Physical, Cognitive, and Social Impacts of Video Games in an Elderly Population by Maria Shapoval, ND
Abstract
The health of the elderly population is becoming increasingly more important as people are living longer and the aging population is growing. Video games can provide an engaging method through which participants can potentially expand and maintain their cognitive skills as well as their physical capabilities, such as mobility, strength, balance, and coordination. Additionally, video games may serve as a means to promote social interaction and develop a sense of belonging. However, video games are a remarkably diverse medium, and the question of which game provides the most therapeutic benefit for cognitive, physical or mental health decline remains to be answered. This review will explore several recent game-based interventions and discuss this impact on cognitive, physical, and social well being.
Introduction
The elderly is a growing demographic and is expected to double by the year 2050 (Kanasi et al 2016). With this increase in aging population comes the expected increase in strokes, neurodegenerative conditions such as dementia’s, and Parkinson’s disease, as well as increase in mental health decline associated with loneliness due to loss of social contact and isolation. Numerous physical rehabilitation and community programs have been developed to provide both cognitive, physical, and social stimulation to this target population. However, with limited access to rehabilitation and exercise programs during the COVID-19 lockdown in many parts of the world, as well as mandated social distancing, the use of video games to provide therapeutic benefit becomes more relevant. Given the diversity of the virtual reality and gaming worlds, it is not clear what type of game is best suited for which population and patient group. This review will explore the current research available on a range of video games and summarize their benefits, limitations, and potential applications.
Currently, the majority of studies are exploring the value of exergames. Exergames are video games that integrate physical exercise into the virtual reality of the game by the use of motion sensing equipment. These include Nintendo Wii games, such as Wii Sports; tennis, golf, bowling and others, and Wii Fit, such as yoga and balance training as well as Microsoft Xbox Kinect games. By definition, exergames do not have to have a ‘serious’ or therapeutic component, however, many of the games are hypothesized to provide both cognitive and physical benefits in an entertaining and motivational way. Additional applications to be discussed here include game-based neurofeedback and the use of ‘whack-a-mole’ game as a form of cognitive assessment.
All of the studies reviewed here explore the therapeutic benefit of games on either healthy elderly populations or participants with various neurological disorders. The neurological disorders include dementia, Alzheimer’s Disease (AD), Parkinson’s disease (PD), post-stroke recovery, mild cognitive impairment (MCI), and Multiple Sclerosis (MS).
Physical Impact
A randomized control trial of 32 healthy elderly participants (ages 65 – 78) compared the physical benefits of exergames to a sedentary lifestyle (Maillot et al 2012). The exergames included Nintendo Wii Sports, Wii Fit, Mario & Sonic on Olympic Games and were played for one hour twice per week for 12 weeks, in pairs to increase the enjoyment aspect of the game. Not surprisingly, these games resulted in statistically significant improvements in physical measurements such as six-minute walk, chair stands, arm curls and average heart rate at the end of a six min walk (p<0.001). However, the exergames also benefited cognitive function demonstrating significant improvements in processing speed (p<0.001) and executive function (p<0.001), while no improvements were seen with visuospatial function. The authors suggest that these cognitive improvements were due to improved oxygen transport and utilization provided by the aerobic component of these exergames. It is unclear if the cognitive improvements were dependent on the physical achievements or if they were related to the social impact provided by the partner involved in the exergame.
To determine whether exergames can provide motor benefits to participants with mobility issues de Melo Cerqueira and colleagues (2020) compared the effects of Kinect based exergames on participants with PD versus healthy elderly in physical and cognitive outcomes. The Microsoft Kinect games included Paddle Panic (simulation of table tennis), Wall Break (requiring kicking), Bump Basin (requiring side stepping) and others. Each session was 45-60 minutes long and there were 10 sessions completed over the course of five weeks. While there were no statistically significant improvements in motor outcomes compared to baseline, including Berg Balance Scale, Timed Up and Go and the 10 Meter Walk Test in either of the two groups, there was significant improvement in the Montreal Cognitive Assessment (MoCA) (p<0.05) compared to baseline in both groups of participants. Additionally, there were significant improvements in the Frontal Assessment Battery in both groups (p<0.05), but these gains were lost in the group with PD at the 30 day follow up, while they were maintained by the healthy elderly.
