Discussing on Gamification for Elderly Literature, Motivation
and Adherence
Jose Barambones
, Ali Abavisani
, Elena Villalba-Mora
, Miguel Gomez-Hernandez
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
Gamification, Serious Games, Exergames, Elderly, Frailty, Discussion.
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.
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.
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
2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
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.
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
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
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
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
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
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
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.
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.
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
prove and guarantee engagement, specially use-
ful in healthcare contexts.
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
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Discussing on Gamification for Elderly Literature, Motivation and Adherence