Developing a ludic framework for counteracting interventions for dementia: A narrative and analytic review

Introduction

Gamification is today’s buzzword, being used in a variety of scenarios across fields of expertise in a bid to find interesting newer solutions for existing problems. The adoption of gamification and its principles can be gauged from ride platforms like Uber to payment approaches like Google’s Gpay and Phone Pe. In an era where the most fascinating work for academia is in the blurring boundaries of established disciplines, it is only natural that the fields of psychology, psychiatry, cognitive science, and game studies come together to view the problems faced by people suffering from neurocognitive disorders.

While research exploring the intersection between the above-mentioned fields has become incredibly popular in the last decade with the Sea Hero Quest experiment being the watershed moment.1, 2 Earlier research has indicated that gaming-based interventions have shown positive signs with patients suffering from dementia and Alzheimer’s related disorders as patients have shown improvement over time with several gaming platforms.3, 4, 5 Studies have also looked at concepts like “exergaming” where gaming related activities have been viewed as a form of exercise for the mind and have consequently shown some cognitive improvement overtime with patients as they experienced fun and engagement.6

Other studies have also looked at the use of innovations like virtual reality, and the use of motion-based technology to help setup and run gaming technology groups for people suffering with dementia and related disorders.4, 5, 6, 7, 8 In a clearly burgeoning area of work, this paper proposes to look at how elements from game studies can be used in order to build counteracting gaming-based interventions. Secondly, the paper also discusses in detail the process of developing a suitable game with the said elements and suggests the creation of a framework that will easily allow for building of future games.

Channeling Flow, Immersion & Engagement

To credit the Sea Hero Quest exercise and its focus on cognitive elements of spatial navigation abilities, for the first time the supposed gold standard of memory loss to detect dementia has been now replaced by a method that is more reliable. By replacing the general complaint of memory loss to one’s specific loss of the spatial skills of navigation can be called a gigantic step forward in detecting dementia.2 By making the act of navigating in a virtual environment on a tiny touch-based screen a trivial pursuit the experiment was able to collect data from one of the largest samples in mental health history.

Looking at the success of the exercise it is important to consider the various elements that make gaming ‘fun’ in the first place. This paper draws broadly from three core concepts from game studies namely, Engagement, Immersion & Flow.

Immersion: Immersion is one of the most prominent elements that is immediately considered with regards to video games. Owing to the bedrock of work with regards to gaming and violence and the addictive abilities of video games as a medium, immersion is often construed in a negative light. Simply put, immersion is a state that players experience when they blur the boundaries of the offline worlds with their online counterparts. A phenomenon that is as likely to happen in worlds of fantasy as video games immersion is key to the use of gaming for building the counteractive intervention. Engagement: A concept suggested by Gordon Calleja in order to replace the more abstract immersion; Calleja has developed a six-point frame in order to study players’ engagement with games.9 By unpacking the video game as a medium into six distinct elements (tactical, performative, affected, shared, narrative and spatial) he then analyses immersion across each of these elements. Calleja points out that when a player is playing, he/she wouldn’t necessarily be able to distinguish between the six elements and would experience the involvement as a unified cognitive sensation.9 Flow: The concept of immersion is best illustrated by most Ludologists using Csikszentmihalyi’s concept of flow. Key to the experience of flow and the Zen state is Csikszentmihalyi’s understanding of the term where he understands the state of being in flow as a heightened experience that he compares to the athletes in the zone, mystics’ ecstasy and artists’ aesthetic rapture and refers to the full involvement of flow as the “excellence in life.” Instances where people experience the Zen state are labeled by him as moments of intense living that are dispersed against the dull background of everyday life.10

Flow amongst players while interacting with games is more common in contrast to “normal” or routine activities of the everyday, the interaction with(in) a game requires the player to engage at multiple levels and enter a state where his/her skills are completely involved in overcoming a challenge while adhering to the rules. Csikszentmihalyi also points out that the person seeks constant moments of flow by either mastering new skills or increasing the difficulty of the challenge.10 It is important to note that in theory, this heightened flow/Zen state is such that once people experience it, they will always strive to experience the intensity and exhilaration repeatedly.10

While the three concepts seem promising it is very important to note that contrary to popular belief, the proverbial Zen state or the feeling of complete immersion in games is never a constant. Like in the conceptualization of Csikszentmihalyi’s heightened state, in gaming too the moments of complete immersion are at best fleeting.11

Thus, the need to build a framework that takes engagement into consideration by allowing for elements of flow and immersion to be generously interspersed is key for this exercise to allow for the players to experience the flow state as frequently as possible.

The challenge here however is two pronged, by trying to introduce a gaming intervention in a generation of people who haven’t experienced gaming as a leisure time activity and may also be less than inclined towards the usage of technological platforms. However, for an intervention like this to truly work there is a need for participants who look at games first as an interesting activity, then gravitate towards looking at it as a habit, begin to engage with it as a practice and eventually begin to think of it as a ritual.12, 13

The need for understanding users’ interactions in the context of the everyday is of paramount importance and it is also important for the suggested methodology to work as the study needs to look at both what games do to people in the conventional fashion but also more importantly look at what users do to the games.12

Need for designing newer interventions

With the increase in average life span, the prevalence of chronic diseases are on the rise.14 This includes cognitive impairment as a sequelae to dementia, traumatic brain injury, autoimmune diseases etc. The barriers to traditional cognitive training (which include paper and pencil exercises) and rehabilitation for neurocognitive disorders include increasing cost of health care, declining caregiver support, non-availability of trained occupational therapists, requirement of labor-intensive therapy, accessibility to therapy, and difficulties in transportation; especially for the disabled.14, 15, 16 These barriers hold validity for both the developed and developing world.17 This constantly growing unmet health needs can only be addressed with the aid of efficient and effective use of technology widely available through portable electronic devices such as smart mobile phones, tablets and laptops with integration of World Wide Web. This technology can be utilized for assessment, therapeutic management, and monitoring of progress.18 Some studies have reported conflicting results.19 However, recent systematic reviews showed that gaming interventions hold promise in cognitive training.20 This necessitates further enhancement of the existing gaming interventions in order to improve delivery of care.

Building the Game

For a ludic based intervention to work the following factors are necessary to be considered for the resultant game to work:

With these as overarching principles for the building of the game, the game can be further personalized based on demographic data, and diagnosis. Trained medical personnel can enlist the deficits hierarchy wise with focus on major domain affected. Reinforcements are identified, adjusted based on performance and to meet ‘eu-stress’ difficulty. A story line with integrated specific assessment through mini games can serve as gamification of the medical intervention. Mean scores are derived and compared to other players and synced to server. Caregivers can be trained to monitor this exercise.

Challenges and Limitations

Several challenges can be anticipated at multiple fronts due to disability and other medical comorbidities. ‘Game pain’ as a factor for non-compliance is difficult to address. User experience must be considered which is influenced by cultural and ethnic factors. The game will also be expected to provide psychological support, improve quality of life, and improve self-esteem.

This article also makes a few assumptions that game related to ability deficit can be learnt and can be generalized to other areas. It also does not consider the probable harms of gaming as therapy such as impact of the patient failing the game or addiction, given that game is intended to be immersive and engaging.

Conclusions

There is rise in global prevalence of cognitive disorders. Technology can serve as an efficient, and cost-effective method to bridge this growing health gap. Gaming interventions are promising but limited. Few consider user-experience, tailored exercises, and functional rehabilitation. Exploiting findings from gaming addiction and concepts from gaming may be of use.

Source of Funding

None.

Conflict of Interest

None.