Exergames for Assessment in Active and Healthy Aging
Emerging Trends and Potentialities
Evdokimos I. Konstantinidis, Panagiotis E. Antoniou and Panagiotis D. Bamidis
Lab of Medical Physics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
Keywords: Stealth Assessment, Exergames, Serious Game, Elderly Care Intervention, Physical Exercise.
Abstract: This paper articulated the position, based on literature research findings as well as experiences and
considerations, of the authors regarding the role of exergames in stealth cognitive assessment. The conclusions
presented therein are based on a long and lasting experience of design, implementation and piloting trials with
seniors over the last six years. They are also supported by literature findings concerning exergames’
engagement, acceptance, perceived usefulness and ease of use. The authors express a positive outlook
regarding the role of daily exergaming programs regarding their capacities in stealth assessment. Furthermore,
it is postulated that additional research efforts should focus on providing even more concrete, evidence based
arguments for convincing researchers and clinicians of the potential clinical value of exergames in terms of
cognitive assessment.
1 INTRODUCTION
Independent and healthy lifestyle of elderly
population has become an increasingly important
social issue, due to the increase of population age
across developed countries. It is documented that
regular physical activity is essential for healthy aging
(Chodzko-Zajko et al., 2009) in terms of physical
(Konstantinidis, Billis, et al., 2014) as well as
cognitive health (Lautenschlager et al., 2008;
Angevaren et al., 2008).
Exergames, which have been in focus of an
increasing number of research efforts, are technology
assisted solutions engaging the elderly in physical
exercise or activity through gaming. They aim to
motivate seniors to get involved in either physical
activity or physical exercise and, hence, promote a
more active lifestyle, through gaming
(Konstantinidis, Billis, et al., 2014). Towards this
end, the emergence of studies measuring exergaming
platforms’ usability for seniors led to proper design
implications, recommendations and guidelines for
exergames (Konstantinidis, Billis, et al., 2014).
Beyond the obvious physical benefits of exercise,
exergames demonstrated positive changes in mood
(Kirk et al., 2013; Gerling et al., 2012), socialization
(Gerling et al., 2011; Velazquez et al., 2013), and
confidence in everyday functional activities (Rendon
et al., 2012) as well as overall quality of life
improvement (Chodzko-Zajko et al., 2009;
Rosenberg et al., 2010).
Serious games for elders, which are games
designed for a primary purpose other than pure
entertainment aimed at a senior target group, focusing
either on cognitive or physical training, are deemed
either preventive/therapeutic interventions or
assessment oriented tools (McCallum, 2012).
Specifically, recent neuroscientific studies provided
increased evidence on the protective effects of
cognitive and physical training with regards to
cognitive decline and dementia (Bamidis et al., 2014).
On the other hand, serious games, especially
cognitive games, are considered as potential
assessment tools by emulating pen and paper
assessment tests (Hagler et al., 2014) or by
encapsulating cognitive tasks in a game-like interface
(Jimison et al., 2010; Jimison and Pavel, 2006;
Tarnanas et al., 2014). The integration of these
assessment techniques in the games, in a way that the
player is unaware of, is defined as stealth assessment
(Shute, 2011).
However, exergames only recently gained the
attention of researchers as cognitive status assessment
means. Virtual environments, simulations of daily
activities and daily usage exergames have just
emerged, exhibiting promising findings (Tarnanas et
al., 2013; Zygouris et al., 2014).
From the previous exposition it appears that the
325
I. Konstantinidis E., E. Antoniou P. and D. Bamidis P..
Exergames for Assessment in Active and Healthy Aging - Emerging Trends and Potentialities.
DOI: 10.5220/0005494503250330
In Proceedings of the 1st International Conference on Information and Communication Technologies for Ageing Well and e-Health (SocialICT-2015),
pages 325-330
ISBN: 978-989-758-102-1
Copyright
c
2015 SCITEPRESS (Science and Technology Publications, Lda.)
potential assessment aspect of exergames is only
starting to be investigated so far. There are not yet
design guidelines or even suggestions about
assessment through exergames, apart from the
general rule for successful assessment through
serious games: participation in the game.
On the other hand, the number of research efforts
on the assessment aspects of exergames is not large
enough to convince the research community for their
value in the field. Corresponding findings can be
deemed as indicators about the potential value of
exergames but not as evidence. Additionally, the role
of serious games has been debated over the last few
years. A large number of commercial or custom
exergaming platforms, which have been utilized by
seniors, are not tailored to them. Therefore, as it is
stated in previous work of the authors
(Konstantinidis, Billis, et al., 2014), they present a
significant learning overheads and entrance barrier
for the elderly users, which, in turn, reduces their
overall efficacy.
In line with this, Robert et al. reported poor
academic and professional acceptance of serious
games (Robert et al., 2014). This is based on the fact
that serious games are viewed by many researchers
and clinicians as expensive toys gaining no scientific
and clinical credibility (Anon, 2014). However, the
acceptance of serious games as tools for new
treatment options, is slowly starting to take root
(Robert et al., 2014).
In the following section (section 2) we present the
arguments about the value of exergames as stealth
assessment tools based both in the literature and in the
authors’ experience in the field. We close this work
in section 3 with some concluding remarks.
