Design of a New Digital Cognitive Screening Tool

on Tablet: AlzVR Project

Florian Maronnat

, Guillaume Loup

, Jonathan Degand

, Frédéric Davesne

and

Samir Otmane

Université Paris-Saclay, Univ. Évry, IBISC, 91020, Évry-Courcouronnes, France

Independent Researcher

Keywords: Digital Tablet, Screening, Alzheimer's Disease, Usability.

Abstract: Alzheimer's disease is the first cause of dementia worldwide without any current curative treatment. It

represents a public health challenge with an increasing prevalence and associated costs. Usual diagnostic

methods rely on extended interviews and paper tests provided by an exterior examiner. We aim to create a

novel, quick cognitive-screening tool on a digital tablet. This program, built and edited with Unity®, runs on

Android® for the Samsung Galaxy Tab S7 FE®. Composed of seven tasks inspired by the Mini-Mental Status

Examination and the Montréal Cognitive Assessment, it browses several cognitive functions. The

architectural design of this tablet application is distinguished by its multifaceted capabilities, encompassing

not only seamless offline functionality but also a mechanism to ensure the singularity of data amalgamated

from diverse sites. Additionally, a paramount emphasis is placed on safeguarding the confidentiality of patient

information in the healthcare domain. Furthermore, the application empowers individual site managers to

access and peruse specific datasets, enhancing their operational efficacy and decision-making processes. We

performed a preliminary usability assessment among 24 healthy patients with a final F-SUS score of

"excellent". Participants perceived the tool as simple to use and completed the test in a mean time of 142

seconds.

1 INTRODUCTION

Alzheimer's disease (AD) is the first cause of

neurodegenerative decline, affecting millions of

people worldwide with a considerable cost for

countries (International et al., 2020). In AD, patients

progressively lose their cognitive abilities, and

behavioral troubles can occur. Without any current

and efficient treatment, loss of memory and

autonomy become an essential burden for caregivers

and families. AD management is a global and public

challenge for health systems that face a constantly

increasing prevalence in aging populations.

Precocious screening of cognitive decline leads to

better and early support for patients and their families.

Unfortunately, general practitioners (GPs) do not

always have enough time to perform initial cognitive

https://orcid.org/0000-0003-3766-5789

https://orcid.org/0000-0003-3476-583X

https://orcid.org/0000-0001-9100-7109

https://orcid.org/0000-0003-2221-4264

explorations. They address their patients at

specialized centers whose appointments can be long,

delaying diagnostic but also symptomatic and social

measures. These labeled memory consultations are

primarily available in hospitals, and the diagnostic

process still relies on paper tests involving an exterior

examiner.

We have developed the AlzVR project, which

aims to propose a multimodal digital program for

cognitive screening. The first published program was

an autonomous immersive assessment composed of

thirteen tasks inspired by MMSE and MoCA and

displayed on Oculus Quest® (Maronnat et al., 2020,

2022). This assessment has not yet been tested among

an older population, but Clay et al. showed that

immersive environments could be efficient in

cognitive screening (Clay et al., 2020). However,

Maronnat, F., Loup, G., Degand, J., Davesne, F. and Otmane, S.

Design of a New Digital Cognitive Screening Tool on Tablet: AlzVR Project.

DOI: 10.5220/0012837800003753

In Proceedings of the 19th International Conference on Software Technologies (ICSOFT 2024), pages 283-292

ISBN: 978-989-758-706-1; ISSN: 2184-2833

283

using virtual reality in primary care can be

challenging to implement. Thus, we developed a new

modality of AlzVR, which could be easier to use as a

non-immersive environment. This auto-questionnaire

would run on a digital tablet with questions inspired

by MMSE and MoCA as in the immersive version.

The assessment should browse several cognitive

functions in a short time.

