Computer-assisted Intervention using Touch-screen Video Game

Technology on Cognitive Function and Behavioural Symptoms for

Community-dwelling Older Chinese Adults with Mild-to-Moderate

Dementia

Preliminary Results of a Randomized Controlled Trial

Ruby Yu

, Dawn Poon

, Ashley Ng

, Kitty Sit

, Jenny Lee

, Bosco Ma

, Cm Lum

, Fannie Yeung

Martin Wong

, Elsie Hui

and Jean Woo

Department of Medicine & Therapeutics, The Chinese University of Hong Kong,

Sha Tin, New Territories, Hong Kong, China

Occupational Therapy Department, Shatin Hospital, Sha Tin, New Territories, Hong Kong, China

Department of Medicine & Geriatrics, Shatin Hospital, Sha Tin, New Territories, Hong Kong, China

Keywords: Ageing, Behavioural and Psychological Symptoms, Cognitive Function, Computer-Assisted Intervention,

Dementia, Video Game.

Abstract: Objective: This study explored the potential benefits of a computer-assisted intervention using touch-screen

videogame technology on cognitive function and behavioural symptoms in older adults with mild-to-

moderate dementia. Methods: A randomized-controlled-trial is being conducted comparing a videogame

training and a conventional cognitive training. Until January 2015, 32 community-dwelling older Chinese

adults (mean age 83y, range 70-99y, 69% women) with mild-to-moderate dementia were randomly assigned

to the videogame training (intervention group n=16) or the cognitive training (control group n=16). The

intervention group performed a computer-assisted training encompassing 4 videogames using touch-screen

interfaces for 30 minutes/session, 1-2 sessions/week for a total of 8 sessions; the control group performed a

matched training encompassing 4 cognitive activities for same amount of time. Results: The intervention

group demonstrated significant improvements in game performance, Montreal Cognitive Assessment

language sub-score, Neuropsychiatric Inventory (NPI) total and distress scores, while the control group

showed improvement in activity performance and NPI distress score (all P<0.05). Compared to the control

group, the intervention group had significantly improved Cohen-Mansfield Agitation Inventory total score

and verbally aggressive sub-score (both P<0.05). Conclusions: Touch-screen videogame training can

alleviate behavioural symptoms in older adults with mild-to-moderate dementia. Its efficacy to improve

cognitive and other related functions warrants further investigation.

1 INTRODUCTION

With a rapidly ageing population, dementia has

become an important public health issue worldwide.

It is a chronic neurodegenerative disease

characterised by progressive neuropathologic

changes (neocortical atrophy, neuron and synapse

loss, neuritic plaques, and neurofibrillary tangles)

and declines in cognitive function (Twamley, 2006).

Nevertheless, evidence from neuroimaging studies

have suggested that individuals with early dementia

retain a range of cognitive capacities and can engage

additional brain regions during cognitive tasks

(Becker, 1996, Grady, 2003). These findings provide

evidence of plasticity in the neural systems in

individuals with dementia. Research on

interventions and particularly cognitive training have

demonstrated altered patterns of brain activity and

task-specific performance enhancement in healthy

adults (Olesen, 2004, Erickson, 2007). As such,

regular training on specific tasks may be able to

provide a progressive challenge to individuals’ (even

with dementia) cognitive abilities and may improve

their cognitive function.

297

Yu R., Poon D., Ng A., Sit K., Lee J., Ma B., Lum C., Yeung F., Wong M., Hui E. and Woo J..

Computer-assisted Intervention using Touch-screen Video Game Technology on Cognitive Function and Behavioural Symptoms for Community-dwelling

Older Chinese Adults with Mild-to-Moderate Dementia - Preliminary Results of a Randomized Controlled Trial.

DOI: 10.5220/0005490402970302

In Proceedings of the 1st International Conference on Information and Communication Technologies for Ageing Well and e-Health (AGEWELL-2015),

pages 297-302

ISBN: 978-989-758-102-1

 2015 SCITEPRESS (Science and Technology Publications, Lda.)

Computerised cognitive training (video games

training) have been recognized as a powerful tool for

improving cognitive function (Green, 2008).

Research results from the last decade have

demonstrated positive effects not only on the

specific cognitive domain(s) being practiced (Stern,

2011, Oei, 2013) but transfer effects to other related

cognitive functions (Mahncke, 2006, Basak, 2008,

Nouchi, 2012). A recent systematic review reported

that for healthy older people, video game training

improved performance in specific cognitive domains

(e.g., reaction time, processing speed) relative to the

control (Kueider, 2012). However, a large-scale

online study of video game training among adults

aged 18–60 failed to show transfer of proficiency

from trained tasks to untrained tasks (Owen, 2010).

More recently, several small studies have been

performed, with mixed results (van Muijden, 2012,

Bozoki, 2013).