2 EXERGAMES FOR
ASSESSMENT
2.1 Exergames for Stealth Assessment
Aerobic exercises are presented as a promising tool
for physical health assessment in exergames by
measuring indirectly the caloric expenditure and heart
rate (Staiano and Calvert, 2011). In the same notion,
the perceived exertion scale (Borg, 1982) could
estimate the senior’s effort since it is directly
correlated with the heart rate. In addition, a large
research effort on assessment in exergames focuses
on fall risk. In-game performance metrics, like
movement and response time (Pisan et al.. 2013), step
length (Garcia et al.. 2012) and grip strength are used
towards fall risk assessment or even early signs
detection of frailty (Zavala-Ibarra and Favela. 2012).
Beyond physical status assessment, only recently,
exergames dealt with cognitive assessment. Virtual
environments (Tarnanas et al., 2013; Zygouris et al.,
2014) as well as daily usage exergames
(Konstantinidis et al., 2015) have recently turned
towards assessment. Some of these works correlated
significantly in-game metrics with standard clinical
screening and assessment tests. However, it should be
kept in mind that the nature of these games requires
extra effort towards cognitive assessment rather than
physical status assessment.
2.2 Exergames Are More Engaging
than Cognitive Games, Thus More
Efficient for Stealth Assessment
Participation to serious games is the main rule for
successful assessment. According to the technology
acceptance model (Davis, 1989), which has been
developed to explain ICT use, perceived usefulness
(PU) and perceived ease of use (PEOU) are the
primary determinants that affect use attitude.
Therefore, the fact that physical exercise’s effects are
observable by the seniors after a very short period of
training, in conjunction with the immediate positive
mood changes after physical activity (Kirk et al.,
2013; Pierce and Pate, 1994; King et al., 2000),
emerge the potential of a strong perceived usefulness
factor of exergames (c.f. Figure 1).
The authors’ experience concurs with that. Wide
pilot trials, in terms of time (2 months) and
participants (116 seniors), of the FitForAll
(Konstantinidis, Billis, et al., 2014) platform
demonstrated this. This platform encapsulated the
American College of Sports Medicine (ACSM) and
the American Heart Association (AHA) protocols,
guidelines and recommendations regarding the exact
type and intensity of elderly exercise regimens
(Chodzko-Zajko et al., 2009). The pre- and post-
intervention Fullerton physical status assessment
provided clear evidence that integration of these
recommendations led to an overall physical status
improvement of the seniors. Besides that, the vast
majority of the participants reported that they felt
their body more light weighted, increased sleep
quality and that they performed daily activities with
greater flexibility even after a small period of
exergaming sessions. Most of them reported that
although they had felt bored to follow an exergaming
regimen before participating in the first sessions, they
were happy to follow the daily regimen. Seniors’
adherence to the daily schedule, and thus to the
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physical exercise protocol schedule, reached 82%.
Moreover, 85.4% of the seniors reported that they
perceived the FFA platform as allowing them to
control their health better. Thus, the incorporation of
existing, established physical exercises during design
and implementation of exergames could serve as an
additional guideline for their design.
On the cognitive games axis, the effects in
cognitive function, could be observed only after long
term training. As an indicative example, Minge et al.
reported the results of a focus group among seniors
where serious games were rated as possibly helpful
(Minge et al., 2014). To this end, authors observed
that seniors tend to undertake cognitive games
because they have been told that they are helpful for
their cognition contrary to exergames of which the
effects are immediately observable in their daily life.
Some of the seniors’ response when they were asked
about exergames, were: “Better mobility. It helped me
with the pain on my back and on my joints. I lost
weight. I fall asleep more easily”. When they were
asked regarding the cognitive games they responded:
“I like these games because they will help my
memory. I believe that they will help me against
dementia”. This delayed emergence of cognitive
games’ perceived effects (as denoted by the
testimonials’ future tense and qualifiers) may not be
able to sustain the initial games’ engaging factor
introducing a larger dropout risk since the participants
might not reach the time threshold of its perceived
usefulness. On the contrary, exergames’ more
immediate effects could be complementary to the
initial motivation which stems from the joyful
experience of the “gaming” component
(Konstantinidis, Billis, et al., 2014; Brox et al., 2011;
Shubert 2010). Finally, there is a trade-off on the
efficiency for stealth assessment (exergames) and the
accuracy of stealth assessment (cognitive games).
2.3 Exergames Acceptance and
Participation
Regarding perceived ease of use, recent technological
advances and services that support controllers utilized
by exergames (e.g. Kinect, Balanceboard, etc.)
(Konstantinidis, Antoniou, et al., 2014), led to rich
internet applications available to contemporary
devices like SmartTV, tablets and smartphones.
