicking on another element is counted as a mistake, and onyou cannot put an item out of place. top of the screen tells the player to try again. If correct, is also The silhouette can be male or female, depending on the indicated with a message. The elements that have already beendifficulty. If male, the clothes are four: shoes, tie, shirt and clicked count as a mistake if you click them again and soundtrousers. Therefore, at least four elements appear on the screen, does not change until you get right which element it belongs.without the dummy. If the figure is female, there are a jacket, The sounds can be heard as often as necessary. When youa handbag, high heels, a skirt and a mobile, a total of five click on the correct item, the sound changes to the next item,pieces. and when all have been clicked correctly, indicates that the You can bring up one set of items or two sets of items for game is finished and data is saved. The sounds order iseach silhouette. That is, in the case of man, can be configured random and the way the figures are placed on the board isto appear a set of trousers, shirt, tie and shoes in yellow colour, random too, so every game is different.and other set in blue colour, and the same for the female The elements vary in type and number to increase thefigure, although in this case the colours are black and blue. complexity, taking from musical instruments or animals, to In the first degree of difficulty, only appears one set of fragments of songs that must be associated with the interpreter.clothes, and the player simply has to drag each garment intohis place, so that you cannot make mistakes. However, when E. Grouping objectsthere are two pieces of each garment, we can control that the 1) Description:player must dress the silhouette in a particular colour or select Various objects appear on the screen related in some waythe clothes in the same colour. and the user will have to separate them into two groupsD. Link sounds with elements according to their relationship. 1) Description: This game, as well as visual and tactile, incorporates soundelements. Various elements are presented on the screen, eachone with a distinctive sound. The user must connect the soundyou hear with its visual representation. 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 have ten weeks of duration, during which patients will havegroup the items based on certain criteria. thirty play sessions, it will try to assess the status of the When starting the game, in the central part appear the patient before the study and at its conclusion, comparing theirfigures, distributed randomly. In the upper left corner evolution against a control group, to try to validate theindicates the way they should be grouped. The areas where the theoretical conclusions initially mentioned in this article andfigures must be carried are green and yellow boxes that are in proposed in the eMotivas project.the ends of the board. When the figures are close enough tothese boxes will automatically move on them. Once placed, a ACKNOWLEDGMENTfigure cannot be moved again. When all have been placed, it Authors thank the eMotiva consortium for theirwill display a message in the middle of the board indicating contribution to this work.that the game has ended. You can vary the difficulty of the game using the number REFERENCESof elements and the number of colours of them. V. CONCLUSIONS  C.L. Ferri, M. Prince, et al, “Global prevalence of dementia: a Delphi The developed games aim to raise enough motivation for consensus study”, The Lancet, vol 366, pp. 2112-2117, Dec. 2005.users to feel connected to their internal dynamics, which  P. Ramos, et al, La enfermedad de Alzheimer y otras demencias.include playful and entertaining aspects, with a high value of Detección y cuidados en personas mayores, ser. Promoción de la Salud en personas mayores. Ed. Madrid, España: Dirección General deauditory stimulation, visual and incorporating progressive Atención Primaria. Comunidad de Madrid, 2007, vol 10.levels of difficulty.  B.J. Fogg, Persuasive Technology: Using Computers to Change What On the one hand, we must emphasize the importance of We Think and Do, 1st ed., Ed. San Francisco, United States of America:those games where, as in the Rowing game, it interacts with Morgan Kaufmann Publishers, 2003.  R. Muñiz, J. Olazarán, Mapa de terapias no farmacológicas parathe movement itself, recreations where the user is moving to demencias tipo Alzheimer. Guía de iniciación para profesionales,increase physical activity and, as a therapeutic tool, aims to International Non Pharmacological Therapies Project, Sep. 2010.improve motor skills. In addition, the overall atmosphere of  J. Olazarán, B. Reisbergi, C. Beck, et al, “Nonpharmacologicalthe game tries to generate an atmosphere of calm and Therapies in Alzheimer’s Disease: A Systematic Review of Efficacy”, Dementia an Geriatric Cognitive Disorders, vol. 30, pp. 161-178, Sep.animosity to involve the player emotionally, which will 2010.increase their motivation to perform the task. Emotions are an  M. Vastenburg, T. Visser, M. Vermaas, D. Keyson, “Designingimportant part of motor learning, a means of reinforcement or acceptable assisted living services for elderly users”, in Europeanfor avoidance of behaviours, are useful to produce a Conference on Ambient Intelligence, Nuremberg, Germany, Nov. 2008, p 1-12.significant motivation to prevent apathy, inactivity orpassivity. On the other hand, the other games try to stimulate differentareas of cognition such as memory, attention or executivefunctions, as well as stimulate visual and auditory perception.The cognitive stimulation has its biological basis inneuroplasticity or plasticity of the nervous system asmentioned in the introduction. On this basis, frequentinteraction with a game environment rich in stimuli, can beconsidered positive in maintaining cognitive abilities inpeople with dementia. Each game presents a challenge and anattempt to improve day by day, which can have effects onpeoples emotional interaction. So the games are presented aselements that can promote motivation. After an initial presentation of the games to the medicalstaff, the first assessments are agree that these appear tocomply with the guidelines of simplicity, the inclusion ofdifferent requested elements of cognitive stimulation andcapacity to be included easily in their daily activities with thepatient.F. Future lines of work: The path or line of work ahead is clearly marked and goesthrough to make a gaming implementation of motivation inthe centres that are part of the project. To carry outsubsequently a randomized controlled study, in subjects withAlzheimer-type dementia, in its later stages. The study will