Relatively few studies of video game

interventions have been performed in older people

with cognitive decline (MCI and dementia) and

results have been mixed, with some studies

suggesting significant improvements in specific

cognitive domains (e.g., verbal learning, memory

measures, execution functions) (Schreiber, 1999,

Barnes, 2009, Man, 2012, Zaccarelli, 2013) and

others reporting no effects (Hofmann, 1996, Finn

and McDonald, 2014) or no incremental effects on

top of a conventional cognitive training (Gaitan,

2013). Therefore, the widely held belief that

computerized cognitive training programs improve

cognitive function in older people with dementia in

our opinion lacks empirical support. If such training

enhances cognitive function, then the question is

whether those benefits transfer to other untrained

cognitive functions? In addition, the effects of video

game training on behavioural and psychological

symptoms (BPSD) in dementia are still lacking.

Therefore, we performed a randomized controlled

trial (RCT) to compare the effects of a computer-

assisted video game training using touch screen

technologies with a conventional cognitive training

in older adults with mild-to-moderate dementia. The

present study documented the preliminary findings

of the changes in task-specific performance,

cognitive functions, and BPSD after the treatments.

2 METHODS

2.1 Study Design

This is a RCT. After eligibility check, subjects and

their carergivers were randomly allocated into either

the video game training (intervention) or the

conventional cognitive training (control) group.

Block randomization was adopted. Subjects and

their carergivers were aware of the treatment

assigned. The rater was blinded to the treatment

allocation. The trainer (trained research assistant) for

both the intervention and the control group were

blinded to the outcome performance. The study was

carried out in the Geriatric Day Hospital of Shatin

Hospital, Hong Kong.

2.2 Subjects

Community-dwelling older adults aged 60 years and

above with mild-to-moderate dementia were

recruited from community dementia day care

centres, geriatric outpatient clinics, and day

hospitals. For this study, subjects with Mini-Mental

State Examination (MMSE) (Folstein, 1975, Chiu,

1994) score 10–24 were included. Criteria for a

diagnosis of dementia was based on the Diagnostic

and Statistical Manual of Mental Disorders (DSM-

IV) (American Psychiatric Association, 2000).

Severity of dementia was determined using Clinical

Dementia Rating (CDR) (Hughes, 1982, Morris,

1997). Only subjects with mild-to-moderate

dementia (CDR 1 or 2) were invited to participate.

Subjects were excluded if they have severe medical

conditions limiting their abilities to complete the

treatment. Concurrent psychotropic medication was

allowed without restriction, but any change in

psychotropic prescription over the course of

treatment period was monitored. Informed consent

was obtained from every eligible subject agreeing to

participate as well as their caregivers. When a

subject was unable to give informed consent, proxy

consent was obtained.

2.3 Video Game Training

Subjects assigned to the intervention group were

invited to participate in the computer-assisted video

game training 30 minutes/session, one to two

sessions/week for a total of eight sessions, provided

by a trained research assistant. Four touch-screen

video games, including 1) Bingo, 2) Connect the dot

ultimate (lite), 3) Find difference, and 4) Mosquito

splash that mainly tap working memory and

attention control were used (Figure 1). Interactive

touch-screens / displays (Sur 40, I-pad, optical touch

computer screen) were used. In Bingo, subjects were

given a figure captured from the objects in daily

lives and they were asked to identify and press the

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same figure in a table with different figures. The

game was won whenever a horizontal, diagonal or

vertical line was made from the pressed figures in

the table. In Connect the dot ultimate (lite), subjects

were asked to connect the dots by pressing the

number on the dots in an ascending order to draw a

cartoon figure. In Find difference, subjects were

asked to find the differences between two photos by

pressing the point of difference within a time limit

for each set of photo. The time limit would be

shortened if mistakes were made. In Mosquito

splash, subjects required to press the mosquitoes on

the screen to squash them. Butterflies were also

appeared on the screen but they should be avoided.

Instructions were provided before each training

session, which was proceeded for at least 30

minutes. During the sessions, reinforcements were

given to encourage participation.

Figure 1: Bingo, Connect the dot ultimate (lite), Find

difference, and Mosquito splash (From left to right).

2.4 Conventional Cognitive Training

Subjects assigned to the control group received

conventional cognitive training activities in which

the training elements were matched with those in the

computer-assisted videogame training. Four

cognitive activities were used, including 1) Beads

sequencing, 2) Stringing pegs & pegboard set, 3)

Find difference, and 4) Power trainer (Figure 2). In

beads sequencing, subjects were asked to stack the

colored beads on a dowel to match the patterned

cards with figures in specific colours and shapes. In

stringing pegs & pegboard set, subjects put the

corrected colour pegs in the holes on the crepe

rubber pad according to the pattern card given. Then

they used corrected colour strings to lace through

each peg hole, as indicated in the pattern card. In

Find difference, subjects were asked to compare two

photos and identify their differences by drawing a

circle on the point of difference. In power trainer,

subjects were asked to do hand cycling using the

machine.

