EXPANSE: A novel narrative serious game for the behavioral assessment of cognitive abilities

Conceptualization of the term "ecological validity" in neuropsychological research on executive function assessment: a systematic review and call to action

OBJECTIVE

"Ecological validity" (EV) is classically defined as test's ability to predict real-world functioning, either alone or together with test's similarity to real-world tasks. In neuropsychological literature on assessment of executive functions (EF), EV is conceptualized inconsistently, leading to misconceptions about the utility of tests. The goal of this systematic review was to examine how EV is conceptualized in studies of EF tests described as ecologically valid.

METHOD

MEDLINE and PsychINFO Databases were searched. PRISMA guidelines were observed. After applying inclusion and exclusion criteria, this search yielded 90 articles. Deductive content analysis was employed to determine how the term EV was used.

RESULTS

About 1/3 of the studies conceptualized EV as the test's ability to predict functional outcomes, 1/3 as both the ability to predict functional outcome and similarity to real-world tasks, and 1/3 were either unclear about the meaning of the term or relied on notions unrelated to classical definitions (e.g., similarity to real-world tasks alone, association with other tests, or the ability to discriminate between populations).

CONCLUSIONS

Conceptualizations of the term EV in literature on EF assessment vary grossly, subsuming the notions of criterion, construct, and face validity, as well as sensitivity/specificity. Such inconsistency makes it difficult to interpret clinical utility of tests that are described as ecologically valid. We call on the field to require that, at minimum, the term EV be clearly defined in all publications, or replaced with more concrete terminology (e.g., criterion validity).

Measuring the Reliability of a Gamified Stroop Task: Quantitative Experiment

BACKGROUND

Few gamified cognitive tasks are subjected to rigorous examination of psychometric properties, despite their use in experimental and clinical settings. Even small manipulations to cognitive tasks require extensive research to understand their effects.

OBJECTIVE

This study aims to investigate how game elements can affect the reliability of scores on a Stroop task. We specifically investigated performance consistency within and across sessions.

METHODS

We created 2 versions of the Stroop task, with and without game elements, and then tested each task with participants at 2 time points. The gamified task used points and feedback as game elements. In this paper, we report on the reliability of the gamified Stroop task in terms of internal consistency and test-retest reliability, compared with the control task. We used a permutation approach to evaluate internal consistency. For test-retest reliability, we calculated the Pearson correlation and intraclass correlation coefficients between each time point. We also descriptively compared the reliability of scores on a trial-by-trial basis, considering the different trial types.

RESULTS

At the first time point, the Stroop effect was reduced in the game condition, indicating an increase in performance. Participants in the game condition had faster reaction times (P=.005) and lower error rates (P=.04) than those in the basic task condition. Furthermore, the game condition led to higher measures of internal consistency at both time points for reaction times and error rates, which indicates a more consistent response pattern. For reaction time in the basic task condition, at time 1, rSpearman-Brown=0.78, 95% CI 0.64-0.89. At time 2, rSpearman-Brown=0.64, 95% CI 0.40-0.81. For reaction time, in the game condition, at time 1, rSpearman-Brown=0.83, 95% CI 0.71-0.91. At time 2, rSpearman-Brown=0.76, 95% CI 0.60-0.88. Similarly, for error rates in the basic task condition, at time 1, rSpearman-Brown=0.76, 95% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95% CI 0.58-0.86. For error rates in the game condition, at time 1, rSpearman-Brown=0.76, 95% CI 0.62-0.87. At time 2, rSpearman-Brown=0.74, 95% CI 0.58-0.86. Test-retest reliability analysis revealed a distinctive performance pattern depending on the trial type, which may be reflective of motivational differences between task versions. In short, especially in the incongruent trials where cognitive conflict occurs, performance in the game condition reaches peak consistency after 100 trials, whereas performance consistency drops after 50 trials for the basic version and only catches up to the game after 250 trials.

CONCLUSIONS

Even subtle gamification can impact task performance albeit not only in terms of a direct difference in performance between conditions. People playing the game reach peak performance sooner, and their performance is more consistent within and across sessions. We advocate for a closer examination of the impact of game elements on performance.

Artificial Intelligence-Driven Serious Games in Healthcare: A Scoping Review (Preprint).. [DOI: 10.2196/preprints.39840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

Artificial Intelligence (AI)-driven serious games have been used in healthcare to offer a customizable and immersive experience. Summarizing the features of the current AI-driven serious games is very important to explore how they have been developed and used and their current state in order to plan on how to leverage them in the current and future healthcare needs.

OBJECTIVE

The current study aimed to explore the features of AI-driven serious games in healthcare as reported by previous research.

