Therapeutic Activities for Elderly People based on Tangible

Interaction

Eva Cerezo

1,2

, Clara Bonillo

and Sandra Baldassarri

1,2

Departamento de Informática e Ingeniería de Sistemas. Universidad de Zaragoza, Spain

Instituto de Investigación en Ingeniería (I3A), Universidad de Zaragoza, Spain

Keywords: Tangible User Interfaces, Elderly, Cognitive Stimulation.

Abstract: The use of natural user interfaces in rehabilitation can contribute to increase the motivation of patients

during the rehabilitation process. Among them, Tangible User Interfaces (TUI) which couple digital

information to everyday physical objects, are considered to be intuitive and especially suitable for elderly

people. The physical interaction with real objects can improve the quality of training for patients who need

cognitive and/or motor rehabilitation. To explore the use of tangible interfaces with the elderly, a tangible

tabletop designed by the AffectiveLab was settled in a nursing home. First of all, the general user

experience of their clients when working with the tabletop was assessed. From this initial evaluation tips for

the creation of tangible tabletop activities for elderly were obtained and applied to the design of new

cognitive and physical stimulation activities for them. From this experience, guidelines for the design of

tangible activities for this kind of users have been extracted and presented in the paper.

1 INTRODUCTION

In the last years, the amount of work aimed to

investigate the potential of the information and

communication technologies (ICT) for enhancing

the wellbeing of elderly people, has considerable

increased. The main focuses of these researches

include combating physical and social isolation and

loneliness, improving social interaction, digital skills

and, specially, they are centred in the improvement

of physical and mental health (Gamberini et al,

2008). New technologies, with their different ways

for interacting, became an important therapeutic,

non-pharmacologic tool, and not only an

entertainment issue (Belleveille, 2008).

Although old people use to have some initial

barriers in accepting digital technology due to their

inexperience or accessibility difficulties, it has been

demonstrated that the use of digital applications and

games (Barbosa et al, 2017) which are meaningful in

older users’ lives (Cañas-Bajo et al, 2016) have

carried very beneficial and positive impact from

active aging, facilitating real change in older

people’s physical or cognitive abilities (Howe et al,

2017). Several studies verify an improvement in

more than 75% of the cases (Zhang and Kaufman,

2016; Nguyen et al, 2017) although there are other

authors that indicate that long-term results are

limited, making it difficult to access the benefits for

older people over time (Cujzek and Vranic, 2017).

Nowadays there are a lot of works that have

introduced digital activities and games to achieve

these objectives for older people (Schutter and

Brown, 2016; Nguyen et al, 2017; Cota and Ishitani,

2015; Levine et al, 2016) mainly in three areas: for

promoting socialization activities (Myhre et al,

2017), for physical exercises and rehabilitation and

for cognitive improvement and rehabilitation

(Wittland et al, 2015; Loos, 2017). In fact, nowadays

therapists have at their disposal numerous tablet and

smartphone applications aimed at helping people

with physical and/or cognitive impairments.

However, these devices are usually based on tactile

interaction that requires the client to perform

relatively precise tactile gestures for adequate finger

detection, which can be difficult to achieve for

people who suffer from motor or cognitive

impairments. On the contrary, natural interaction-

based applications may offer some extra benefits to

therapy. The tangible interaction approach proposes

that the interaction between the user and the

application should be done using physical objects of

daily use (Ishii and Ullmer, 1997). Among these

Cerezo, E., Bonillo, C. and Baldassarri, S.

Therapeutic Activities for Elderly People based on Tangible Interaction.

DOI: 10.5220/0009816602810290

In Proceedings of the 6th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2020), pages 281-290

ISBN: 978-989-758-420-6

281

tangible innovative systems, the use of tabletops in

the therapy context has begun to spread during the

last 10 years. A tabletop is a computer device whose

physical appearance is very similar to a normal

table. Its surface is virtually augmented using a

projection of images and sounds coming from a

computer application, and the interaction is carried

out through movements of the fingers on the

tabletop surface (multi-touch). In the case of

tangible tabletops, the device is able to detect and

identify the different objects placed on its surface, to

track the different manipulations that users carry out

with them and to show information related to those

manipulations on the surface (tangible). This manner

of interaction has several advantages, since the wide

surface of the tabletop provides a large space to

work the user’s visual but also motor skills, the

audio-visual stimulation motivates them and they

can work with a bigger range of activities that cover

one or more aspects of cognitive stimulation.

