1. Serious Games for Dementia Illness Detection and
Motivation: The eMotiva Experience
José Luis Bayo Montón #1, Carlos Fernandez-LLatas#2, Juan Miguel García-Gomez*3, Vicente Traver Salcedo#4
#
ITACA – Health and Wellbeing Technologies
Universidad Politécnica de Valencia, Spain
1
jobamon@itaca.upv.es
2
carfell@itaca.upv.es
4
vtraver@itaca.upv.es
*
ITACA - Biomedical Informatics Group
Universidad Politécnica de Valencia, Spain
3
juanmig@ibime.upv.es
Abstract— The increase in age-related diseases in our society is from society. To overcome this, we need further treatment of
growing constantly as a result of medical advances, about 824.00 the disease beyond the mere management.
new cases of dementia are diagnosed each year. Different studies The stimulation and maintenance of brain function level is
show that thanks to the plasticity of the nervous system, brain based on the plasticity of the nervous system, a term that
degenerative processes may be delayed, this requires an adequate
refers to the ability of our Central Nervous System to create
stimulation of cognitive activity. The stimulation activities in
patients with dementia, it is particularly difficult since it is and modify neural connections throughout life to compensate
necessary to maintain the patient's motivation at all times. for certain losses. With proper stimulation, the brain creates
The eMotiva project is an Internet tool of the future that tries to new neural connections, which helps not to lose or maintain
create a synergy between doctors and people with cognitive for more time higher functions when a disease such as
degeneration caused by diseases associated with dementia to Alzheimer's begins neuronal destruction, [2]. Motivational
promote social inclusion as a therapeutic method for patients processes are suitable for the treatment of these patients, based
through the use of digital content in response to behaviour on brain plasticity, and may include exercises of attention,
disorders. orientation, memory, money management, calculation,
This article focuses on part of the developments made within the
reasoning, and social adjustment.
project, to ensure that the patient perform a series of activities
which stimulate different cognitive processes such as memory or Current good practices in the care of older people are based
attention, all trying to keep the patient motivated to achieve on comprehensive approaches that include actions such as the
activities continuity and perceives that these are not a burden, stimulation and maintenance of cognitive processes. It has
but as an activity of leisure. To achieve this, the project has used been shown that continuous stimulation of cognitive activity
the paradigm of serious games used as a therapeutic tool. can alleviate the degenerative process of the diseases
associated with dementia.
I. INTRODUCTION The eMotiva's project raises the design and the
The aging of the population is without doubt one of the implementation of an active and comprehensive system for
hallmarks of our time and should be classified as a success in monitoring and motivation of people with dementia in
the health field. However, the increasing number of elderly institutional residences. The implementation of the monitoring
means that the number of diseases of the aging process itself subsystem is based on pattern recognition in time series, to
is increasing, as is the case of dementia. It is estimated that detect behaviour patterns associated to disorders, and personal
there are about 5,752,754 people in Europe with dementia and motivation is based on the technologies of motivation. B.J.
there are 824,000 new cases per year. In Spain, it affects about Fogg [3] defines persuasive technology or motivating as a
550,000 people, representing 1.24% of the population. Spain system designed to change attitudes or behaviours of people.
is framed in the top 5 European countries in terms of number
of cases with dementia and the third in terms of percentage II. OBJETIVES
from the total population [1]. The primary goal of administered therapies in dementia is
Behaviour disorders of dementia are a reality faced by the stimulate mental abilities of the affected, maintain their
patients, families and health professionals given the long autonomy and their social relations. In general, therapies
evolution of this disease, and the relatively rapid deterioration administered to patients with dementia affect that patients at
that occurs, the management of behavioural symptoms is so levels cognitive, functional (Activities of Daily Living) and /
important or more, than to trust on the potential benefit of or behavioural.
treatment of cognitive symptoms. These disorders often affect Based on this, eMotiva poses a motivation system that
the life of care-dependent people, who may then be excluded seeks to promote skills in people with dementia at a cognitive
level, to encourage mobility and promote a state of relaxation.

2. The objective is defined as the creation of innovative
multimedia motivation tools, which enables influence on the
attitudes or behaviour of people with dementia to alleviate
their disease process.
III. MATERIALS AND METHODS
Within the treatments in dementia we can distinguish two
types of therapy: drug therapy and nonpharmacological
therapy, both compatible to be developed simultaneously.
The nonpharmacological therapy is defined as "a non-
chemical intervention, theoretically supported, focused and
replicable, made over the patient or caregiver and potentially
able to obtain a relevant benefit” [4]. Recent publications
confirm that nonpharmacological therapies have several
positive clinical effects: improve domains such as cognition, Figure 1 - All-in-one PC, MSI Wind Top
behaviour or mood, and reduce caregiver burden, avoid or
postpone entry into old people’s homes, and can reduce the In those games that require physical interaction it has been
cost care economic [5]. chosen to use the Wiimote remote control, this device can
In this line are raised the motivational systems within the measure acceleration in three axes of movement, offering
project eMotiva, aimed at developing nonpharmacological information from the user movements. We have chosen this
therapies focused on Alzheimer's patient. controller instead of one made to order or another brand, for
As a motivational tool, it is proposed a software with a its low cost and for being shown its usefulness and ease of use
games format, focused on two lines: one line on the cognitive in existing developments in other studies.
stimulation of the person with dementia, and other line on
physical stimulation and relaxation.