2 RELATED WORK

Numerous tests exist to assess cognition (global or

precise evaluation), but the Mini-Mental Status

Examination (MMSE) (Folstein et al., 1975) and the

Montréal Cognitive Assessment (MoCA)

(Nasreddine et al., 2005) are widely used in primary

screening, and most professionals know them. Both

tests share several questions and explore

approximately the same cognitive functions, even

though MoCA evaluates frontal deficits more

precisely. They both browse several cognitive

functions quickly and can be repeated through the

medical following of patients. More recently, the

MoCA seems to have a higher sensitivity (Se) than

the MMSE in differentiating healthy subjects from

demented patients, whereas MMSE still performs a

higher specificity (Sp) (Ciesielska et al., 2016).

Nevertheless, there are good correlations between the

two tests (Bergeron et al., 2017; Chua et al., 2019).

Besides these classical evaluations, numerous

authors have developed new screening tools on digital

tablets that show good correlations with usual tests.

Although several recent systematic reviews have

been published (Amanzadeh et al., 2022; Chan et al.,

2021; Tsoy et al., 2021), only one meta-analysis with

good results focused on digital drawing tasks (Chan

et al., 2022). In all these studies, numerical tests could

run either on digital tablets or simple computer touch

screens and were self or hetero-administered.

Unfortunately, few of these programs were available

in French (Liu et al., 2021; Rai et al., 2020; Wu et al.,

2017), limiting their use in francophone patients.

Finally, they have not exceeded the

experimentation stage and are not used in daily

practice by health practitioners, whereas many of

these applications are already available on

commercial platforms such as Apple iTunes or

Google Play Store (Thabtah et al., 2020).

However, the usability of digital tablets has been

globally demonstrated among large populations

(Kortum & Sorber, 2015), and there is better

accessibility to new technologies, with most patients

owning a tablet or a smartphone.

Physicians would benefit from using these innovative

tools to perform early cognitive assessments in

primary care before addressing their patients for

specialized consultations. Digital tablet assessment

should be short, reliable, and understandable for

patients with cognitive tasks reproducing classical

questions from usual paper tests.

Facing this lack of available digital assessments,

we aim to create a new auto-questionnaire on a

touchscreen-based application inspired by MMSE

and MoCA tests.

3 MATERIALS AND METHODS

3.1 Experiences Architecture

We constructed our program using Unity®

(v.2021.3.11) for Android® (tablet).

The game consists of 3 main scenes:

1. The "Menu" scene includes the main menu,

medical questionnaires, and results consultation;

2. The "InGame" scene contains the tutorial and

all the user's tasks;

3. The "Survey" scene collects user feedback,

which the administrator can only consult.

The main module of the "InGame" scene, the

GameManager, references the list of nine tasks to be

performed. Although each task has a different

objective, each has textual and audio instruction and

then proposes none, one or several answers in the

form of images or text. So, the "JExperience" parent

class groups all the attributes and methods common to

all the tasks. However, the specific features of each

task have necessitated the creation of new classes

("JExpMonoChoice", "JExpChoiceTown", "JExp

Images") inherited from "JExperience" (Figure 1).

3.2 Welcome Menu

Three scenes compose AlzVR: the welcome menu,

playing scene, and F-SUS questionnaire.

When launching the application, there are three

possibilities (Figure 2):

1. Supervised experience: medical questionnaire

and cognitive assessment;

2. Quick experience: cognitive assessment only;

3. Results: Results visualization.

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3.3 Medical Questionnaire

The supervised experience includes a primary

medical questionnaire to collect socio-demographic

items (name, age, type of residence) and medical

background (diagnostic, previous cognitive tests,

treatments, and sensory loss).

3.4 Anonymization

After the last validation of the medical questionnaire,

the program generates an automatic anonymized

number composed of date and hour until seconds

without integrating the name's initials. A typical

anonymous number looks like

YYYYMMDDHHMMSS. This process safeguards

the confidentiality of patient information (personal

information) and allows a further blinded analysis. In

"quick experience", an "A" precedes all anonymized

numbers, such as A-YYYYMMDDHHMMSS. In

"supervised experience", the letter of an eventual

medical center can be automatically added before the

number.

Figure 1: Main classes' diagram.