Additionally, by keeping the objects on the physical

side of the user, not only the emotional impact of the

game is reinforced (Iwata et al, 2010), but also

important benefits emerge when applied to young

children (Marco et al, 2013a), children with special

needs (Li et al, 2008), the elderly (Gamberini et al,

2006), and people with motor or cognitive

disabilities (Leitner et al, 2007). Nevertheless, and in

spite of their potential, tangible tabletops

applications in therapy are rare.

The AffectiveLab of the University of Zaragoza

has developed NIKVision (Marco el at, 2013b), a

tangible tabletop device. NikVision is a vision-based

tabletop initially designed for very young children

and children with special needs. Thanks to an

agreement with the Aragonese Institute of Social

Services (IASS) we were able to settle on of our

tabletops in a big public nursing home. In this paper

we present the tangible activities we developed

specially for the clients of the nursing home.

The paper is organized as follows. Section 2 is

devoted to present the state of the art about tangible

tabletops and rehabilitation. In section 3, the

NikVision tabletop and the first experiences in the

nursing home are presented. Section 4 presents the

tangible activities developed and their evaluation

with the nursing home clients. Section 5 presents the

discussion and, finally, in section 6, the conclusions

are exposed.

2 STATE OF THE ART

Following, a revision of tangible interaction

experiences for old adults in rehabilitation, mainly

focusing on tabletops, is presented.

Leitner et al. (2007) present a prototype of a

tabletop specifically for cognitive and physical

rehabilitation. The authors also propose several

activities based on the manipulation of cubes with

different patterns drawn on them. To complete the

task, the user must align the cubes to form the same

image as that shown on the tabletop surface.

Gamberini et al. (2006, 2009) have developed

several memory game activities for keeping old

people cognitive skills by using a tabletop. The users

interact with the tabletop by manipulating special

pencils. The tabletop allows playing up to four

persons, who can be or not collocated around the

same tabletop device, since different tabletops can

be connected remotely. The Memo-game activity is

similar to the popular game of finding pairs, in

which the users gain points when making pairs and

lose points when they fail to pair two images

correctly. Some Minigames activities can be done

for recovering the points when they lose. The aim of

these games is to improve cognitive functions like

memory, reasoning, selective attention, divided

attention and classification.

Other applications have been developed for the

cognitive training of adults and elderly people

(Kwon et al, 2013): the E-CoRe system (Embodied

Cognitive Rehabilitation System) is aimed to delay

or prevent cognitive problems by training three

specific cognitive processes: attention, memory and

reasoning. For this purpose, they use tangible objects

and a tabletop interface to train patients to perform

activities of daily living (Jung et al, 2013). The

application simulates making cookies by

manipulating different objects, adjusting the number

of cookies, selecting their shape and setting the oven

temperature, and then, adding syrup and toppings to

their cookies. The users have to follow certain

instructions while remembering the steps that they

have already done, so they are continuously working

their attention and memory skills. In a later work,

(Song et al, 2016) compared tangible tabletop-based

training, with the E-CORE platform, with computer-

based training, that involves singular mental tasks

using keyboard and mouse, with RehaCom

application. Although the sample is small, they

found that embodied cognitive rehabilitation helps

improve patients’ cognitive functions and increases

patients’ motivation for rehabilitation.

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Also, an European Research project called

Sociable (Sociable, 2019) has been carried out a for

cognitive training. It is focused on people with

cognitive disorders and uses a tactile tabletop to run

a great variety of activities organized in categories:

memory, attention, reasoning, language and

orientation. They have developed tactile tabletop

versions of popular games like Finding pairs or

Guess Who, together with several activities very

similar to traditional puzzles.

Finally, there some other works that successfully

use tangible interfaces to improve social skills. In

this way, different tabletop games (Mahmud et al,

2010) for stimulating social interaction were

designed, in the first place for improving interaction

between children and older people and in the second

to promote wellbeing. Also, there are some tangible

products that have been used for improving social

networks in elderly people. TEPOS (Tangible

Entertainment Projection System) is an

entertainment device that connects the real world

with digital world for elderly people to engage with

families and other people by projecting different

games on any surface (TUVIE, 2019).