Another study examining the effects of exergames on motor function of participants with PD is a small observation study by Severiano and colleagues (2018). In this study, participants (n=16) had access to various exergames that worked with Nintendo Wii Balance Board, including Soccer Heading, Tablet Tilt, Tight Rope Walk and Ski Slalom. The participants engaged in these for 50 minutes twice per week for a total of 20 sessions. Significant improvements compared to baseline were observed in Dizziness Handicap Inventory (p=0.001), Sitting-Rising Test (p=0.0222), and Berg Balance Scale (p=0.03), with the later being correlated to reduced risk of falling, which is particularly significant with this condition. One distinguishing feature of this study compared to that of de Melo Cerqueira and colleagues (2020) is the use of the Wii Balance Board that can pick up subtle changes in the shift in weight, as opposed to a sensor position one meter away from the participant that was used in the later study. This sensor can detect changes in movement but is likely to miss the subtle shifts in weight that may be immeasurable from this distance and thus less likely to provide this feedback to the participant, which can explain the lack of benefit in balance reported by de Melo Cerquiera and colleagues (2020).
A recent randomized control trial by Kannan and colleagues (2019) examined the effect of exergame on the physical and cognitive function of participants recovering from stroke (n=25). All participants were able to stand independently for five minutes and had suffered the stroke more than six months ago but were experiencing some hemiparesis. The exergames combined both balance and coordination physical training with various language, memory, and mathematical skills training using Nintendo Wii Fit (such as Bubble Balance, Table Tilt, Tight-Rope Walking, and others), while the conventional training group included stretching, strengthening, balance and endurance training without any cognitive training. There were 10 90-minute sessions completed over the course of six weeks. There were significant improvements in balance (p<0.05) in both exergame and conventional training groups compared to baseline, and significant improvements in cognitive function compared to conventional training, which was measured using Letter-Number Sequencing task that measures verbal working memory (p<0.01). While this study demonstrates capacity to improve balance without the use of the Wii Balance Board, it is difficult to make strong conclusions since the method to assess balance were different between the Kannan and colleagues (2019) and Severiano and colleagues (2018) studies. However, from the four studies discussed here it is clear that some cognitive benefit can be achieved through exergames. The next set of meta-analyses will explore the question of potential cognitive improvements in more detail.
Cognitive Impact
Stanmore and colleagues (2017) completed a meta-analysis of 17 randomized controlled trials with a total of 926 participants. Participants included healthy elderly adults as well as those with neurocognitive impairments such as MCI, sub-acute stroke, schizophrenia, and PD, though the majority of the studies were exclusive to healthy adults. On average the exergame sessions ran for 15-60 minutes 3.2 times per week for 10 weeks. Outcomes included significant improvement in global cognition and executive functions, such as inhibitory control and task-switching flexibility as compared to wait list control groups and physical exercise interventions. Stanmore and colleagues (2017) concluded that exergames provide greater benefit for cognitive function than physical exercise alone, but do not outperform cognitive training interventions. This statement is echoed by a more recent review paper by Sokolov and colleagues (2020), which reports improvement in executive function, attention, and visuospatial processing by both healthy elderly and those with mild cognitive impairment. Sokolov’s work suggests that outperforming physical exercise is not a consistent pattern seen with exergames, though the researchers agree that exergames increase the likelihood of participants adhering to physical exercise required within the game.
Another meta-analysis of 13 control studies (including eight randomized control trials) explored the benefits of exergames on cognitive function of individuals with various neurological disorders (Mura et all 2018). The participants included those recovering from stroke, and those suffering with MS, PD, dyslexia, MCI, and those diagnosed with Down’s syndrome. The interventions relied on Nintendo Wii Sports and Wii Fit, while the alternative comparison ranged widely from occupational therapy, simple walking, computer-assisted cognitive training, group, or individual balance training, wait list and others. The sessions also differed in frequency and duration ranging from 30-90 minutes one to five times per week for two to 24 weeks. The analysis demonstrated significant improvement in visuospatial perception (p<0.001; 5 studies), and executive function (p<0.005; 8 studies), but no significant improvement in attention and global cognitive function compared to the alternative. Mixed results were obtained with respect to follow up with two studies reporting loss of benefit after intervention ended, while three studies demonstrated preserved benefit on executive function in participants with PD and stroke. The authors also highlight the importance of adherence to the intervention and share a quote from one of the participants, “…they looked forward to play the next session and came to therapy more willingly in order to improve their scores”. While the intrinsic benefit derived from physical or cognitive exercise seems to be incredibly important, the extrinsic reward of an ‘improved score’ appears to be more motivating.