3.5 Playing Scene

3.5.1 General Aspect

The visual aspect should be simple without any

cognitive surcharge. All scenes appear on a uniform-

coloured background.

In all experiences, the user must select answers by

touching one or several buttons. These buttons are

big, allowing for an easy touch. A maximum of 8

buttons are on the screen, ensuring good visibility. All

the pictures implemented into the scenes (cognitive

tasks) are royalty-free.

Figure 2: Welcome menu view.

3.5.2 Answer Modality

Since the user selects all the answers, a confirmation

screen appears with a button "Yes" and "No". This

step avoids inattentive answers and validates the

choice (Figure 3). A "Yes" leads to the next question,

and "No" allows a new chance to answer. Each

exercise lasts 30 seconds maximum. The next

question automatically occurs if the user does not

answer within the time (counted as "Timeout"). The

choice of a "No" in the confirmation step reinitializes

the time, but only three attempts are allowed. In every

Figure 3: Answer modalities.

Design of a New Digital Cognitive Screening Tool on Tablet: AlzVR Project

285

case (success or failure), a message "Well done!"

congratulates the user. This message provides a

cheerful ambiance and can reduce further false results

of stress or fear.

3.5.3 Preliminary Training Task

A training session occurs before the cognitive

questionnaire to ensure a good understanding of the

tablet's functioning. The user needs to touch shapes

on the screen following an oral order delivered by the

program "Please touch the shape – a heart" (Figure 4).

A failure in the training tasks leads to the assessment's

stopping, and the test cannot continue.

Figure 4: Training task.

3.5.4 Cognitive Questionnaire

If the training tasks are successful, the cognitive

assessment begins and comprises seven tasks from

the MMSE and the MoCA. We wanted a varied

assessment, so we selected questions from multiple

cognitive fields presented in Table 1.

Table 1: Numerical cognitive tasks.

Paper

test

Cognitive function

lored

Numerical

nitive task

MoCA,

MMSE

Auditory memory

and attention

Three words task

(

immediate recall

)

MoCA

Memory and

attention

Clock recognition

MoCA,

MMSE

Auditory memory

and attention

Three words tasks

(

dela

ed recall

)

MoCA,

MMSE

Spatial orientation

Flags

Town

MoCA,

MMSE

Temporal

orientation

Season

Yea

MoCA Abstraction Abstraction

The first task is the « three words » test. In the MMSE

or MoCA, the examiner orally delivers the three

words, and the patient must repeat them (immediately

and with a delayed recall). To get a self-

questionnaire, we kept the oral deliverance by the

program (sound only) but replaced the oral repetition

with a choice of 3 images among eight. There is still

an immediate and delayed recall. The three words

belong to different semantic fields (animal, vehicle,

and vegetable).

The clock recognition task is inspired by the clock

drawing test (Sunderland et al., 1989), where the

patients draw a circle, number, and needles indicating

a precise hour (11h10, for example). We created a

novel task proposing three different clocks: the good

one (10h30), the symmetric clock (05h50), and a false

clock. The oral instruction delivers the hour to choose

("select the clock indicating …"), and the patient

selects on the screen. There are two series of clocks

followed by the three words delayed recall.

To explore spatial and temporal orientation, we

selected a simple format with an oral question (what

is the current season? Select the country's flag where

we are) and several pictures as answers. The country

is represented as a flag, limiting written instructions

for spatial orientation. Names of town are presented

as classical French signs. The answer for the town can

be changed depending on the site assessment.

Temporal orientation tasks are relatively similar,

as the user needs to select the current season and

present the name of the season and a typical image

(Figure 5). Considering varying dates for season

changes, we left a 48-hour margin for the answer.

In the year test, we introduced several confusing

dates (minus one year, minus one century). All dates

finish by the same number as the current year.

In the MoCA test, abstraction's ability is tested on

the similarity between two words (for example, an

orange and a banana are fruits). In the abstraction

task, the user must fill a fruit series with a third picture

(Figure 6). A confusing element is among the four

choices (one picture from the three-word test).

Figure 5: Season test.