Regarding physical and motor rehabilitation

through tabletops and tangible interaction, there are

many works focused in limb rehabilitation after

traumatic brain injury or stroke (Annett et al, 2009,

Kwon et al, 2013, Mumford et al, 2008).

As conclusion, many works have already proven

the advantages of using tabletops and tangible

interaction in rehabilitation of elderly people. This is

why we decided to install one of our tabletops in a

nursing home as it is explained next.

3 NIKVision TABLETOP AND

THE ROMAREDA NURSING

HOME

3.1 NIKVision Tabletop Description

NIKVision (Marco et al, 2013b) is a tangible

tabletop based on the physical manipulation of

physical objects over the table surface. Any object

can be used to interact with the tabletop on the

condition that a printed marker (called fiducial) is

attached to its base (see Figure 1). Theses markers

are recognized by using reacTIVision visual

recognition software (Kaltenbrunner and Bencina,

2007) to track the position and orientation of the

pieces placed on the surface (see Figure 2c). An

infrared light USB camera (see Figure 2b) captures

video from underneath the table and streams it to the

computer station which executes the visual

recognition and activity software. Active image

projection on the table is provided by rear projection

(see Figure 2d) through a mirror inside the table (see

Figure 2e) and the speakers (see Figure 2f)

reproduce the audio of the activities.

Figure 1: Example of fiducial attached to a playing piece.

Figure 2: NIKVision Tabletop.

3.2 Case Study

A NIKVision tabletop was installed in the Romareda

nursing home thanks to an agreement with the

Aragonese Institute of Social Services (IASS). This

nursing home is considered the reference home in

the region.

Once the tabletop was installed, it was decided to

carry out an initial evaluation to detect how elderly

people react and their user experiences.

The Romareda therapy group was composed of

thirty-seven people (23 women and 14 men) aged 63

to 99 years with different mental health problems.

With the help of the occupational therapist (OT) the

clients were divided in turn in two subgroups:

 Cognitive Problems: people belonging to this

group suffered from attention and memory

problems. They had also hearing and eyesight

impairments, and got easily tired and

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283

distracted. During their regular therapy

sessions, they did activities like finding the

differences or similarities between images and

puzzles.

 Dementia: people belonging to this group need

the constant help of the therapist in order to do

their therapeutic activities. They presented

problems of concentration, memory, autonomy

and self-control.

The clients tested, individually, activities that

had been previously created: memory, attention and

reasoning activities (for more details see (Bonillo et

al, 2019)). With this evaluation we wanted to have a

first measure of the user experience while doing the

activities on the tabletop. Several people took part in

the evaluation session: the OT of the Romareda

nursing home, who helped the clients while they

tested the activities, and two experts, in charge of

observing, taking notes and providing the clients

with the pieces to be used. It was decided not to take

photographs or film the tests as the OT explained

that they would feel annoyed and it could make them

act not naturally or not act at all.

3.3 Lessons Learned

The vast majority of the clients was satisfied with

the activities with the tabletop and expressed their

desire to use it again. Some very interesting

conclusions were obtained:

 Almost all the clients needed a practical

example of the activities to know how to

complete them. For that reason, we concluded

that it could be necessary to add an initial task

just at the beginning of the activities that

explained how to complete them.

 Many of the activities were too difficult for

many of them: therefore, when designing

activities several levels of difficulties have to

be considered carefully and the OT has to be

able to select one of them and/or switch from

one to another during the session.

 Practically none of the clients paid attention to

the feedback. The clients ignored the audio that

sounded just at the beginning of the activities

and that explained how the activity had to be

done, since the clients were used to hear the

instructions directly from their therapist and

consequently they did not identify the audio

that was sounding from the tabletop as such.

Also, they did not understand either that the

neutral, happy and sad faces that appeared on

the activities were indicating the result of their

actions on the tabletop. They just saw them just

as mere decoration of the activity.