Figure 2: Beads sequencing, Stringing pegs & pegboard,

Find difference, and Power trainer (From left to right).

2.5 Outcome Measures

This preliminary analysis focused on task-specific

performance, cognitive function as well as

psychological and behavioural measures assessed at

the baseline (pre-), during, and post-treatment. Task

performance was estimated with the task-specific

scores of response accuracy (e.g., number of correct

responses) and response time (e.g., attention time,

time to respond correctly to the stimuli/complete the

required task) that were measured across all video

games and activities administered. A higher score

generally means that the subject performed better.

Cognitive functions were measured with the

Chinese version of the MMSE. It contains 20 items

and scores range from 0 to 30. A higher score

denotes better cognitive functioning. To screen for

additional cognitive domains, language and attention

subsets of the Montreal Cognitive Assessment

(MoCA) (Nasreddine, 2005, Yeung, 2014), digit

span (Wechsler, 1997), and the category verbal

fluency tests (CVFT) (Thurstone, 1938, Mok, 2004)

were also included.

Neuropsychiatric symptoms were assessed with

the Chinese version of the Neuropsychiatric

Inventory (NPI) (Cummings, 1994, Leung, 2001). It

is an informant based standard assessment for a wide

range of neuropsychiatric symptoms. Scores of the

scale can range from 0 to 144, with the higher score

representing higher frequency and/or higher severity

of the symptoms. Agitated behaviour was assessed

with the Chinese version of the Cohen-Mansfield

Agitation Inventory (CMAI) (Cohen-Mansfield,

1989, Choy, 2001). Scores of the scale can range

from 29 to 203, with the higher score reflecting

more severe agitation. Depressive symptoms were

assessed with the Chinese version of the Cornell

Scale for Depression in Dementia (CSDD)

(Alexopoulos, 1988, Lam, 2004, Lin, 2008). The

information was elicited through two semi-

structured interviews, one with the patient and one

with the caregiver. Scores above 10 indicate a

probable major depression. Scores above 18 indicate

a definite major depression. The simplified face

scale was used to assess mood state before and after

each treatment session. It is a very brief, pictorial

scale of mood which uses a sequence of seven faces

and does not require reading literacy (Wada, 2005)

2.6 Statistical Analysis

An intention-to-treat analysis was carried out, in that

all available data was included. Differences between

pre- and post-treatment were compared using pair-t-

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tests. Differences between the intervention and

control groups in relation to outcome measures were

compared using the analysis of independent-t-tests.

Effect sizes were computed. A threshold of 0.2 SD

was used to estimate the minimal clinically

important differences in task-specific change scores.

Subjects were then classified as having “improved”

(change score > +0.2 SD, “no change” (-0.2 SD <

change score < +0.2 SD), or “declined” (change

score > -0.2 SD) for the task-specific performance.

statistics was adopted to examine whether the

percentage of those assessed as “improved” is

greater within and between the treatment groups.

Data analyses were conducted by SPSS. A P<0.05

was taken as the level of statistical significance.

3 PRELIMINARY RESULTS

Recruitment began in June 2014 and the completion

of trial is expected for June 2015. Between June

2014 and January 2015, 32 older Chinese men and

women aged 60 years and older with mild-to-

moderate dementia were recruited and completed the

post-treatment assessment. The mean age of the

subjects was 83 (range 70-99) years, 69% were

women, 75% were classified as mild dementia

(CDR=1), and the overall mean MMSE was 16.6±

3.9. All subjects were able to perform the training

tasks according to the instructions. On average, 94%

subjects engaged in the games/activities properly

across the sessions. The intervention group was

comparable with the control group with regard to

age, sex, education, and the outcome measures,

including cognitive functions, BPSD, depressive

symptoms, and mood. Of the 32 subjects, 30

completed all eight sessions, one competed seven,

and one completed six sessions.

For task-specific performance (in terms of

response accuracy and time), 77% subjects in the

intervention group improved on the training games

(i.e., “improved” cluster), which was significantly

more than the portion of subjects classified into “no

change” (15%) or “declined” (7%, P<0.01). The

improvement was also seen in the control group

(93% improved, P<0.01).

For cognitive function, the intervention group

demonstrated significant improvements in MoCA

language sub-scores (pre 1.5, post 2.0, P<0.05,

Effect Size (ES) 0.82). However, evaluation of other

cognitive abilities (e.g., MMSE total score and sub-

scores, MoCA attention sub-scores, digit span, and

the CVFT) did not reveal any significant changes.