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3.6 Results Menu

The results' menu allows a simple visualization of the

patient's score after the cognitive questionnaire

(Figure 7). A password protects this section and only

uses an anonymized number (ID patient). Three

possibilities exist: "X" (failure), "V" (success), and

"?" (Timeout).

Figure 6: Abstraction test.

Figure 7: Results menu view.

3.7 F-SUS Questionnaire

After the cognitive tasks, we implemented the French

translation of the System Usability Scale (Brooke,

1996), the F-SUS questionnaire (Gronier & Baudet,

2021). It evaluates global satisfaction through ten

questions and five degrees of response from 1

(strongly disagree) to 5 (strongly agree). F-SUS

results do not appear in the results menu and are

directly stored.

3.8 Data Storage

All data are stored inside the tablet's internal memory

in CSV format. This type of file can be easily

exported and exploited. We planned separate storage

for personal information (first name, last name, date

of birth) from other results (experiences and F-SUS)

in different files. All results are presented using only

the anonymized identification number. Thus, a

blinded analysis is possible using only anonymized

data (Figure 8). Correspondence with identified data

is restricted to investigators.

Figure 8: Process of data storage and anonymization.

3.9 Preliminary Usability Assessment

3.9.1 Study Population

We carried out an experimental, qualitative study in

IBISC Laboratory (University of Évry-Paris Saclay,

Department of Sciences and Technologies) among

volunteers (staff and students) to assess preliminary

usability using ISO 9241-11 norm (International

Organization for Standardization, 2018) and the

Nielsen method (Valentin & Lemarchand, 2010). The

tablet was a Samsung Galaxy Tab S7 FE® (screen of

315.0 mm, 2560x1600) running on Android 11 (user

interface One UI 3.1).

The exclusion criteria were age < 18 years old, no

understanding of the French language, and visual or

hearing loss with no equipment.

Participants were recruited through mailing lists

of university and advertisements in locals.

3.9.2 Ethical Statement

This work has been carried out in accordance with the

Declaration of Helsinki of the World Medical

Association, revised in 2013 for experiments

involving humans. Data exploitation was anonymous

using an automatic number of participation generated

from the date and hour of completion. The local

University Paris-Saclay ethics committee approved

all documents and protocols on 2022/07/07 (file 433).

Informed consent was obtained from all subjects

involved in the study. Participation was free with no

remuneration.

Design of a New Digital Cognitive Screening Tool on Tablet: AlzVR Project

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3.9.3 Stages

Participants successively and anonymously achieved

several stages:

1. Pre-questionnaire: fill in an online questionnaire

to collect socio-demographic data (age,

profession, sex) and numerical habits

(smartphone and tablets);

2. Quick experience;

3. F-SUS questionnaire;

4. Post-questionnaire: online questionnaire to collect

free comments about the program.

3.9.4 Data Collection and Analysis

During the tests, we collected the following

parameters: answer (success, fail), number of trials,

and response time (ms).

We chose the total F-SUS score calculated on the

author's recommendation (Brooke, 1996; Gronier &

Baudet, 2021) as the primary endpoint to assess

usability with a goal of 85.5 %, considered

"excellent".

All data were blinded, collected, and analyzed

using the anonymized numbers of participants.

4 RESULTS

4.1 Population

We included 24 participants between 2022/09/27 and

2022/10/12. Their socio-demographics are presented

in Table 2, and their numerical habits are in Table 3.

Table 2: Socio-demographic characteristics of the

population.

Population (n = 24)

Gender (F/M) 10/14

Age* (years)

(

)

[min-max]

41.88 (13.11)

[23-66]

Profession

Student 2

Enginee

Doctoral student 3

Technician 3

Researche

Administrative 9

* m = mean; sd = standard deviation; min = minimum;

max = maximum

4.2 Success Rate

Cognitive tasks were completed by 100% of

participants. We observed a success rate for the

questions of 97.4 % (187 correct answers out of 192).

The two tests that presented failures were the clock

task (2 failures) and the season (3 failures).

Table 3: Numerical habits of the population.

