Discussing on Gamiﬁcation for Elderly Literature, Motivation

and Adherence

Jose Barambones

, Ali Abavisani

, Elena Villalba-Mora

1,2

, Miguel Gomez-Hernandez

1,3

and Xavier Ferre

Center for Biomedical Technology, Universidad Polit

ecnica de Madrid, Spain

Biomedical Research Networking Centre in Bioengineering Biomaterials and Nanomedicine (CIBER-BBN), Spain

Aalborg University, Denmark

Keywords:

Gamiﬁcation, Serious Games, Exergames, Elderly, Frailty, Discussion.

Abstract:

Gamiﬁcation and Serious games techniques have been accepted as an effective method to strengthen the per-

formance and motivation of people in education, health, entertainment, workplace and business. Concretely,

exergames have been increasingly applied to raise physical activities and health or physical performance im-

provement among elders. To the extend of our understanding, there is an extensive research on gamiﬁcation

and serious games for elderly in health. However, conducted studies assume certain issues regarding context

biases, lack of applied guidelines or standardization, or weak results. We assert that a greater effort must be

applied to explore and understand the needs and motivations of elderly players. Further, for improving the

impact in proof-of-concept solutions and experiments some well-known guidelines or foundations must be

adopted. In our current work, we are applying exergames on elderly with frailty condition in order to improve

patient engagement in healthcare prevention and intervention. We suggest that to detect and reinforce such

traits on elderly is adequate to extend the literature properly.

1 INTRODUCTION

In recent years, a rapid increase of consumer soft-

ware inspired by the video-gaming has been per-

ceived. Gamiﬁcation emerges from this phenomenon

as a powerful tool for Human-Computer Interaction

research such playful design, serious games, purpose-

ful games, pervasive games, and exergames, inter alia.

In a nutshell, gamiﬁcation refers to game structures

and components to solve user problems. From an

industry-based perspective, gamiﬁcation and serious

games methods have been used to increase participa-

tion and to encourage behavioural changes from the

audience. From a scientiﬁc point of view, gamiﬁca-

tion reinforces and improves behaviours and user ca-

pacities with special focus on learning and health (Ka-

surinen and Knutas, 2018). Concretely, exergames are

a set of gamiﬁcation components from the family of

serious games deﬁned as virtual games that require

physical exertion to be played.

The World Health Organization (WHO) deﬁnes

“Healthy Ageing” as the process of developing and

maintaining the functional ability that enables well-

being in older ages. In other words, to maintain and

preserve the intrinsic capacity of the individual, its en-

vironmental characteristics and their interaction. In

parallel, by 2050 life expectancy will surpass 90 years

and one in six people in the world will be over age 65

(WHO, 2019; UN, 2019).

As far as we are concerned, although extensive

research on gamiﬁcation for health exists, there are

many concerns about gamiﬁcation focused on elderly.

While there are remarkable research in this topic, i.a.

guidelines (Czaja and Lee, 2002; Ijsselsteijn et al.,

2007), study of engagement and adherence (de Vette

et al., 2015), and rehabilitation (Laver et al., 2017;

Skjæret et al., 2016), literature still remains poor due

to low-quality evidence, assumed biases, and lack of

user adherence, among others. In addition, to ap-

ply gamiﬁcation for ageing becomes challenging due

to the lack of familiarity of the elderly with games

and its components, metaphors and mental processes,

i.a. points, status, stages, badges. etc. However, ex-

ergames sound promising to ﬁll this gap, motivating

elders to do exercise because of its fun, aiming for

a proper adherence and motivation that enforce the

mentioned capacities.

308

Barambones, J., Abavisani, A., Villalba-Mora, E., Gomez-Hernandez, M. and Ferre, X.

Discussing on Gamiﬁcation for Elderly Literature, Motivation and Adherence.

DOI: 10.5220/0009818003080313

In Proceedings of the 6th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2020), pages 308-313