A recent randomized controlled trial by Karssemeijer and colleagues (2019), which was not included in the earlier meta-analyses, compared the cognitive effects of exergames versus aerobic exercise to control (no intervention) in participants with dementia. The exergame required participants to navigate a virtual reality on a stationary bicycle. In addition to the navigational component, participants had to engage in other cognitive tasks that targeted processing speed, task switching and response inhibition. The aerobic exercise was limited to cycling on a stationary bike, while the control group did not engage in any exercise at all. The sessions ranged from 30-50 minutes and occurred three times per week for 12 weeks. The outcomes were assessed at baseline, at the end of the study and at the 12 weeks follow up. Both types of training were considered light as they hovered at an average of 42% of maximum heart rate. There was no significant difference between either training group in executive function, episodic memory or working memory compared to control. The only significant improvement was in psychomotor speed (p=0.007 for aerobic training and p=0.009 for exergame), which was maintained at the 12-week follow up. As can be seen from these reviews and clinical trial, exergames are not created equally and effect different aspects of cognitive function, though in most cases there are improvements with executive function and visuospatial perception.
Social Impact
As the COVID 19 virus forced citizens of various countries into quarantine, social isolation has become an obvious complication. Social isolation is an important driving force in experience of loneliness, which has been correlated with numerous health detriments including dementia and depression (Sundström et al 2020). Gabbiadini and colleagues (2020) set out to examine the effect of technology, including video games, on the perception of loneliness and belonging. This observation study took place in Italy during the March 2020 lock-down where participants were required to stay inside for several weeks without physical contact with anyone outside the household. Using a questionnaire, the researchers assessed the degree to which participants engaged in various technological communication tools including video calls, streaming movies in party mode, playing online board games and online multiple video games, and compared this to their results of various psychosocial assessment such as the UCLA Loneliness Scale-Revised, Brief Irritability Test, State-Trait Anger Expression Inventory, and others. Not surprisingly, connecting with others through various technological means correlated positively with a sense of belongingness and negatively with feelings of loneliness, boredom, anger, and irritability. However, as the study did not separate the type of technology that was being used, these results cannot be specifically applied to the video games alone.
To explore the impact of exergames on the experience of loneliness, Li and colleagues (2018) conducted a systematic review of 10 clinical trials. The studies incorporated exergames from Nintendo Wii Sports, such as tennis, bowling, golf, basketball and boxing, Nintendo Fit package, such as yoga and balance games, as well as various exergames by Microsoft Xbox Kinect. The majority of the studies provided 40 min sessions at two to three sessions per week for six-12 weeks. The studies compared these exergames to traditional board games as well as group experiences like watching TV. Despite the fact that both traditional board games and watching TV were group activities, exergames proved to be more engaging and provided the participants with a greater sense of connection as illustrated by reduced loneliness perception. Perhaps being physically active together is an important variable in reducing the sense of loneliness or being physically active helps to raise the mood more than could be accomplished with an enjoyable but sedentary activity like traditional board games, and greater mood could reduce perception of loneliness.
Additional Applications
Game-based neurofeedback (NFT) incorporates the use of commercial grade electroencephalogram (EEG) into the design of the game, whereby the EEG becomes the joystick. The participant must alter their brain waves by engaging in specific cognitive skills in order to accomplish specific game tasks. Jirayucharoensak and colleagues (2019) designed a randomized control trial with 65 women with MCI and 54 healthy elderly women and compared the impact of NFT, exergame and regular lifestyle on cognition. The participants in NFT and exergame groups completed a total of 20 sessions, each session was 20 minutes, and were assessed before and right after the completion of the study. During the game, the participant is required to maintain their focus and attention on a particular component. An example of this game would be where a participant is required to focus on a bear on the computer screen. If the patient is successful at maintaining attention, as assessed using the EEG, the game provides this feedback to the participant by having the bear run faster. Once the attention is lost and the participant is distracted, the EEG signals this to the game and the participant receives feedback by observing the bear slow down. The NFT demonstrated significant improvement (compared to exergame and control) not only in sustained visual attention, which was the target skill, but also in working memory. These improvements occurred in both healthy and MCI groups.