In order to ensure that the games are in line with the work
methodology of residential institutions, in-depth interviews
there have been conducted with medical personnel of the
Asociación de Familiares de enfermos de Alzheimer (AFA)
and the Boni Mediero's residence in Salamanca, and the staff
of San Sebastian's residential centre in La Pobla de Vallbona
(Valencia).
A. Devices Figure 2 - Wiimote remote control
When designing and developing systems to encourage or
persuade older people, we must take into account the barriers B. Software Technology
that they encounter in adopting and using new technologies. For the development of games there have been used two
Martijn H. Vastenburg et al. [6], indicate the complexity and different software development technologies. In the
learning as well as lack of perceived benefit, as key factors to immersive type games there have been used the Microsoft
consider when developing systems of motivation for older XNA technology, which is a set of tools for developing games
people, as users may find the cost of adopting new technology with high graphics capabilities and performance, for both the
more than the expected benefit. In these cases they suggest to Xbox console and computers running Windows. The second
increase the direct benefit that the technology produces to technology used for non-immersive games is Windows
increase the benefit perceived by the user. Presentation Foundation (WPF), this technology is not
To break the barrier of learning and simplify the use of specifically designed for games, but it offers a large
games, it was decided to use natural interaction techniques infrastructure and graphics power with animation, video and
based on the use of touchscreens as interface with the audio capabilities. This puts it on the ability to develop non-
computer, eliminating the use of keyboards and mice, in immersive games with high graphics performance and
particular it has been chosen an All-in-one PC which includes interaction, reducing the development time compared with the
the computer and a touch screen in a compact and nice design, technologies specially designed for games and 3D
reducing the psychological barrier of dealing with a computer. environments such as XNA.
IV. RESULTS
Within the project there are several game environments that
can be divided according to their objective into: cognitive
stimulation environments and physical stimulation
environments.

3. The cognitive stimulation games seek to work the areas The screen shows a series of tiles and the user has to click
such as attention, memory or executive functions, being on them in a particular order. This order may be numeric or
cognitive areas the most affected at the beginning of dementia. size.
These games are presented in a touchscreen environment,
allowing users to interact with the game in a simple and
intuitive way, and are fully configurable as they allow
defining different scenarios playing with their parameters,
such as difficulty or number of items involved in the game.
On the other hand, with the aim of stimulating physically,
we propose a virtual paradise which seeks to encourage the
abandonment of the idle, transmit peace and quiet to the
player.
All in line with the conclusions drawn from interviews with
medical personnel, where the main lines were: The use of
simple equipment, easy to use and intuitive; Development of
games that incorporate visual or auditory stimuli to improve Figure 4 - Follow the sequence (screen capture)
memory, strengthen the patient's daily life activities, allowing
customization of the games to the needs and abilities of the
patient, and finally not forgetting the fun as the engine of 2) How to play:
motivation for encouraging the use of games. At the beginning of the game, the tiles are displayed, and
A. Rowing the player must click on the appropriate order. In the case of
numbered tiles, each tile carries within it a number, starting
1) Description: with 1 and ending in the number of tiles that you have on the
The game is based on a realistic graphical model that board. The player must to click the tiles in increased
allows users to immerse themselves in a tropical paradise and numerical order.
interact with it. If we play by size, on the board appear tiles of various sizes,
The game features several scenarios where the user can but this time without a number. In this case, the player must
move slowly interacting with the game using the Wiimote click the tiles beginning with the smallest and ending with the
remote control. largest.
The figure shows a tropical paradise with an island in the If the appropriate tile is clicked, it turns green, indicating
background, a sunny day and clear water, this scenario intends that is the correct. If is wrong, on top of the screen is displays
to convey peace and quiet to the user. a message encouraging you to try again, and is counted as a
mistake. Once all the tiles are lit, it is indicated in the same
part of the screen that the game is over and scores are stored.
If you click on a green tile also counts as a mistake.
You can configure how tiles appear on the board, having
three distributions. In the first distribution tiles are arranged in
a straight line. In the second, the tiles are aligned along a line
by decreasing size. In the third, the tiles are randomly
distributed across the board. So the game has defined six
levels of difficulty, which cover all combinations of tile types
and distributions on the board.
C. Dress the doll
1) Description:
The screen shows a doll and a set of clothes. The user
Figure 3 - Rowing (screen capture) should dress the doll with the appropriate ones.
2) How to play:
To play you need a screen and a Wiimote. The remote
control is taken as an oar and using gentle circular motion, the
camera is moved around the stage following a predefined path.