ISBN: 978-989-758-420-6

We conducted a qualitative analysis using sec-

ondary data from a literature review that includes

both scientiﬁc and grey literature. The search and

the initial analysis were conducted separately by the

main researchers, whilst the discussion and position-

ing were concluded by the all the authors. As our

early conclusions, a greater effort on gamiﬁcation for

ageing must be conducted. Concretely, our position is

twofold: to ensure usability for seniors through gam-

iﬁcation given their capacities as players and, in par-

allel, to explore and understand the needs and mo-

tivations of elderly players in order to improve user

adherence and extend the current theory. In addition,

further well-controlled studies are required to estab-

lish unambiguously the effects gamiﬁcation on dif-

ferent types of elderly users. Moving forward, our

current work aims to extend exergaming to tailored

intervention for elderly with frailty condition. Frailty

condition is an intermediate state in the ageing tra-

jectory with increased vulnerability and preceding the

onset of disability. In contrast to permanent disability,

frailty advance can be potentially reversed through

appropriate interventions (Fried et al., 2001). Accord-

ingly, we aim to apply gamiﬁcation techniques tai-

lored to elderly given their functional status and mo-

tivational trait. Indeed, the long term goal is, through

these techniques and extensions, be capable to recog-

nize the motivational trait itself. Indeed, we want to

demonstrate that engagement and adherence on elders

are linked with concrete traits such personal mastery

and failure avoidance. To do so, exergames are proved

to be suitable to improve patients motivation as well

as their health.

2 BACKGROUND

Gamiﬁcation is deﬁned by the use of design elements

from games in non-game contexts. This broader def-

inition emerges from the industry and research ap-

proaches, i.a. productivity games, surveillance enter-

tainment, gameful/playful design, behavioral games,

serious games, and pervasive games. Over recent

years, gamiﬁcation techniques have been accepted

as effective methods to develop the performance and

motivation of people. Different research approaches

have applied gamiﬁed systems, such as education,

health, entertainment, business, and exercise (Deter-

ding et al., 2011).

Several studies shows how gamiﬁcation litera-

ture are becoming popular in different research ar-

eas. Trendiest approaches in gamiﬁcation are stud-

ies based on proof-of-concept prototypes (computer

science education, ecology and sustainability, and

motivational reinforcement), theoretical analysis of

components, and applicability on e-learning educa-

tion (Seaborn and Fels, 2015; Kasurinen and Knu-

tas, 2018). Most frequent objectives in the literature

are aimed to comprehend how gamiﬁcation affects

user performance, mainly the intrinsic motivation and

need satisfaction. Indeed, some effort has been ap-

plied to empirically study through experiments and

evaluation in mentioned concepts from a psycholog-

ical (Hamari et al., 2014; Sailer et al., 2017; Mekler

et al., 2017) and neurological perspectives (Mond

ejar

et al., 2016), among others.

2.1 Gamiﬁcation for Elderly

Serious games are deﬁned as any form of playful

resource, mainly interactive or computer-based, to

be used with the intention to be more than enter-

tainment. Games for Health are a subset of serious

games, where the purpose of the game is to improve

the health of the player, either via exercise inducing

games or via promoting the health-enhancing activi-

ties (Kasurinen and Knutas, 2018). Exergames are de-

ﬁned as virtual games that require physical exertion to

be played and emerge from the hypothesis of motivat-

ing adults to do exercise because of its fun. Literature

shows how gamiﬁcation through exergames in health

has emerged as a popular strategy, both in commer-

cial culture and research as a means of inﬂuencing

behaviors (Lister et al., 2014). Other studies aims to

improve adherence through long-term and sustainable

user motivation to workout through exergames (G

obel

et al., 2010).

As introduced below, to care and develop the in-

trinsic capacity of the individual is crucial to maintain

and preserve the functional ability on elderly. Intrin-

sic capacity comprises all the mental and physical ca-

pacities that a person can draw on and includes their

ability to walk, think, see, hear and remember. The

level of intrinsic capacity is inﬂuenced by a number

of factors such as the presence of diseases, injuries

and age-related changes (WHO, 2019). Physical ac-

tivities are a vital element at all ages, particularly in

elders to manage their daily life. This includes an ad-

equate strength, balance, and ﬂexibility, among other

requirements. Exergames have been increasingly ap-

plied to raise physical activities and health or physi-

cal performance improvement among elders, through

motivating elder people to do exercise and mightily

acquire sufﬁcient physical exertion (Kirk et al., 2013).

Despite the remarkable set of casual games that

are not adequately designed in terms of speed, amount

of information, and movement options (Wollersheim

et al., 2010), recent research has measured the in-

Discussing on Gamiﬁcation for Elderly Literature, Motivation and Adherence

309

ﬂuence of interactive video games and virtual reality

games in the rehabilitation of diseases on elders. For

example, from the stroke literature, there are stud-

ies about using gamiﬁed technology and exergames

to research about rehabilitation in stroke recovering

(Laver et al., 2017). Several reviews have indicated

that the engagement of older adults in exergaming is

feasible and safe or mightily raise the balancing po-

tential of participants. Although exergame program-

ming might be a substitute for many joint exercises

with balance features, research on exergaming pro-

poses methodology alternatives on protocols of inter-

vention for users (Laufer et al., 2014; Skjæret et al.,

2016). These factors have supported the efﬁciency of

exergames to boost the physical functioning in older

adults. Thus, exergames are a proper exercise tech-

nique for older patients and as a tool to maintain

physical functions, health, and independence (Molina

et al., 2014; Skjæret et al., 2016).