 The typology of the pieces did not pose any

problem as they accepted both those flat and

those three dimensional. But they had

difficulties recognizing some objects. The

therapist suggested that for future activities it

could be better to use real images instead of

pictures, since probably that way the clients

would be able to recognize them more easily.

 Clients with wheelchair had difficulties to

complete some activities. These clients had to

resolve the activities laterally in order to be

able to perform the activities on the tabletop.

Besides, the clients who also had bad mobility

in their upper limbs had difficulties when

completing the activities that required to place

the objects in the superior (or even centre)

zones of the tabletop.

 The OT expressed the importance of promoting

social interaction between their clients and

suggested the design of a new multiplayer

activity for the tabletop.

After the general positive feedback obtained

from these first evaluations from clients and

therapists, we decided to design new activities

specially designed for them, following their

feedback and recommendations. Due to the extreme

difficulties that dementia patients encountered with

even the easiest activities it was decided to focus on

the cognitive problems group. The new activities are

presented in the next section.

4 TANGIBLE TABLETOP

ACTIVITIES FOR THE

ELDERLY

Three new activities were designed. From these, one

of them was especially devoted to work upper-half

motor skills. It was the first of this kind designed for

the NIKVision tabletop.

All the activities were developed by using

KitVision, a toolkit designed to create tangible

activities for the NikVision tabletops (Bonillo et al,

2019). The new activities have been designed with

several different levels of difficulty so that the

therapist can choose one of them depending on the

client’s abilities. All the activities begin with an

audio explanation that indicates the objective of the

task, together with a positive audio feedback of the

answers of the user.

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Next the three new activities are presented,

explaining their aim and levels of difficulty, the

physical and virtual objects they use and their

therapeutic goals.

4.1 Clothes Activity

Aim of the Activity: This first activity is based on

the daily task of getting dressed and has three

different levels of difficulty:

 Easy: the background shows a body part

(hand, feet, head…) together with the

silhouette of two pieces of clothing. One of

them corresponds to the body part while the

other do not. The user has to select the correct

one and place it on the right body part (see

Figure 3).

 Medium: this time instead of a body part, the

background shows the whole body of a person

(man or woman). The user has to select the

clothing that corresponds to the gender of the

person: for example, heels or skirt to the

woman, and shoes and pants to the man.

 Difficult: in this level, the users have first to

complete a word related to the weather with

the vowels missing: “Sun”, “Rain”, and

“Snow”. After that, the background shows a

person together with four different pieces of

clothing. In addition, through a window the

weather that the users have just completed can

be seen. Then, taking it into account they have

to choose the most adequate clothes to wear:

for example, if it is sunny they have to choose

the sunglasses and the fan (see Figure 4).

Figure 3: Clothes activity (easy level).

Figure 4: Clothes activity (difficult level).

Virtual and Physical Elements: The virtual

elements consist of the different background that

shows the body parts. Users interact with the

tabletop by using different objects with realistic

drawings of pieces of clothing and letters (see Figure

5).

Figure 5: Objects of the Clothes activity.

Therapeutic Goals: this activity allows the

consolidation of the semantic memory in the field of

the clothing, together with the weather.

Also, it allows working the relation between

analogous elements thanks to the association of the

clothing with its corresponding body part, and the

relation between different elements when you have

to choose clothes depending on the genre and on the

weather. In the most difficult level, language is

subtly worked thanks to the words that have to be

completed to advance in the activity. Fine motor

skills are addressed when users have to pick up the

two-dimensional objects to place them on the

tabletop. Finally, the audio feedback (changing

between man and woman depending on the task)

enhances the short-term memory and complements

the information showed on the tabletop.

4.2 Shapes Activity

Aim of the Activity: In this activity users have to

select the shapes indicated by the activity and situate

them on the box displayed on the tabletop. There are

two different levels of difficulty (easy and hard) and

a multi-player level that combines tasks that appear

in the easy and medium levels.

 Easy: this level is focused on the work with a

single type of shape (circles or squares) but

with different sizes and colours, increasing the

number of pieces involved with each task.

 Hard: in this level the users work with the

two types of shapes. In this level, the number

of correct answers increases.

 Multi-player: in this case, all the available

toys are divided in two so that each player has

Therapeutic Activities for Elderly People based on Tangible Interaction

285

half of them. Also, the division is made in a

way that the solution contains pieces

belonging to both users, so that they have to

collaborate to complete the task (see Figure

6).