B. Follow the sequence
1) Description:

4. Figure 5 - Dress the doll (screen capture) Figure 6 - Link sounds with elements (screen capture)
2) How to play: 2) How to play:
The screen shows a figure that can be male or female, and To start the game, the user must click on the button labelled
many different clothing. The player must drag each piece of "Play Sound" that appears on the left side of the board. When
clothing to the area where it belongs. When it is close enough, clicked, it plays an audio associated with any of the items
the garment is adjusted automatically, and a message reports represented on the board. Having heard the sound, you must
that it has been placed properly. When the article does not click on the element of the board related to that sound,
approach to the area corresponding to it, nothing happens, so clicking on another element is counted as a mistake, and on
you cannot put an item out of place. top of the screen tells the player to try again. If correct, is also
The silhouette can be male or female, depending on the indicated with a message. The elements that have already been
difficulty. If male, the clothes are four: shoes, tie, shirt and clicked count as a mistake if you click them again and sound
trousers. Therefore, at least four elements appear on the screen, does not change until you get right which element it belongs.
without the dummy. If the figure is female, there are a jacket, The sounds can be heard as often as necessary. When you
a handbag, high heels, a skirt and a mobile, a total of five click on the correct item, the sound changes to the next item,
pieces. and when all have been clicked correctly, indicates that the
You can bring up one set of items or two sets of items for game is finished and data is saved. The sounds order is
each silhouette. That is, in the case of man, can be configured random and the way the figures are placed on the board is
to appear a set of trousers, shirt, tie and shoes in yellow colour, random too, so every game is different.
and other set in blue colour, and the same for the female The elements vary in type and number to increase the
figure, although in this case the colours are black and blue. complexity, taking from musical instruments or animals, to
In the first degree of difficulty, only appears one set of fragments of songs that must be associated with the interpreter.
clothes, and the player simply has to drag each garment into
his place, so that you cannot make mistakes. However, when E. Grouping objects
there are two pieces of each garment, we can control that the 1) Description:
player must dress the silhouette in a particular colour or select Various objects appear on the screen related in some way
the clothes in the same colour. and the user will have to separate them into two groups
D. Link sounds with elements according to their relationship.
1) Description:
This game, as well as visual and tactile, incorporates sound
elements. Various elements are presented on the screen, each
one with a distinctive sound. The user must connect the sound
you hear with its visual representation.
Figure 7 - Grouping objects (screen capture)
2) How to play:
The game is to group shapes according to their shape or
colour. It features a configurable number of elements on the

5. board that the player must drag to a defined area, in which to have ten weeks of duration, during which patients will have
group the items based on certain criteria. thirty play sessions, it will try to assess the status of the
When starting the game, in the central part appear the patient before the study and at its conclusion, comparing their
figures, distributed randomly. In the upper left corner evolution against a control group, to try to validate the
indicates the way they should be grouped. The areas where the theoretical conclusions initially mentioned in this article and
figures must be carried are green and yellow boxes that are in proposed in the eMotiva's project.
the ends of the board. When the figures are close enough to
these boxes will automatically move on them. Once placed, a ACKNOWLEDGMENT
figure cannot be moved again. When all have been placed, it Authors thank the eMotiva consortium for their
will display a message in the middle of the board indicating contribution to this work.
that the game has ended.
You can vary the difficulty of the game using the number REFERENCES
of elements and the number of colours of them.
V. CONCLUSIONS
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The developed games aim to raise enough motivation for consensus study”, The Lancet, vol 366, pp. 2112-2117, Dec. 2005.
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include playful and entertaining aspects, with a high value of Detección y cuidados en personas mayores, ser. Promoción de la Salud
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On the one hand, we must emphasize the importance of We Think and Do, 1st ed., Ed. San Francisco, United States of America:
those games where, as in the Rowing game, it interacts with Morgan Kaufmann Publishers, 2003.
[4] R. Muñiz, J. Olazarán, Mapa de terapias no farmacológicas para
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significant motivation to prevent apathy, inactivity or
passivity.
On the other hand, the other games try to stimulate different
areas of cognition such as memory, attention or executive
functions, as well as stimulate visual and auditory perception.
The cognitive stimulation has its biological basis in
neuroplasticity or plasticity of the nervous system as
mentioned in the introduction. On this basis, frequent
interaction with a game environment rich in stimuli, can be
considered positive in maintaining cognitive abilities in
people with dementia. Each game presents a challenge and an
attempt to improve day by day, which can have effects on
people's emotional interaction. So the games are presented as
elements that can promote motivation.
After an initial presentation of the games to the medical
staff, the first assessments are agree that these appear to
comply with the guidelines of simplicity, the inclusion of
different requested elements of cognitive stimulation and
capacity to be included easily in their daily activities with the
patient.
F. Future lines of work:
The path or line of work ahead is clearly marked and goes
through to make a gaming implementation of motivation in
the centres that are part of the project. To carry out
subsequently a randomized controlled study, in subjects with
Alzheimer-type dementia, in its later stages. The study will