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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 4  |  Page : 157-162

Gamifying elderly care: Feasibility of a digital gaming solution for active aging

1 Imaginary srl, Milan, Italy
2 O'Joy Care Services, Singapore

Date of Web Publication3-Mar-2017

Correspondence Address:
Antonio Ascolese
c/o Imaginary srl, Piazza Caiazzo, 3, 20124, Milan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_43_16

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Background and Objectives: Aging society is a social health issue that digital gaming solutions can address by enabling both infrastructures as advanced environments for care and patients as active people in their aging. Cost-effective patient management may be emphasized thanks to the communication protocols that allow remote monitoring and intervention by medical professionals. Services for elderly depend on their behavior and lifestyle toward personal health management. Digital games could increase seniors' engagement and motivation. However, a few studies have looked at the acceptance of digital games by the elderly. The study here presented aims to evaluate the feasibility of a gaming rehabilitation platform. Materials and Methods: In Singapore, fifty elderly practiced 30-min sessions and evaluated their experience with a new tool based on game scenarios for rehabilitation. Results: Results are discussed in the light of Davis' Technology Acceptance Model, highlighting mainly a good perceived usefulness of the service. Conclusions: This preliminary study is encouraging the spread of digital medical games for old patients.

Keywords: Aging society, elderly, gamification, rehabilitation, serious games, technology

How to cite this article:
Ascolese A, Kiat J, Pannese L, Morganti L. Gamifying elderly care: Feasibility of a digital gaming solution for active aging. Digit Med 2016;2:157-62

How to cite this URL:
Ascolese A, Kiat J, Pannese L, Morganti L. Gamifying elderly care: Feasibility of a digital gaming solution for active aging. Digit Med [serial online] 2016 [cited 2023 Jun 10];2:157-62. Available from: http://www.digitmedicine.com/text.asp?2016/2/4/157/201268

  Introduction Top

The World Health Organization defines active aging as “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age” (Definition from “What is aging?” {World Health Organization, 2002}, available online at http://www.who.int/aging/active_aging/en/). Hospitalization is a common condition among the elderly who need support to enhance their ability to perform daily actions; still, it is not an opportunity that society could bear for all the elderly or for prolonged periods. The increased life expectancies and reduced mortality rates are positive consequences of the scientific progress, but they also represent a serious challenge to society and an open issue for national health services. The percentages of active population and people beyond retirement clearly depict the phenomenon of aging society, where care for the elderly must be carried out also by family members at home, as a support to hospitals and nursing houses. Chronic illnesses and rehabilitation processes need constant support by specialists to supplement that which cannot be managed by the usual health providers. The patient needs specific help to manage personal health, and technology is a crucial resource for this process mainly because of the chance to record and monitor medical parameters with wearable sensors and to manage continuous and effective communication flows between users and clinicians. A massive intervention for all the elderly population should include regular exercise, whose efficacy has been demonstrated, especially in areas of fall prevention,[1] cardiovascular risk,[2] and cognition:[3] encouraging physical and mental exercises at the earliest possible age is a main issue.

The main challenge is the development of solutions providing at the same time the basis of a long-term lifestyle behavioral change while supporting the medical profession with tools to reduce unnecessary workload and enable them to be as productive as possible in their practices. Continuous training and the chance to practice far from hospital need identifying specific solutions not to lose the compliance to the therapy due to a decrease in patient's motivation to adhere to the therapy: a promising way to nurture motivation is using games to make daily exercises funny. The main challenges are the integration between a gaming experience and a scientific approach to rehabilitation and the ways through which they could be provided to patients. Technologies such as Nintendo Wii and Microsoft Kinect can offer services that have been proven comparable to classic exercise in terms of physical recovery, safeguarding at the same time a better adherence than conventional exercises.[4],[5] Further reviews also highlighted decreased depression, increased cognition, and improved quality of life among elderly playing digital games.[6] Evidence also suggests that preventative interventions such as increasing physically activity, consuming a Mediterranean diet,[7] completing cognitive training,[8] and improving social support [9] may help delay the onset of cognitive decline and slow down disease progression.[10]

