Neuropsychological Testing Through a Nintendo Wii® Console Luciano GAMBERINIa,1 , Stefano CARDULLO a, Bruno SERAGLIA a and Adalberto BORDIN b a University of Padova, Department of General Psychology b ‘Anni Sereni’ Elderly Care Center Abstract. In recent years, videogames have demonstrated their positive effects in the psychological treatments and cognitive training of the old population. In this paper we present a pilot study in which a group of elderly people in an old people's home was requested to play a set of cognitive tasks administered through a popular videogames console, the Nintendo Wii®. The results obtained by comparing the Wii® cognitive games with traditional paper and pencil tests are described and discussed to orient further improvements. Keywords. Cognitive training, elderly, videogames
Introduction The worldwide growth of the old population is expected to increase rapidly until 2050 and over [1]. This expansion highlights the need to elaborate simple, quick and low-cost solutions in order to intervene and delay the natural cognitive decline connected with aging [2,3], and then keep the elderly population as much independent and self-sufficient as possible. Side by side with classic cognitive training, new methodologies adopting digital technologies have emerged, to help reach this goal on a large scale. Several researches have focused the attention on the analysis of the effects produced by the interaction with computerized applications, such as videogames [4,5], on different populations. Overall, results show a positive impact on several cognitive functions (executive control functions, attention, visual processing and reaction times) both in young [6-9] adults and elderly people [10-14]. Normally videogames are developed for young people [19], when trying to develop games for the elderly population special attention should be paid to their needs in terms of usability [15,16] in order to prevent boredom and anxiety to increase at the expense of motivation and concentration [17,18]. Nintendo Wii®Mote controller provides a new interface rationale for videogames that involves natural physical interactions, along with the normal cognitive functions stimulation, and could then prove more usable than other input techniques, such as joystick, pen or keyboard, to unfamiliar users. This paper focuses on a set of videogames developed for the Nintendo Wii® platform in order to test and exercise the cognitive skills of the elderly person. Differently from other applications of Nintendo Wii® to elderly care centers, which usually employ the videogames licensed by Nintendo® [20-22], the cognitive games included in the software presented here are entirely developed by us. Our aim was to validate these cognitive games measuring their correlation with traditional and standardized paper and pencil (PP) neuropsychological tests, and then gain some insights on the kind of improvements needed. 1. Games The cognitive games developed for this study address three main cognitive functions: attention, memory and motor control. The first game addresses attention and requires identifying a target shape in a set of shapes. The second game, testing short-term digit memory, requires to memorize a series of numbers and then to repeat the series in the correct order. The third one, testing working memory, consists of memorizing some letters (consonants) and then reminding them; between memorizing and reminding users are given an interference task, which lasts ten seconds and consists of performing two additions. The final game, testing visual-motor skills requires to hit some target points avoiding at the same time to hit other
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Corresponding Author: Luciano Gamberini, University of Padova, Via Venezia 8, Padova, Italy 35131; Email:
[email protected]
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objects (Figure 1). All games are built using Adobe® Macromedia® Flash® Professional 8.0 with ActionScript 2.0 code and include several incremental difficulty levels. 2. Method For the pilot validation described here, the games were compared with standardized PP neuropsychological tests measuring respectively sustained and selective attention (“Deux Barrages” [23]), short term digit memory (“Digit Span” (DS) [24], working memory (“Memory with Interference” (MI) [24]), and visualmotor skills (“Trail Making Test A” (TMT) [24]). ® physical or cognitive impairment were recruited (M=77; SD=9.92; Twenty participants without any Figure 1. Screenshots from the Wii Tests: Attention (1a), Memory DS (1b), Memory MI (1c), range=61-97) in the old people's home “Anni Sereni” in Scorzè (Venice). Motor Control (1d). In the first session elderly were administered the Wii® games (see Figure 1); they sat comfortably and games were video projected on a wall in front of them. The experimenter sat at their left, providing instructions and helping in case of trouble. After one week, the same participants were requested to take the series of PP neuropsychological tests, administered according to the manual. Performance measures were collected and compared in order to measure convergent validity with
®
Figure 1. Screenshots from the Wii Tests: Attention (1a), Memory DS (1b), Memory MI (1c), Motor Control (1d).