METHODS

We carried out a scoping review to achieve the above-mentioned objective. The most popular databases in information technology and health fields (e.g., MEDLINE and IEEE Xplore) were searched using keywords related to serious games and AI. These terms were selected based on the target intervention (i.e., AI) and the target disease (i.e., COVID-19). Two reviewers independently performed the study selection process. Three reviewers independently used Microsoft Excel to extract data from the included studies. A narrative approach was used for data synthesis.

RESULTS

The search process returned 1470 records. Of these records, 46 met all eligibility criteria. 60 different serious games were found in the included studies. Motor impairment was the most common health condition targeted by these serious games. Serious games in most of the studies were used for rehabilitation. The serious games in the majority of the included studies can be played by only single player. Most serious games were played on standalone devices (offline games). The most common genres of serious games were role-playing games, puzzle games, and platformer games. Unity was the most prominent game engine used to develop serious games. Personal computers (PCs) were the most common platforms used to play serious games. The most common algorithms used in the included studies were Support Vector Machine (SVM), Convolutional Neural Network (CNN), Artificial Neural Networks (ANN), and Random Forest (RF). The most common purposes of AI were the detection of disease and the evaluation of user's performance. The dataset size ranged from 36 to 795,600, with an average of about 52,124. The most common validation techniques used in the included studies were K-fold cross-validation and training test split validation. Accuracy was the most commonly used metric to evaluate the performance of AI models.

CONCLUSIONS

The last decade witnessed an increase in the development of AI-driven serious games for healthcare purposes and targeting various health conditions and leveraging multiple AI algorithms; this rising trend is expected to continue for years to come. While the evidence uncovered in this study shows promising applications of AI-driven serious games, larger and more rigorous, diverse, and robust studies may be needed to examine the efficacy and effectiveness of AI-driven serious games in different populations with different health conditions.

Effectiveness of Serious Games for Improving Executive Functions Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.36123]

BACKGROUND

Executive functions are one of the known cognitive abilities that decline with age. They are the high-order cognitive processes that enable an individual to concentrate, plan, and take action. Serious games, which are games developed for specific purposes other than entertainment, could play a positive role in improving executive functions. Several systematic reviews have pooled the evidence about the effectiveness of serious games in improving executive functions; however, they are limited by some weaknesses.

OBJECTIVE

This study aims to investigate the effectiveness of serious games for improving executive functions among older adults with cognitive impairment.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted. To retrieve relevant studies, 8 electronic databases were searched. Further, reference lists of the included studies and relevant reviews were screened, and we checked studies that cited our included studies. Two reviewers independently checked the eligibility of the studies, extracted data from the included studies, assessed the risk of bias, and appraised the quality of the evidence. We used a narrative and statistical approach, as appropriate, to synthesize results of the included studies.

RESULTS

Of 548 publications identified, 16 RCTs were eventually included in this review. Of the 16 studies, 14 studies were included in 6 meta-analyses. Our meta-analyses showed that serious games are as effective as no or passive interventions at improving executive functions (<i>P</i>=.29). Surprisingly, conventional exercises were more effective than serious games at improving executive functions (<i>P</i>=.03). Our subgroup analysis showed that both types of serious games (cognitive training games, <i>P</i>=.08; exergames, <i>P</i>=.16) are as effective as conventional exercises at improving executive functions. No difference was found between adaptive serious games and nonadaptive serious games for improving executive functions (<i>P</i>=.59).

CONCLUSIONS

Serious games are not superior to no or passive interventions and conventional exercises at improving executive functions among older adults with cognitive impairment. However, our findings remain inconclusive due to the low quality of the evidence, the small sample size in most included studies, and the paucity of studies included in the meta-analyses. Accordingly, until more robust evidence is available, serious games should not be offered by health care providers nor used by patients for improving executive functions among older adults with cognitive impairment. Further reviews are needed to assess the long-term effect of serious games on specific executive functions or other cognitive abilities among people from different age groups with or without cognitive impairment.

CLINICALTRIAL

PROSPERO CRD42021272757; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272757

The effectiveness of serious games in improving executive functions among older adults with cognitive impairment: A systematic review and meta-analysis (Preprint)

Background

Executive functions are one of the known cognitive abilities that decline with age. They are the high-order cognitive processes that enable an individual to concentrate, plan, and take action. Serious games, which are games developed for specific purposes other than entertainment, could play a positive role in improving executive functions. Several systematic reviews have pooled the evidence about the effectiveness of serious games in improving executive functions; however, they are limited by some weaknesses.

Objective

This study aims to investigate the effectiveness of serious games for improving executive functions among older adults with cognitive impairment.