For BPSD, both groups reduced their NPI distress

scores (intervention pre 2.7, post 1.3, P<0.05, ES

0.62, control pre 3.9, post 2.4, P<0.05, ES 0.28), but

only subjects in the intervention group significantly

reduced their NPI total score (pre 12.8, post 7.9,

P<0.05, ES 0.45).

Compared to the control group, the intervention

group had significantly improved CMAI total score

(intervention mean-diff -1.4, control mean-diff 2.1,

P<0.05, ES 0.84) and verbally aggressive sub-score

(intervention mean-diff -1.4, control mean-diff 1.6,

P<0.05, ES 0.84). Nevertheless, the pre-to-post

differences in CMAI were not significant for either

group (P=0.070-0.187). No differences in CSDD or

simplified face scale scores were observed within or

between groups.

4 DISCUSSION

In this era of digital technology, video game training

has been reported in several trials with promising

results (Green, 2008). Similarly, there are supporting

data that video game training could be an alternative

choice for patients with cognitive decline (Schreiber,

1999, Barnes, 2009, Man, 2012, Zaccarelli, 2013).

However, others reported no significant effects

(Hofmann, 1996, Finn, 2014, Gaitan, 2013). This

study explored the potential benefits of a video game

training in older adults with mild-to-moderate

dementia. The preliminary findings demonstrated

that while both treatment groups exhibited some

signs of improvement in their performance on

cognitive tasks after the training sessions, there were

no significant changes on the MMSE total score, and

no improvements were found in the specific

cognitive domains/related functions, except for the

language ability (MoCA language sub-score), which

was improved in the intervention group. It is

unlikely that the improvements were due to practice

effects as the control group was administered the

same instrument the same number of times. The

improvement in language ability demonstrated a

potential transfer effect of the video game training,

because language was an untrained cognitive

function in this study.

However, we are unable to determine the precise

mechanisms by which the beneficial effect was

achieved. The mechanism of this transfer effect

could be explained by the theory which

hypothesized that transfer can occur if the training

and transfer tasks involve overlapping processing

components and engage the same brain

regions.(Jonides, 2004, Dahlin, 2008) Since 77% of

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our subjects improved their game performance,

where working memory and attention control that

were trained in the video games in this study are

involved in the same brain region (left ventrolateral

prefrontal cortex, VLPFC) with language processing

(Thompson-Schill, 2005), therefore, the transfer

effect of the video game training on language

processing could be mediated through VLPFC.

However, there were no effects of the performance

on recall, attention and calculation, orientation,

registration, digit span, or the CVFT. There is a

possibility that the training duration of our study

may not be sufficient enough to obtain the transfer

of training. In addition, our measurements of those

specific cognitive domains may not be appropriate to

detect the transfer effect to untrained tasks. Hence,

the potential transfer effect of video game training

warrants further investigation.

We also found that the video game training was

more effective in alleviating BPSD than the

conventional cognitive training. The NPI total score

decreased by as much as 51.9% and 38.5% in the

intervention group and the control group,

respectively. Furthermore, compared to the control

group, the intervention group had significantly

improved CMAI total score and verbally aggressive

sub-score. The underlying mechanism for this is not

clear. Possibly, BPSD are a manifestation of feelings

of loneliness, boredom, or feelings that decrease

with the involvement of stimulating activities and/or

social interaction. Several studies have reported that

various psychological interventions and stimulating

activities are associated with improvements in BPSD

(Ballard, 2002, Cohen-Mansfield, 1997). Therefore,

our results seem to corroborate the hypothesis that

BPSD are in great part the result of stimulus and

social deprivation. To our knowledge, this is the first

study to assess the effects of video game training on

BPSD in dementia. Our findings suggested that

video game training is a possible alternative therapy

for managing BPSD in dementia. Further analysis of

social interaction during the intervention using

observation data will be performed at the next stage

to elucidate the possible pathway.

There are several limitations in this study. We

are not able to specify whether the positive effects

are the result of a particular video game, or of

several, or all in this current analysis. Moreover, the

sample size was small which may have obscured the

detection of potential difference between the groups.

Despite these limitations, our study has several

methodological strengths. We used an extensive

assessment tools, allowing us to obtain measures in

multiple cognitive functions, as well as BPSD,

depression, and mood.

5 CONCLUSIONS

These findings suggest that touch-screen video game

training is feasible and may be potentially a training

approach in alleviating behavioural symptoms in

older adults with mild-to-moderate dementia. Its

efficacy to improve cognitive and other untrained

functions warrants further investigation. Our

findings required substantiation by larger samples.

ACKNOWLEDGEMENTS

The study was supported by the Direct Grant for

Research 2013/2014 (Reference No.: 2013.1.042),

Faculty of Medicine, the Chinese University of

Hong Kong.

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