The use of feedback and the navigation menu is

the same as in the previous activity.

Virtual and Physical Elements: the virtual

elements of this activity consist of the background

showing the box and the different geometrical

figures involved in the task. Users interact with the

tabletop by using geometrical shapes (see Figure 7).

Figure 6: Shapes activity (Multi-player).

Figure 7: Objects of the Shapes activity.

Therapeutic Goals: this activity allows working the

association between physical elements with the

concepts they represent, together with the inductive

reasoning that allows carrying out the process of

thinking from the specific concepts to the general

concepts. In the multiplayer level, the activity fosters

the communication between the people that are

playing and cooperation, since they need to work

together to complete the task. The use of two-

dimensional pieces enhances, again, fine motor

skills. Finally, short-term memory is reinforced

thanks to feedback completing once again the visual

information displayed on the tabletop.

4.3 Roads Activity

Aim of the Activity: the last activity is focused on

upper-half motor skills. Users have to move the

object on the tabletop surface by following a virtual

road, and also by avoiding physical obstacles in the

most difficult levels. Again, this activity has three

different levels of difficulty:

 Easy: the different tasks just have a single

road and there are not any obstacles. The

roads are rather straight, without many bends.

 Medium: obstacles begin to appear and each

task has two different roads to choose. An

audio plays saying which road (red, green or

blue) the user has to follow, and the user has

to select it with the corresponding object.

 Hard: in the most difficult level the two roads

interject so that the user has to pay attention

and continue for the correct road. Also, in the

last tasks both roads are of the same grey

colour, to increase the difficulty even more.

Obstacles are placed in all the tasks (see

Figure 8).

In this case, an audio was added as feedback to

indicate the user when he/she is deviating from the

path.

Figure 8: Roads activity (hard level).

Virtual and Physical Elements: the virtual

elements are the backgrounds showing the different

paths. The objects with which the users interact are

different handles designed to work different kinds of

“grabbing” actions (see Figure 9). The obstacles

used in the most difficult levels are also physical

(see Figure 10).

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286

Figure 9: Objects of the Roads activity fostering different

“grabbing” actions.

Figure 10: Obstacles used in the Roads activity.

Therapeutic Goals: the activity allows the

development and maintenance of procedural

memory in the use of tridimensional objects with

different handles, representative of different daily

situations. Fine motor skills are addressed,

especially the movement of the upper limbs. Also,

spatial orientation is worked, together with divided

and sustained attention since in the most difficult

levels the user has to focus his/her attention on one

of the two different paths, and to concentrate to

follow it correctly. In general, hand-eye coordination

is worked, fostering the skill that enables the eyes to

guide the hands in accurate movement.

4.4 Evaluating the New Activities

The evaluation session took place in the room of the

nursing home where a NIKVision tabletop was

installed. The clients were called one by one in order

to test the tabletop activities.

Before beginning with the activities a small

questionnaire was made (orally) to the user, with the

name, sex, age, mobility of the upper limbs and

trunk, if he/she used wheelchair and the type of

contact with the technology. One of the researchers

was in charge of explaining very briefly the activity

to be performed to the clients and help them.

Questions about every activity were made just after

having tested the activity.

Initially, it was about getting those clients who

had already worked with the NIKVision table, but

after the indisposition of certain patients, some other

people who met the characteristics of target users

(adults with cognitive problems but not dementia)

were recruited, about half of them using

wheelchairs. The users tested individually the cloths

and roads activities; then they played in couples the

shapes activity.

In the Clothes activity the clients were able to

recognize the pieces of clothing and divide them

according to genre. They took their time placing the

objects on their corresponding place (pants/skirt on

the man/woman’s legs, or shoes/heels on the

man/woman’s feet). They understood the audio

instructions but they usually needed to hear them

more than once. They had more difficulties with the

Hard level of difficulty: they have to complete the

words related to the weather, since they focus on

what the audio is saying to discover the word that

they have to complete, and sometimes the audio

does not say it directly (for example, the audio says

“it’s raining” but the word they have to complete is

simply “rain”).