Studies have shown that these devices are far more
useful to elderly users for access to internet based
services (Werner et al., 2012). Moreover, the ease of
access provided by these devices, far outweighs the
lack of versatility in comparison with traditional
computer systems. Therefore, barriers in participating
to exergames due to technology constraints (PC
usage, etc.) have been lifted in the last years. More
specifically, the Kinect smart TV combination could
be deemed as a natural interface for exergaming. To
the authors’ experience (Konstantinidis, Billis, et al.,
2014), the seniors reported that 5 days familiarization
with the exergaming platform were enough for
feeling that have mastered the platform. On the other
hand, when the exergames utilized by the seniors by
means of Kinect gestures and postures through a
smart TV, the seniors reported that they needed 4
days for the same feeling.
2.4 Carefully Designed Features
Increase Stealth Assessment
Quality and Accuracy
The authors’ experience during the design and
implementation of FitForAll as well as during the
intervention trials, the data analysis and the literature
research led to a number of design recommendations
for exergames which have bearing on assessment.
Designing and incorporating proper in-game
stealth assessment is a challenging (Bellotti et
al., 2013) process. However, the value of its
outcome denotes it as a promising component
of serious games and justifies the extra effort.
Exergames should be tailored to the elders in
order to secure increased adherence.
When serious games are utilized for assessment
of elders not familiar with the technology, a
short learning period is required. Assessment
during this period reflects also familiarization
and initial perception of components.
High resolution monitoring, incorporating as
much as reasonably acquirable information as
possible, provides opportunities for data
mining towards new design recommendations.
Exergames could incorporate games that
motivate users to perform tasks identical to
those in standard assessment tests both in the
cognitive and in the physical domain
Cognitive tasks should be required during
exergames but without overloading the elders.
Open policies for exergaming data
accompanied by semantic markup have to be
provisioned inherently in future research.
Twin scope exergames, focusing both to
prevention and assessment, is feasible. A
game’s daily session could be divided in long
training periods and short assessment periods
with less physical intensity (focus on cognitive
assessment) so as to avoid cognitive overload
ExergamesforAssessmentinActiveandHealthyAging-EmergingTrendsandPotentialities
327
and to prevent overexertion and wrong pacing
(Gerling et al., 2012).
A very simple assessment task, which could be
representative of the elders’ daily mood and
cognitive function (e.g. reaction time), should
be included in the beginning of the serious
game in order to provide a baseline for each
daily session.
Figure 1: Perceived ease of use and perceived usefulness
are greatly affected by the exergame’s interface and its
physical exercise intensity. Both of these factors have to be
tailored to the seniors in order to ensure engagement with
the game and consequently stealth monitoring.
2.5 Screening Games versus
Exergames
Virtual environments have entered in the field of the
cognitive assessment. Walking on a treadmill
visualized as a stroll in a virtual environment
(Tarnanas et al., 2013; Tarnanas et al., 2014), or
trying to accomplish some daily tasks (Zygouris et al.,
2014), were exploited as screening games with
promising results as such. However, the very fact that
these games are administered as screening games and
not as daily usage games may open them to the same
vulnerabilities as conventional clinical assessment.
Clinical cognitive screening is not part of the elder’s
lifestyle (Jimison et al., 2010). Besides this, seniors
have strong motivation to do well on cognitive
screening tests, to prove that they are not suffering
from cognitive decline, to avoid social stigma
(McKanna et al., 2009). Moreover, day to day
variations in performance can confuse the diagnosis
for a significant time periods (McKanna et al., 2009).
Contrary to that, as discussed above, exergames
are adoptable by seniors in daily life. Due to that
temporal immediacy, the aforementioned vulnerable
points are negated. There is, of course, a trade-off on
the accuracy of the cognitive assessment of
exergames which is undergoing research. Preliminary
results of the authors’ work reveals a classification
accuracy among healthy, people with mild cognitive
impairment and mild dementia over 70%
(Konstantinidis et al., 2015). This accuracy level,
with respect of the fact that the seniors did not
consider exergames as monitoring tool (Antoniou et
al., 2015), turn out to be a promising combination in
accordance with the Plato’s statement “...you can
discover more about a person in an hour of play than
in a year of conversation...”.
2.6 Exergames in Light of Healthcare
Cost Reduction
The absence of an effective treatment against
cognitive decline denotes the early administration of
the available treatments as the more efficient
approach (Gauthier, 2005). An unobtrusive and low
cost tool that could contribute to early detection of
cognitive decline symptoms could provide
opportunities for early administration of available
treatments at a time that they may be more effective
(Jimison and Pavel, 2006). Such a system could
contribute to the delay of cognitive decline onset,
since it is already well documented that physical
exercise is a preventive intervention for it (Bamidis et
al., 2014). Moreover, exergames that could be used
by the seniors themselves in their home would
contribute to the insurances’ and public healthcare
system’s cost reduction (Robert et al., 2014). To this
end, the financial benefits and costs of serious games
with prevention and screening aspects must be
measured in conjunction to the value of timely and
correct diagnosis (Borson et al., 2013).
3 CONCLUSIONS
This position paper aims to provide some food for
thought about exergames and their role in cognitive
assessment in conjunction with their primary scope
which is physical training. Both literature findings
and the authors’ experience substantiate the claim that
exergames will continue to remain in the focus of
research within the next decade. Additional research
efforts should be put on providing evidence based
arguments for researchers and clinicians about the
potential clinical value of the exergames as means of
assessment.
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