Digital medicine will have a crucial role in facing the clinical conditions of the elderly in the aging society.[11] Gamification offers powerful opportunities within this framework: It is defined as the application of game psychologies and mechanics within nongame scenarios. Gamification stems from psychological theory of operant conditioning behavioral changes by rewarding some actions and punishing others within the game environment:[12] rewards include points and leader boards,[13] badges,[14] progress monitoring as progress bars or tick charts,[15] and positive feedback, for example, an encouraging message after a user has completed a task.[16] The goal of gamification is to enhance the self-efficacy of players toward the performance of a specific task:[17] in the medical area, health choices are dependent on self-efficacy,[18] so patients will adhere to their clinical process of prevention or rehabilitation if they feel confident while practicing. If participants are not motivated to engage with a system/app, they may not experience the full benefit of the proposed solution. It is also important to address participants' motivations to engage with the technology used in a specific context as unfamiliarity and the feelings of incompetence could be a barrier to participation. Successful gamification should use the three principles: Providing meaning to participants, enabling mastery to maintain flow, and ensuring autonomy so users can participate freely.[19] The most important tip to follow in order to increase the users' engagement in gamified app is to “intrinsically motivate” users to participate in the gamified solution. In general, motivation refers to psychological processes that are responsible for initiating and continuing goal-directed behaviors.[20] Intrinsic motivation is based on the human need to be competent and make choices without external influence (according to the self-determination theory).[21] With respect to the “health-related behaviors,” in general, users are not intrinsically motivated to accomplish them. Since humans like to feel in control, it is not suggested to simply offer extrinsic rewards when gamifying health behaviors as it can diminish users' internal drive to complete an activity.[22]

Game mechanics are mainly adapted to engage and motivate patients by transforming them into players by highlighting the skills acquired through scores and thus making the therapeutic process clear and funnier than usual. Further social dynamics borrowed by games can facilitate the development of networks between patients creating social connections and virtual communities that could be powerful clinical resources for elderly patients. Performing exercises through digital games to optimize elderly opportunities for health has to face a preliminary challenge: The acceptance of these games by a population which is not used to this kind of medium. For example, the investigation here presented took place in Singapore where only 27% of those above 60 use computers (Elderly help drive tech adoption in Singapore: IDA survey [Internet]. Channel NewsAsia. [Cited 2016 Sep 5]. Available from: http://www.channelnewsasia.com/news/singapore/elderly-help-drive-tech/2295642.html). With an aging population, 20% of Singaporeans will be above the age of 65 years by 2030 (Ministry of Health Singapore [Internet]. Speech by Mr. Gan Kim Yong, Minister for Health, at the SG50 Scientific Conference on Ageing, on 19 March 2015. [Cited 2016 Aug 4]. Available from: https://www.moh.gov.sg/content/moh_web/home/pressroom/speeches_d/2015/speech-by-mr-gan-kim-yong-minister-for-health-at-the-sg50-scie.html), making this increasingly relevant. Most studies dealt with the technical aspects,[23],[24],[25],[26] without investigating the elderly's perceptions and acceptance of using digital games for exercise. These psychological factors are so influential that it is worth considering them from the first phases of development by adopting a user-centered design approach that takes into account the characteristics of the specific target population of the technological solution. Based on these premises, investigating the role of perceptions and acceptance of elderly toward the use of digital games is necessary to identify whether the service provided can overcome this preliminary barrier that is so crucial because it could prevent old patients to approach to this kind of medical intervention, in some cases even to think about that as a feasible option. This paper reports an exploratory study that evaluates the feasibility of using a digital gaming system as an exercises platform for the healthy elderly population in Singapore.

  Materials and Methods Top


The exergame system selected was RehAbility (More details about the Rehability, solution website is available here: http://rehability.me), which was developed in Italy by imaginary srl for rehabilitation therapy. It uses Microsoft Kinect, a motion sensing input device launched in 2010 that allows users to play games purely through body movements and voice commands.[27] RehAbility is an innovative solution, specifically designed for neurological patients, with the objective of providing game-like physical [Figure 1] and cognitive rehabilitation. With RehAbility patients can do their rehabilitation exercises autonomously but with constant remote medical supervision, from either home or the center in which they are hospitalized. Physicians have their own interface from where they can set up therapy plans and monitor the results, while patients can access their plan from their own computer and complete exercise routines designed using gamification principles. RehAbility has been codesigned with physicians and patients.
Figure 1: Screenshot from an exergame