Question*

100

Have you ever used a smartphone?

(%)

12.37 (4.8) If yes, for how many years? m(sd)

Everyday 100 If yes, during 2022, how often? (%)

Yes 96

Have you ever used a digital tablet?

(%)

No 4

8.25 (3.13) If yes, for how many years? m(sd)

Everyday 21.7

If yes, during 2022, how often? (%)

Once/week13.1

Once/month17.4

Once/year 47.8

* m = mean; sd = standard deviation

4.3 Time of Completion

The average test administration time (excluding

training tasks) was 141.47 (± 18.77) seconds, and

details of task completion times are presented in

Table 4.

4.4 F-SUS Questionnaire

Ninety-six percent of participants completed the F-

SUS questionnaire (one person left the application

before completing it), and the results for each

question are presented in Table 5. The overall score

on the F-SUS questionnaire was 89.24%, considered

"excellent".

4.5 General Remarks

In the post-questionnaire, we collected general

opinions about the computer program. Users

overwhelmingly found the program to be easy to use.

The negative remarks reported were the lack of

fluidity of the oral instructions and the tests being

judged too simple. User reviews are shown in Figure 9.

5 DISCUSSION

Numerous existing paper tests assessed cognition for

a global screening or precisely for a specific function

(De Roeck et al., 2019). At the same time, several

authors studied the possibility of digital tablet use in

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evaluating cognitive decline and performing training

tasks in healthy and cognitively impaired patients

(Koo & Vizer, 2019; Wilson et al., 2022). Despite

these numerous and efficient digital tests (Chan et al.,

2021), cognitive evaluations still rely on paper tests

and need an exterior examiner. Facing an increasing

prevalence of patients in the future decades

(International et al., 2020) with a more and more

precise diagnostic (biological, functional) (Dubois et

al., 2021), there is a need to get simple, quick and

performing tools to help practitioners in cognitive

decline screening. During our conception, we chose

to create a new tool in the French language inspired

by two primary used and recommended tests (Janssen

et al., 2017; Pinto et al., 2019): MMSE, MoCA, and

the clock drawing test (CDT) (integrated into the

MoCA).

In usual tests, the patient answers most of the

questions orally to the examiner. Conceiving our

tasks, we chose not to use speech recognition because

of its current limitations (Basak et al., 2023).

Incorrect speech interpretation would have led to

false results. However, excluding oral answers does

not allow a global language evaluation as in MMSE

or MoCA.

Table 4: Tasks completion times.

Completion time*

m(sd) [min-max]

Cognitive task

31.98 (2.62)

[25.16-38.60]

Three words task (immediate recall)

36.43 (5.49)

[25.86-51.05]

Clock recognition (2 series)

17.41 (2.83)

[11.04-22.65]

Three words task (delayed recall)

12.23 (1.87)

[8.66-16.29]

Flags

10.91 (2.39)

[6.95-16.45]

Town

10.41 (2.12)

[6.38-14.68]

Year

11.73 (3.97)

[6.75-23.68]

Season

10.39 (2.67)

[6.23-15.19]

Abstraction

141.47 (18.77)

[97.64-183.58]

Total

* m = mean; sd = standard deviation; min = minimum;

max = maximum

CDT is hugely used in daily practice and belongs to

quick screening tools such as Codex (Belmin et al.,

2007) or Minicog (Borson et al., 2003). Müller et al.

have proposed a digital clock drawing task using a

stylus (Müller et al., 2019), showing good

correlations with paper tests. This transposition still

requires exterior human validation or automatic

image analysis, as proposed by Park et al. (Park &

Lee, 2021). We wanted a simple and short task with

no exterior analysis, so we switched from a drawing

task to a recognition picture task. Drawing a clock

and placing needles requires visuospatial abilities and

executive functions. Nevertheless, there were

technical limitations to producing a self-administered

questionnaire with few written instructions, no

exterior validation, and simple orders. These

limitations may lead to potential bias in cognitive

evaluation with an underestimation of executive

functions.