Another interesting way to apply games is in the field of screening and monitoring. Wilkinson and colleagues (2018) demonstrated the potential for using a video game in the emergency department to identify patients with significant cognitive deficiencies. The group compared the score of “whack-a-mole” video game to validated cognitive assessments such as the MMSE and MoCA and were able to correlate the poor score with these assessments. They argue that this type of game assessment could be generalized to other healthcare settings, including long-term healthcare facilities where these games could be used to monitor for progression, treatment response and/or identify acute changes that would otherwise take longer to recognize. On the topic of long-term healthcare facilities, this research team also reported on the testing of the application of ambient activity wall unit (ABBY). ABBY is not a video game, but an interactive technology designed to engage patients with dementia with sensory interactive content that has been populated with media content selected for the specific individual patient. This technology is made to be accessible completely without any support from staff at all times (24/7). After three months, the patients (n=27) demonstrated statistically significant reduction in physical and verbal agitation, paranoia, delusions, aggressiveness, and anxiety and increase in quality of life. While the ABBY did not have any cognitive training built into the interface, and differences observed did not reach statistically significance, it did trend towards cognitive improvement (p=0.080). Furthermore, there was an added benefit of this technology in that staff experienced a significant decrease in burn-out after one months of having patients interact with ABBY.
General Benefits and Limitations
There is limited discussion of the potential safety issues surrounding exergames and regular video games. The studies were careful to either exclude patients with severe mobility problems that would be at risk of falling or provided a physiotherapist as a supervisor to ensure safety. With these provisions in place, there were no adverse events reported in any of the studies reviewed here, except for one.
West and colleagues (2018) report reduction in the size of the hippocampus after engagement with first person shooting games. These games require the participant to engage in navigational strategies to proceed through the game. Two navigational strategies that were discussed included spatial strategy – “spontaneously encod-[ing] the relationship between landmarks” and non-spatial strategy where the participant memorized a sequence of events and used this information to navigate throughout the game. The study utilized an MRI to analyze the baseline characteristics of the participants and the impact that these games had on their neuroanatomy. They discovered that participants with reduced hippocampus were often engaging in non-spatial navigational strategies, which do not require the use of the hippocampus and were most likely to suffer from further loss of grey matter within their hippocampus after engaging in these games. Participants who employed spatial-based navigational strategies used their hippocampus more during the game and thus did not suffer the loss of the associated grey matter. This finding, while alarming, can help to explain the discrepancies seen in the cognitive benefits from video games. While most of the research examines the differences between video games in their design and their posology, this study highlights the importance of comparing the participants according to their game strategies and neuroanatomy, suggesting that the same game can have vastly different outcomes on their neuroplasticity and subsequent cognitive outcomes.
In addition to the potential physical, cognitive, and social benefits already discussed prior, there were several other important features reported by the researchers in the studies reviewed here. Several studies commented on the enjoyment and fun entertainment provided by the video games (Li et al 2017, Mura et al 2018). This enjoyment serves as a motivator to engage in physical exercise through exergames. Since adherence to exercise is often limited by lack of desirability of this activity, finding ways to increase compliance is important especially in a population often suffering from mood disorders. Another relevant benefit is that the majority of the commercial exergames can be accessed at home. This increases participation for patients with mobility issues that find travel difficult, as well as allows engagement during lockdowns. These games are also relatively more affordable than some of the exercise and sports programs.
The diversity across video games allows for this intervention to cater to a wide range of interests and range of cognitive and physical capabilities. For example, patients with limited lower leg mobility that are confined to a wheelchair can still engage in the exergames that target upper body strength and reap the cognitive benefits associated with the challenge that these games provide. Lastly, these games do not have to be played alone, which can increase their enjoyment and benefit.