2.2 Motivation, Pros, and Cons

The approach of gamiﬁed apps for health has funda-

mentally questioned or subject to debate by the scien-

tiﬁc community. In addition to entertainment value,

there are evidences of a substantial therapeutic value

in playing digital games. However, deﬁnitional sub-

jectivity, diverse or unstated theoretical foundations,

incongruities among empirical ﬁndings, and inade-

quate experimental design remain matters of concern.

Digital games allow elderly people, like other

users, to bond socially, either by online or physically

co-located with their companions, thereby enhancing

their social connectedness and potentially enlarging

their social support structure. Despite this potential,

seniors are proportionally underrepresented as con-

sumers of digital games, creating a signiﬁcant and

largely untapped market opportunity.One of the rea-

sons for this has been the focus of game developer stu-

dios to develop games primarily for adolescent users,

where games which do not usually resonate well with

the interests, needs, abilities and limitations of elders.

As a consequence of both functional limitations and

a simple lack of technological experience, seniors are

hurt more by usability problems than younger users.

Results through gamiﬁcation justify its popular-

ity in healthcare, such as telemedicine (Tabak et al.,

2015), cognitive therapy (Gerling and Masuch, 2011),

and motivation (Minge et al., 2014), among others.

While gamiﬁcation has been extensively used regard-

less the age condition, focus on elderly still remains

reduced in terms of adherence, engagement, and ﬁ-

nal products. In fact, studies shows how elderly pop-

ulation are under-represented as customer of digital

games, since the games do not fulﬁl their needs, inter-

est, and usability demands (Ijsselsteijn et al., 2007).

On the other hand, although this area has an

emerging tendency of research, a remarkable set of

studies shows low-quality evidence, potential biases,

lack of user adherence, or even harmful situations

with users. Reviews, either systematic or not, tend

to assume the high variability between studies in dif-

ferent aspects, i.a. context, methodology, experi-

ments procedures, intervention protocols, outcome,

and other limitations (Hamari et al., 2014; Laufer

et al., 2014). Indeed, even with the widespread use

of gamiﬁcation principles, the lack of professional

guidelines or standards enforce such biases on the

comparisons (Lister et al., 2014). The studies are

signiﬁcantly heterogeneous regarding the technology

and the games used in their experiments. This leads

to a dependence on the results to such assets attached

to the interventions, from well-known game consoles

to tailored proof-of-concept prototypes. Lack of ex-

tensive gamiﬁcation researches has signalled the re-

quirement of potential usage of gamiﬁed apps for el-

derly to change their health behaviours. Following the

recent studies, game console and mobile apps have

been conﬁrmed to be useful and complementary to

health interventions. However, the majority of rigor-

ous researches have been used to deﬁne the efﬁcacy

and to establish evidence of best practices. The con-

clusion is limited by the variety of reporting of ad-

herence and usage data. We understand that probably

gamiﬁcation for health literature possesses signiﬁcant

heterogeneity, according to the selected perspective-

based between studies. Concerning health symp-

toms, studies found some negative cases have been

presented along with the researches like mild tran-

sient dizziness, headaches, pains, showing that inter-

ventions must be speciﬁcally controlled for elderly

(Laver et al., 2017). These adverse events are com-

mon but casual and not be of great concern. However,

it becomes relevant in elderly population for an ef-

fective adherence, even critical in users with frailty

condition.

3 POSITIONING

Despite a few more studies concerning gamiﬁcation

and exergames, most of them lack of an appropri-

ate methodology. Most game developers are still un-

aware of basic game accessibility guidelines and ob-

viating certain age ranges of potential users such se-

niors. This situation can should be drastically im-

proved through extensive user testing with elders and

the use of design guidelines that are speciﬁcally tai-

TEG 2020 - Special Session on Technology, Elderly Games

310

lored to the elderly population. There is a substan-

tial body of literature focused on elderly, including in-

terface design guidelines and game design techniques

(Deterding et al., 2011; Gerling et al., 2012; Mond

ejar

et al., 2016; Ruzic et al., 2016). Several design rec-

ommendations can be distilled from this literature.