Figure 9: Word cloud of user reviews.

Finally, our assessment does not evaluate writing

abilities because we did not want to use a stylus or

further human validation. Thus, it is known that

dysgraphia is a symptom of AD (Onofri et al., 2016).

Despite exploring several questions and different

cognitive fields, our new assessment has limitations

that need following and potential future upgrades in

new versions.

Before evaluating our digital tool in an elderly

population, we performed a short usability

assessment of a healthy population (without cognitive

decline) among university users.

Completion time should be short, and the mean time

observed in our study (142 seconds) is a good result.

Moreover, usability reached the global score of

89.24%, surpassing the initial objective of 85.5% and

close to 90.9% (« best imaginable »).

The participants globally perceived the test as easy to

use, corresponding to F-SUS scores (questions 3, 5,

7, and 8). It was a positive evaluation because

participants did not know about cognitive tests and

thus discovered them for the first time. These results

are preliminary satisfying data, but there is a

considerable limitation about the population. Indeed,

our participants were young (41.88 years old),

healthy, and used to touch screens. This mean age is

widely below the age of AD patients (> 60 years)

Design of a New Digital Cognitive Screening Tool on Tablet: AlzVR Project

289

(National Institute on Aging, n.d.), which can explain

the observed good results. They may not be

transposable into an elderly population with cognitive

decline and poor use of tablets. Nevertheless, our

population uses tablets poorly, with less than 50% of

people using them yearly (Table 3). The questions

were negatively perceived as « too simple » or « too

slow », due to the young age of our participants.

AlzVR should be tested in an older patient population

for usability assessment and accuracy of

discrimination between healthy and demented

subjects.

Although the participants were healthy, we noted

errors in the clock recognition task, probably due to

the needle shapes signaled in complimentary remarks

(Figure 9). However, recent findings showed that

students had more and more difficulties reading

traditional clocks (BBC News, 2018), and our two

failed users were 24 years old. These difficulties

appear in the mean task time of realization (Table 4);

indeed, it is the task with the most significant

difference between the minimal and maximal time of

realization. Season errors may be explained by the

recent season changes (summer/autumn) before the

beginning of the study (September 27). We also found

an extensive range in task time realization.

When extracting the results from the tablet, we

reported no errors in the CSV files. Data were easily

exploitable and well anonymized.

Table 5: F-SUS questionnaire results.

Result*

m(sd)

Question

2.70 (1.46)

I think that I would like to use this system

frequently.

1.52 (0.71)I found the system unnecessarily complex.

4.91 (0.28)I thought the system was easy to use.

1 (0)

I think that I would need the support of a

technical

erson to be able to use this s

stem.

4.65 (0.87)

I found the various functions in this system

were well inte

rated.

1.43 (0.97)

I thought there was too much inconsistency in

this system.

4.96 (0.20)

I would imagine that most people would learn

to use this s

stem ver

uickl

1.65 (1.34)I found the system very cumbersome to use.

4.83 (0.38)I felt very confident using the system.

1.74 (1.42)

I needed to learn a lot of things before I could

oin

with this s

ste

* m = mean; sd = standard deviation

6 CONCLUSIONS

We have developed a new digital cognitive screening

tool with preliminary good feedback among a young

and healthy population. The application could also be

transposed onto smartphones to enhance its diffusion

and utilization. This preliminary study belongs to the

global study COGNUM-AlzVR, which aims to

evaluate the efficiency and relevance of two

numerical programs on tablets for cognitive

assessment in AD patients. The Committee for the

Protection of People of Ile de France approved the

multicentric project in 2022, and the study began in

April 2023 (NCT06032611).

ACKNOWLEDGEMENTS

The authors thank all participants and the Génopole

(Evry-Courcouronnes, France) for their partnership

with IBISC Laboratory.

CONFLICTS OF INTEREST

The authors declare no conflict of interest and have

no known competing financial or personal

relationships that could be viewed as influencing the

work reported in this paper. This work did not receive

any grant from funding agencies in the public,

commercial, or not-for-profit sectors.

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