In the Shapes activity, the clients had more

difficulty with the Medium level of difficulty where

they had to place on their own, performing better on

the collaborative level since the number of pieces

they had to manipulate was lower. A good

interaction between players was observed, and

sometimes they even helped each other to be able to

complete the exercise. One thing that would be

necessary to improve for the next version of this

activity is the size of the virtual box: it should be

bigger so that clients did not have to waste too much

time in reorganizing the pieces so that all of them

fitted well inside.

Finally, in the Roads activity the clients reacted

well with the different way of grabbing. They were

able to follow the roads, presenting the expected

difficulties in the last level of difficulty when the

roads overlapped. They also managed to overcome

the physical obstacles while playing. However, the

audio feedback was a little slow to sound when they

stepped out the road, and it was decided to widen the

roads for the next version of the activity.

In general, the evaluation was positive and, in

spite of the few mistakes detected in the design of

the activities, it was observed their adequacy to the

target group they addressed.

5 DISCUSSION

The developed activities were evaluated with elders

with cognitive problems because of their age. These

people are amongst the most vulnerable groups in

most countries and they could benefit from new

Therapeutic Activities for Elderly People based on Tangible Interaction

287

computerized tools and interactive devices. While

guidelines for design for these users have been

suggested, most of them discuss rather low level

details of accessibility, such as alt texts for images,

or navigational design. The lack of research on the

impact in the collective of the latest interactive

paradigms, such as augmented reality, multimodal or

tangible interfaces, is evident.

From our experiences with the elderly we

obtained some interesting clues:

 Initial images containing clues or instructions

have to be shown with enough time in order to

be assimilated by the patients.

 The use of real images instead of drawings

could be more suitable with elder users.

 For the patients with wheelchair, the

interactive areas of the activities must be

closer to the border of the tabletop so that they

can reach them.

 Finally, regarding the feedback, there are

certain users that do not pay much attention to

audio feedback, since they are used to

listening to the instructions from their

therapist. In addition, some of them do not

recognize the visual feedback as such,

mistaking it as a decoration of the activity.

Consequently, with this kind of patients it is

necessary to rethink the way of giving

feedback in a way that they could understand

it. However, after analysing the behaviour and

response of the users that paid attention to the

feedback, we have deduced the following

considerations to take into account when

designing the feedback:

 Wrong feedback (based on either

animations or just sounds) should be used

with care. Most patients are motivated by

positive feedback, but some of the can

easily be frustrated by negative feedback.

 Visual feedback has to be placed close to

the corresponding active area where the

user is focusing his/her attention so that it

is not missed.

We hope these reflections will be useful to other

researchers and designers of interactive applications

oriented to adults with cognitive impairments.

6 CONCLUSIONS

In this paper we have presented the experience of

using the tangible tabletop NikVision in the

cognitive stimulation of elderly people. Thanks to an

agreement with the Aragonese Institute of Social

Services (IASS) we were able to settle on of our

tabletops in a big public nursing home. Thanks to

that, we were able to carry out some initial

evaluations to see the reactions of the older people to

the tabletops and tangible interaction. The residents

were divided into two main groups: the group with

cognitive impairments and the dementia group.

From the results of that initial experience, we were

able to extract useful guidelines in order to tackle the

design of tangible activities for the residents. It was

decided to focus in the cognitive impairments group

as it was stated to be the group that could benefit

more the therapeutic potential of the tabletop. Three

new activities were developed applying a user-center

design approach with permanent contact with final

users and their therapists. From the experience, we

could extract guidelines for the design and

evaluation of tangible activities for this kind of users

that could be useful for other researchers.

In the near future we will focus our efforts in

developing new activities and doing a long-term

evaluation of the effect of the activities. Also, the

acceptance by elderly people of this kind of

technology, these activities over tabletops and the

tangible interaction, will be analysed.

ACKNOWLEDGEMENTS

We would like to thank Maria Nebra and the

therapists for their work with the elderly in the

nursing home.

This research was partly funded by the Spanish

Science, Innovation and University Ministry

(MCIU), the National Research Agency (AEI) and

the EU (FEDER) through the contract RTI2018-

096986-B-C31 and by the Aragonese Government

through the AffectiveLab-T60-20R project.

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