Click here to view

A preliminary intervention was made following a user-centered design approach scheduling eight focus groups (4 in Italy and 4 in the UK) as a crucial step within the iterative process in the development of serious games and gamification to develop a usable and acceptable prototype of the application. Participants were recruited who were suffering from normal or mild cognitive impairment as assessed by the mini mental state examination [28] or the Montreal cognitive assessment.[29] Each focus group involved a minimum of four and maximum of eight people, of both genders, with an age between 65 and 80 years. The eight focus groups were involved at different stages of the design process, with different purposes, according to prototype status:First of all, information on the experience of participants about games and games for health and motivation was elicited. Then, themes emerged were presented in a gamified way and different games were tested to collect feedback both from the usability and acceptability point of view; finally, these feedbacks were used to improve the prototype.


Davis' Technology Acceptance Model (TAM)[30] was adopted as a framework [Figure 2] to analyze participants' responses. In this model, factors contributing to user acceptance of any new technology are “perceived ease of use” and “perceived usefulness,” which have been lately expanded with “attitude toward using” and “behavioral intention to use.” For the purpose of discussion, this study combined the two, referring to it as participants' “attitude toward using.” Immediately after the session, participants were given a questionnaire, with 10 statements graded using a 5-point Likert scale ranging from “strongly disagree” to “strongly agree”: The first four questions deal with factor 1 “perceived ease of use”, four other questions deal with factor 2 “perceived usefulness”, and the last two investigate factor 3 “attitude toward using”.
Figure 2: Technology Acceptance Model

Click here to view


The elderly were recruited from O'Joy Care Services, a voluntary welfare organization promoting healthy aging in Singapore. Participants were screened for exclusion criteria putting them at risk or preventing them from using the games:

  • Difficulty in understanding instructions of the games
  • Previous seizure episodes
  • Known cardiorespiratory condition where exercise is not advised
  • Joint pain preventing repetitive movements
  • Others (e.g., recent acute myocardial infarction, vasovagal episodes).

Participants (n = 50) ranged from ages 58 to 83 years; 96% were female, all were Chinese, and only 2% had previous gaming experience [Table 1].
Table 1: The O'Joy Care Services Sample description

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Informed consent was obtained from the participants before the intervention. It was given adequate time to read through and clarify any issues they have. Consent was taken in an enclosed room without intrusion to protect confidentiality and participation was purely voluntary. National Healthcare Group Domain Specific Review Board approval was obtained before the commencement of this study. Each participant was allocated a single session lasting 30 min to use the RehAbility game system. Four games in the RehAbility system were sampled. Game settings and difficulty were standardized for all participants. Participant data were anonymized.

  Results Top

User feedbacks for development

The focus groups carried out during development ended in a gamification model that the target participants feel comfortable with, can engage with, and will motivate them to persevere during an autonomous intervention. The main suggestions were as follows:

  • Older people may find difficulties in interpreting the graphical display of information, preferring numbers rather than graphics alone
  • The elderly with no previous experience with technological tools, such as a tablet computer, can learn very quickly how to use these devices
  • Interface design issues need to be carefully considered with age-related visual decline and manual dexterity usability.

Perceived ease of use

All participants were able to use the RehAbility system with guidance from an investigator by the end of the session. Ninety-four percent of participants found the game enjoyable, with many reporting that the game provided them with not only physical but also “mental stimulation”. Seventy-eight disagreed that the games would cause them more harm than good, with only a small number reporting any problems while playing the games. The complexity of the system had more mixed responses, with 24% agreeing and 64% disagreeing that the system would be too complex at home.

Perceived usefulness

Most participants felt that the games were useful in both exercise (78%) and cognition (82%). Eighty-eight percent also agreed that the games gave them the motivation to exercise more. When asked to compare conventional exercise with the games, many participants found them difficult to compare, stating that each had their strengths and weaknesses. Nonetheless, when asked to choose an option, 50% considered them comparable, 30% found them inferior, and 16% found them superior. Two participants were unable to give an answer. Some participants also commented that the games were “not strenuous enough”, “only involving the arms”, and “repetitive”. Others suggested that they were perhaps “more suited for patients with reduced mobility or recovering from stroke”.

Attitude toward use

Attitudes of participants toward using the games were generally positive, wanting more of such games produced (88%), and wanting them in elderly care services (86%). Eighty percent would also recommend the games to other elderly. However, 70% of participants felt that they would not purchase the games at home. Reasons stated in the comments section included cost issues, “lack of time”, and the preference to engage in activities that had “more social interaction”.