References
de Melo Cerqueira TM, de Moura JA, de Lira JO, Leal JC, D’Amelio M, do Santos Mendes FA. Cognitive and motor effects of Kinect-based games training in people with and without Parkinson’s disease: A preliminary study. Physiother Res Int. 2020 Jan;25(1):e1807.
Gabbiadini A, Baldissarri C, Durante F, Valtorta RR, De Rosa M, Gallucci M. Together Apart: The Mitigating Role of Digital Communication Technologies on Negative Affect During the COVID-19 Outbreak in Italy. Front Psychol. 2020 Oct 21;11: 554678.
Jirayucharoensak S, Israsena P, Pan-Ngum S, Hemrungrojn S, Maes M. A game-based neurofeedback training system to enhance cognitive performance in healthy elderly subjects and in patients with amnestic mild cognitive impairment. Clin Interv Aging. 2019;14:347-360.
Kanasi E, Ayilavarapu S, Jones J. The aging population: demographics and the biology of aging. Periodontol 2000. 2016 Oct;72(1):13-18.
Kannan L, Vora J, Bhatt T, Hughes SL. Cognitive-motor exergaming for reducing fall risk in people with chronic stroke: A randomized controlled trial. NeuroRehabilitation. 2019;44(4):493-510.
Karssemeijer EGA, Aaronson JA, Bossers WJR, Donders R, Olde Rikkert MGM, Kessels RPC. The quest for synergy between physical exercise and cognitive stimulation via exergaming in people with dementia: a randomized controlled trial. Alzheimers Res Ther. 2019 Jan 5;11(1):3.
Li J, Xu X, Pham TP, Theng YL, Katajapuu N, Luimula M. Exergames Designed for Older Adults: A Pilot Evaluation on Psychosocial Well-Being. Games Health J. 2017 Dec;6(6):371-378.
Li J, Erdt M, Chen L, Cao Y, Lee SQ, Theng YL. The Social Effects of Exergames on Older Adults: Systematic Review and Metric Analysis. J Med Internet Res. 2018 Jun 28;20(6):e10486.
Maillot P, Perrot A, Hartley A. Effects of interactive physical-activity video-game training on physical and cognitive function in older adults. Psychol Aging. 2012 Sep;27(3):589-600.
Mura G, Carta MG, Sancassiani F, Machado S, Prosperini L. Active exergames to improve cognitive functioning in neurological disabilities: a systematic review and meta-analysis. Eur J Phys Rehabil Med. 2018 Jun;54(3):450-462.
Severiano MIR, Zeigelboim BS, Teive HAG, Santos GJB, Fonseca VR. Effect of virtual reality in Parkinson’s disease: a prospective observational study. Arq Neuropsiquiatr. 2018 Feb;76(2):78-84.
Sokolov AA, Collignon A, Bieler-Aeschlimann M. Serious video games and virtual reality for prevention and neurorehabilitation of cognitive decline because of aging and neurodegeneration. Curr Opin Neurol. 2020 Apr;33(2):239-248.
Stanmore E, Stubbs B, Vancampfort D, de Bruin ED, Firth J. The effect of active video games on cognitive functioning in clinical and non-clinical populations: A meta-analysis of randomized controlled trials. Neurosci Biobehav Rev. 2017 Jul;78:34-43.
Sundström A, Adolfsson AN, Nordin M, Adolfsson R. Loneliness Increases the Risk of All-Cause Dementia and Alzheimer’s Disease. J Gerontol B Psychol Sci Soc Sci. 2020 Apr 16;75(5):919-926.
West GL, Konishi K, Diarra M, Benady-Chorney J, Drisdelle BL, Dahmani L, Sodums DJ, Lepore F, Jolicoeur P, Bohbot VD. Impact of video games on plasticity of the hippocampus. Mol Psychiatry. 2018 Jul;23(7):1566-1574.
Wilkinson A, Tong T, Zare A, Kanik M, Chignell M. Monitoring Health Status in Long Term Care Through the Use of Ambient Technologies and Serious Games. IEEE J Biomed Health Inform. 2018 Nov;22(6):1807-1813.