Methods

A systematic review of randomized controlled trials (RCTs) was conducted. To retrieve relevant studies, 8 electronic databases were searched. Further, reference lists of the included studies and relevant reviews were screened, and we checked studies that cited our included studies. Two reviewers independently checked the eligibility of the studies, extracted data from the included studies, assessed the risk of bias, and appraised the quality of the evidence. We used a narrative and statistical approach, as appropriate, to synthesize results of the included studies.

Results

Of 548 publications identified, 16 RCTs were eventually included in this review. Of the 16 studies, 14 studies were included in 6 meta-analyses. Our meta-analyses showed that serious games are as effective as no or passive interventions at improving executive functions (P=.29). Surprisingly, conventional exercises were more effective than serious games at improving executive functions (P=.03). Our subgroup analysis showed that both types of serious games (cognitive training games, P=.08; exergames, P=.16) are as effective as conventional exercises at improving executive functions. No difference was found between adaptive serious games and nonadaptive serious games for improving executive functions (P=.59).

Conclusions

Serious games are not superior to no or passive interventions and conventional exercises at improving executive functions among older adults with cognitive impairment. However, our findings remain inconclusive due to the low quality of the evidence, the small sample size in most included studies, and the paucity of studies included in the meta-analyses. Accordingly, until more robust evidence is available, serious games should not be offered by health care providers nor used by patients for improving executive functions among older adults with cognitive impairment. Further reviews are needed to assess the long-term effect of serious games on specific executive functions or other cognitive abilities among people from different age groups with or without cognitive impairment.

Trial Registration

PROSPERO CRD42021272757; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272757

A Novel Game-Based Intelligent Test for Detecting Elderly Cognitive Function Impairment

PURPOSES

This research explores the game-based intelligent test (GBIT), predicts the possibilities of Mini-Mental State Examination (MMSE) scores and the risk of cognitive impairment, and then verifies GBIT as one of the reliable and valid cognitive assessment tools.

METHODS

This study recruited 117 elderly subjects in Taiwan (average age is 79.92 ± 8.68, average height is 156.91 ± 8.01, average weight is 59.14 ± 9.67, and average MMSE score is 23.33 ± 6.16). A multiple regression model was used to analyze the GBIT parameters of the elderly's reaction, attention, coordination, and memory to predict their MMSE performance. The binary logistic regression was then utilized to predict their risk of cognitive impairment. The statistical significance level was set as α = 0.05.

RESULTS

Multiple regression analysis showed that gender, the correct number of reactions, and the correct number of memory have a significantly positive predictive power on MMSE of the elderly (F = 37.60, R 2 = 0.69, and p < 0.05). Binary logistic regression analysis noted that the correct average number of reactions falls by one question, and the ratio of cognitive dysfunction risk increases 1.09 times (p < 0.05); the correct average number of memory drops by one question, the ratio of cognitive dysfunction risk increases 3.76 times (p < 0.05), and the overall model predictive power is 88.20% (sensitivity: 84.00%; specificity: 92.30%).

CONCLUSIONS

This study verifies that GBIT is reliable and can effectively predict the cognitive function and risk of cognitive impairment in the elderly. Therefore, GBIT can be used as one of the feasible tools for evaluating older people's cognitive function.

The Making and Evaluation of Digital Games Used for the Assessment of Attention: Systematic Review

Background

Serious games are now widely used in many contexts, including psychological research and clinical use. One area of growing interest is that of cognitive assessment, which seeks to measure different cognitive functions such as memory, attention, and perception. Measuring these functions at both the population and individual levels can inform research and indicate health issues. Attention is an important function to assess, as an accurate measure of attention can help diagnose many common disorders, such as attention-deficit/hyperactivity disorder and dementia. However, using games to assess attention poses unique problems, as games inherently manipulate attention through elements such as sound effects, graphics, and rewards, and research on adding game elements to assessments (ie, gamification) has shown mixed results. The process for developing cognitive tasks is robust, with high psychometric standards that must be met before these tasks are used for assessment. Although games offer more diverse approaches for assessment, there is no standard for how they should be developed or evaluated.

Objective

To better understand the field and provide guidance to interdisciplinary researchers, we aim to answer the question: How are digital games used for the cognitive assessment of attention made and measured?

Methods

We searched several databases for papers that described a digital game used to assess attention that could be deployed remotely without specialized hardware. We used Rayyan, a systematic review software, to screen the records before conducting a systematic review.