  Discussion Top

The results report the acceptance of the platform RehAbility that represents a well-structured tool to test the acceptance of a digital gaming solution amongst a sample of old patients. The service is evaluated in its possible role of replacing long-term hospitalization in public health services by developing new easy-to-use technological solution through which the engagement of the patient is both a resource for personal lifestyle and for a possible remote clinical evaluation. Hence, the discussion would not involve specific clinical results, but how participants perceived the interaction with this innovative way of digital clinical intervention.

The focus group carried out during the design phase highlighted information which is consistent with literature [31],[32] although it is crucial to check them for the development of every single prototype which will have specific characteristics due to the type of target and the current technological level.

The responses of the Singapore trial will be framed using the TAM, discussing the perceived ease of use, the perceived usefulness and participants' attitude toward using RehAbility.

Perceived ease of use

A majority of participants agreed that the game was enjoyable: Enjoyment has been reported as an important factor in exercise participation in the elderly, which could in turn impact adherence to exercise programs.[33] Most participants had no prior gaming experience, so having only 2 participants feeling difficulty in understanding and discomfort while playing the games highlights a possible feasibility of the platform even for the elderly not used to technology. Only 24% of participants found the system too complicated to be used at home: The system was set up by the investigator, and the game session was conducted with the investigator facilitating and giving instructions. The complexity of the system could be an obstacle, and the assistance of a caregiver during the first uses of the system would be necessary.

Perceived usefulness

The perceived usefulness of the RehAbility system was generally high. A large majority agreed that the games not only showed benefits as exercise but also motivated them to practice more. Impacts on cognition and memory were also perceived. However, when asked to directly compare the games to conventional exercise, the results were less clear. Almost one out of three participants found the games less effective than conventional exercise, with many of them explaining that the games were not strenuous enough, and they did not feel they were doing much exercise. As a result, the games tend to be slow, less difficult, and only involved the upper limbs; hence, it could be insufficiently challenging to the healthy participants. Far from a research setting, a specific set of rules allowing the player to advance through different levels that set increasing levels of difficulty are necessary. Clinicians could then choose whether they would like the platform to recognize and adapt the difficult to the players or they would like to set the level in person so that it could be possible to focus on specific tasks although the outcome performance of the patient is already good.

Attitude toward using

The results show that a majority of participants wanted to see more of such games and would recommend the games to their peers, suggesting a high acceptance rate. However, this seemed confined to the context of the elderly care center (86%), as opposed to home (20%). Participants stressed the need of social interaction; probably, thinking about using it at home emphasizes this perceived lack. Further development should provide communication tools to foster social interaction between different home settings.

Limitations and future research

To improve the reliability of the questionnaire used in this study, a Cronbach's alpha test could also be applied to the adapted version of the questionnaire. This study recruited predominantly Chinese female; hence, it may not represent the acceptance of the general elderly population. Moreover, participants were active members of the senior center, so they may not be representative of the general population, which may lead a more sedentary lifestyle. A further study could investigate the impact of the platform on participants with various levels of physical activity. Given that the games are intended for long-term use, the short session of 30 min may not have been adequate to evaluate the acceptance of these games. Future studies could lengthen the study period with multiple sessions and determine if the acceptance changes over time. Many repetitions could affect both the perceived acceptance of the platform and its ease of use: The first one would be challenged by boredom, whereas the second one could increase through spontaneous problem solving about usability issues.

  Conclusions Top

This preliminary study reports a positive acceptance of a digital solution among a population of elderly in Singapore. With growing computer literacy in the elderly, it seems that these games will become increasingly applicable in the society to come. The results of this study are encouraging, showing potential for the use of exergames, especially in elderly care centers. Future research can be done to explore the different types of games in different settings.

Financial support and sponsorship

This work has been supported by the European Commission under the collaborative project REHAB@HOME (Engaging Game-based Home Rehabilitation for Improved Quality of Life) funded by the European Commission under the Seventh Framework Program, FP7-HEALTH-2012-INNOVATION-1.

This work has been supported by the European Commission under the collaborative project DOREMI (Decrease of cOgnitive decline, malnutRition, and sedEntariness) by IFMBE Proceedings Vol. 57.

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1]

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