Pearson’s correlation coefficient. 3. Results The results show a significant correlation between the electronic and PP versions of all tests, except for the Digit Span (see Table 1). Table 1. Pearson coefficient values between Wii® tests and corresponding paper and pencil tests (PP Tests); *. Correlation is significant at the 0.01 level (2-tailed); **. Correlation is significant at the 0.05 level (2-tailed).
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For sustained and selective attention two measures were correlated, given that in the Wii® the task started over in case of mistakes and then each level could be executed more than once. Thus the measures were the sum of the average time taken to complete each difficulty level in the Wii®, and ratio between error and speed rate in the Deux Barrages test. The correlation was significant (r = .777) (see Figure 2). Regarding the working memory test, the errors at the Wii® and memory correlated significantly (0.689) (Figure 3a). Although significant, this value is still pretty low probably because of some additional difficulties in the input modality in the Wii® version of the test: the elderly met some difficulty in pointing at the object on the screen while pressing the “A” button on the Wii®Mote; facilitating the input entry could permit to obtain a higher correlation. The same issue could explain the results of the short-term memory
Figure 2. Y axis, time spent to solve Wii® cognitive game; X axis, ratio between error and speed rate recorded in paper and pencil test.
test whose, correlation with the Digital Span was not significant (r=.263). Finally, the correlation between all the difficulty levels of the Wii® cognitive game with TMT-A was calculated, finding a significant correlation with the first difficulty level (r = .464); with a broader sample it could be possible to balance the performance of extreme values, in order to reduce their influence on the sample (Figure 3b).
Figure 3. a) Y-axis, number of error doing an interference of two additions on Wii® Test; X-axis, number of error doing an interference of count forward by twos for 10 seconds on x axis. b) Y-axis, time of execution of 1° Difficulty Level of Wii® Game; X-axis, TMT A score.
4. Conclusion The results of this pilot study encourage pursuing in this direction, while at the same time pointing at the way in which the games can be improved. Our primary goal was to develop games that make neuropsychological tests more attractive to the elderly people and exploiting Nintendo Wii® ergonomic features. Moreover, being small, financially affordable and portable, Nintendo Wii® can be used not only in elderly care centers but also at home, allowing the participation to the rest of the family. On the other hand,
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adding physical interaction could worsen the performance at some tasks, adding some unexpected difficulties. Some adjustments are then needed, for instance to the input modality, by enlarging the targets. This consideration will be the ground for future studies, in order to find a good fit between task requisites and their implementation in the Wii® interface. References [1] UN. World Population Prospects: The 2008 Revision. Population Database. United Nations Populations Division, 2010. Available online at: http://esa.un.org/unpp. [2] R. Levy, Aging-associated cognitive decline, International Psychogeriatrics, 6 (1994), 63-8. [3] J.M Starr, I.J Deary, S. Inch, S. Cross, W.J. Maclennan, Age-associated cognitive decline in healthy old people, Age and Ageing, 26 (1997), 295-300. [4] L. Gamberini, G. Barresi, A. Majer, F. Scarpetta, A game a day keeps the doctor away: a short review of computer games in mental healthcare, Journal of CyberTherapy & Rehabilitation, 1(2) (2008), 127-139. 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Ivory, The virtual census: representations of gender, race and age in videogames, New Media Society, 11(5) (2009), 815-834. [20] C. Neufeldt, Wii® play with elderly people, International reports on socio-informatics, 6(3) (2009), 50-59. [21] R. Brown, H. Sugarman, A. Burstin, Use of the Nintendo Wii® Fit for the Treatment of Balance Problems in an Elderly Patient with Stroke: A Case Report, Proceedings of the 10th Congress of the European Federation for Research in Rehabilitation, September 9-12, 2009, Riga, Latvia. [22] Y. Theng, A.B. Dahlan, M.L. Akmal, T.Z. Myint. An Exploratory Study on Senior Citizens’ Perceptions of the Nintendo Wii®: The Case of Singapore Proceedings of ICREAT 2009, April 22-26, 2009, Singapore. [23] R. Zazzo, Test dei deux barrages: manuale, Organizzazioni Speciali, Firenze, 1980. [24] S. Mondini, Esame neuropsicologico breve: una batteria di test per lo screening neuropsicologico, R. Cortina, Milano, 2003. Acknowledgements: The authors would like to thank ‘Anni Sereni’ Elderly Care Center (VE) for hosting the study and ‘Nintendo Italia’ for providing us with some equipment.
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