Results

The initial database search returned 49,365 papers. Our screening process resulted in a total of 74 papers that used a digital game to measure cognitive functions related to attention. Across the studies in our review, we found three approaches to making assessment games: gamifying cognitive tasks, creating custom games based on theories of cognition, and exploring potential assessment properties of commercial games. With regard to measuring the assessment properties of these games (eg, how accurately they assess attention), we found three approaches: comparison to a traditional cognitive task, comparison to a clinical diagnosis, and comparison to knowledge of cognition; however, most studies in our review did not evaluate the game’s properties (eg, if participants enjoyed the game).

Conclusions

Our review provides an overview of how games used for the assessment of attention are developed and evaluated. We further identified three barriers to advancing the field: reliance on assumptions, lack of evaluation, and lack of integration and standardization. We then recommend the best practices to address these barriers. Our review can act as a resource to help guide the field toward more standardized approaches and rigorous evaluation required for the widespread adoption of assessment games.

Wearable Devices for Physical Activity and Healthcare Monitoring in Elderly People: A Critical Review

The availability of wearable devices (WDs) to collect biometric information and their use during activities of daily living is significantly increasing in the general population. These small electronic devices, which record fitness and health-related outcomes, have been broadly utilized in industries such as medicine, healthcare, and fitness. Since they are simple to use and progressively cheaper, they have also been used for numerous research purposes. However, despite their increasing popularity, most of these WDs do not accurately measure the proclaimed outcomes. In fact, research is equivocal about whether they are valid and reliable methods to specifically evaluate physical activity and health-related outcomes in older adults, since they are mostly designed and produced considering younger subjects' physical and mental characteristics. Additionally, their constant evolution through continuous upgrades and redesigned versions, suggests the need for constant up-to-date reviews and research. Accordingly, this article aims to scrutinize the state-of-the-art scientific evidence about the usefulness of WDs, specifically on older adults, to monitor physical activity and health-related outcomes. This critical review not only aims to inform older consumers but also aid researchers in study design when selecting physical activity and healthcare monitoring devices for elderly people.

Validation of a mobile game-based assessment of cognitive control among children and adolescents

Cognitive control is the most fundamental psychological function that underlies the execution of many other psychological functions. A mobile game application could be a useful strategy to evaluate cognitive control in the groups of children and adolescents. Although a serious game that is based on gamification would be an optimal platform for the administration of behavioral and clinical assessments of children and adolescents, most studies on gamification have been conducted among adults and older adults than among children and adolescents. This study aimed to assess cognitive control using a mobile game that used gamification and compared the results to those from traditional neuropsychological tests for children and adolescents. In order to address this objective, this study used a serious game, namely, “CoCon,” which was developed to assess cognitive control in children and adolescents. This study included 100 participants from a community sample (mean age = 11.75 years, ranged from 9 to 16 years, SD = 1.40 years; Male = 59(59%), Female = 41(41%)). The analyses interrogated the relationships among various game behaviors scores of CoCon, the standardized neuropsychological tests (K-WISC-IV, CTT, and Stroop), and self-reporting executive function difficulty questionnaire. As results, a mobile game application-based assessment proved to be a reliable and valid measure of the cognitive control in children and adolescents. The index scores from the CoCon were significantly related to various cognitive control functions and differentiated between the high and low cognitive control groups. Specifically, even though the participants completed the mobile game ‘CoCon’ in their natural habitats, the CoCon scores were comparable to the measures from standard neuropsychological tests. In conclusion, the present findings suggest that mobile games that use advanced technology and sophisticated psychological strategies can serve as a new and expanded platform for the administration of psychological assessments.

Are 3D virtual environments better than 2D interfaces in serious games performance? An explorative study for the assessment of executive functions

Executive functions refer to higher-order cognitive processes that supervise and guide goal-directed and adaptive behaviors in response to everyday situations. The traditional measures used to assess executive functions include paper-and-pencil tests and/or computerized tests that have been found to have a moderate level of ecological validity in predicting real-world performance. Serious games (SG) represent a novel methodological approach, allowing investigating subjects' performance in real-simulated situations. Serious games are computer games whose primary purposes include investigating human behaviors and changes. Furthermore, SG can also vary according to the technology used and the interaction. Indeed, a SG can be rendered via a nonimmersive screen-based (2D) or via an immersive virtual reality game (3D). Starting from these premises, we compared a narrative-contextualized SG in 2D and 3D, correlating them with traditional tests. Findings showed different condition correlations with the traditional tasks and the comparison between the two systems have revealed that 3D is able to generate lower reaction times, higher correct answers, and lower perseverative responses in attentional abilities, inhibition control, and cognitive shifting than 2D condition. The present study yielded evidence on the use of more ecological tools to identify the functional cognitive status in real-simulated contexts along with traditional evaluation.