Mainly, the interface design for elderly users should

minimize the burden on functions that may have suf-

fered decline, such as demands on spatial memory,

working memory, visual functions or motor ability.

Furthermore, interfaces should be adaptable to com-

pensate for particular functional limitations (sensory,

motor or cognitive) of elderly users. Regarding the

health goals using exergames on elderly, there is a

need of results in terms of effectiveness, according to

the widespread perception that exergames is a poten-

tial candidate as a training tool beside the applied pop-

ular games and gaming consoles (Laufer et al., 2014).

We assert that, in parallel to ensuring usability

of games for seniors, community need to make sure

that there are substantial perceived beneﬁts for elderly

users, so that they are willing to invest their valuable

time and energy in what can potentially be a reward-

ing experience. To explore and understand the needs

and motivations of elderly users, there is a great need

for a substantial research effort, which includes focus

group studies, interviews, surveys and general mar-

ket segmentation research. In addition, further well-

controlled studies are required to establish unambigu-

ously the effects of different genres of digital games

on different types of elderly users, putting the various

hypothesized beneﬁts to a much more detailed test.

For example, one remarkable application of ex-

ergames for elderly is fall prevention. As mentioned

before, elderly people are subject to fall frequently

and consequences are raised with ageing. After-

wards, ageing is related with both impaired move-

ment dynamic and with a deterioration of cognitive

processing, involving working memory and conclud-

ing to a frailty condition. Falling prevention train-

ing programs in seniors have included balance, mus-

cle strength, ﬂexibility and endurance, but also rein-

force falls occurrences given a high dose of exercise

and challenging balance exercises. Indeed, exergames

are promising for home designed strength and balance

training on both elders and healthy adults.

An interesting scenario is coming in the follow-

ing years: due to the irremediable aging of the ﬁrst

generations of players, this community may pre-

served knowledge, skills and experiences that pos-

sibly changes the adherence implications when they

become elderly. For example, the ﬁrst generation of

players (Pong, Atari, Coleco, Odyssey...) are from

70’s. It can provoke a change in the premises and

a new way to encourage engagement through tech-

niques and resources based on by such familiarity.

4 ONGOING WORK

As explained before, frailty condition is an interme-

diate state in the ageing trajectory with increased vul-

nerability and preceding the onset of disability, po-

tentially reversed through appropriate interventions

(Fried et al., 2001). Our current work consists on

a larger effort to improve the patient condition and

exercise engagement through his motivational trait in

falling prevention. In our context, patient interven-

tions are based on his functional status from clinical

data during visits. Foremost, we aim to adapt inter-

ventions given the patient motivational trait. That

is, to provide a tailored treatment including physi-

cal exercises where, by exergaming techniques, pa-

tients are expected to maintain their adherence. Af-

terwards, we raised to extend and improve such in-

terventions recognizing the patient motivational trait.

That is, to recognize patient behaviours, intentions,

effort and persistence over the time from frailty pa-

tients. By transforming motivation input from a con-

stant to be assumed to a variable to be inferred our ob-

jective is twofold: First, we aimed to provide health-

care professionals information for not solely tailored

interventions, but also prevention. Second, strengthen

patient motivation to guarantee his engagement. To

the extend of our understanding, motivation reinforce-

ment on elderly is mainly based on failure avoidance

and personal mastery, rather than other gamiﬁcation

components related with game difﬁculty, challenges,

or competitiveness. Accordingly, these goals can be

achieved if we focus on such traits.

5 CONCLUSIONS

In this paper we discussed on the current state of the

art on gamiﬁcation for elderly. Further, we question

the accuracy of literature due to different contextual

factors in the studies, concluding to low-quality

evidence, biases, and lack of user adherence, among

others. From our qualitative analysis, we assert that

more effort in this topic is needed through a deeper

study using different approaches, i.a. study of elderly

condition related to games, and applying well-known

guidelines on gamiﬁcation and game design for

elderly. Based on our concerns, to apply gamiﬁca-

tion focused on reinforce motivation such personal

mastery and failure avoidance are the best traits to im-

Discussing on Gamiﬁcation for Elderly Literature, Motivation and Adherence

311

prove and guarantee engagement, specially use-

ful in healthcare contexts.

ACKNOWLEDGEMENTS

We would like to thank FEDER funds for coﬁnancing

our home institutions. Special thanks to the volun-

teers in the study, in particular to older people, for

their unselﬁsh collaboration, their enthusiasm, and

dedication.

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