# data[].attributes.headline
VR Trips Help Treat Depression in the Elderly

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VR Trips Help Treat Depression in the Elderly

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https://www.youtube.com/watch?v=YW99DHOl098

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VR Trips Help Treat Depression in the Elderly

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As the U.S. ages, older Americans flock to video games

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As the U.S. ages, older Americans flock to video games

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https://www.cbsnews.com/news/video-games-senior-citizen-video-gamers-growing-by-millions/

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As the U.S. ages, older Americans flock to video games

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Seniors like the sense of community, while for developers they represent a growing and potentially lucrative market

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https://www.youtube.com/watch?v=3qEVCqEoPas

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https://www.youtube.com/watch?v=xLlsIxOBF64

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Nantendo: older brains benefit from video games

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Nantendo: older brains benefit from video games

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https://www.youtube.com/watch?v=WEV4ErdTlJo

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Nantendo: older brains benefit from video games

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Meet online gaming's fast growing community: senior citizens

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Meet online gaming's fast growing community: senior citizens

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https://www.nbcnews.com/video/senior-citizens-among-fastest-growing-community-in-online-gaming-67774021795

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Meet online gaming's fast growing community: senior citizens

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There's a surprising population growing in the online video game community - senior citizens. Elderly gamers are turning to video games for brain stimulation and social interaction.

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The game that can give you 10 extra years of life | Jane McGonigal

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The game that can give you 10 extra years of life | Jane McGonigal

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https://www.youtube.com/watch?v=lfBpsV1Hwqs

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The game that can give you 10 extra years of life | Jane McGonigal

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Exergame design for elderly users: the case study of SilverBalance

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Exergame design for elderly users: the case study of SilverBalance

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https://dl.acm.org/doi/abs/10.1145/1971630.1971650

# data[].attributes.attachment_link.authors[].name
Kathrin Maria Gerling University of Duisburg-Essen, Duisburg, Germany

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Exergame design for elderly users | Proceedings of the 7th International Conference on Advances in Computer Entertainment Technology

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Exergame design for elderly users: the case study of SilverBalance

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Senior citizen gaming: more than just buffets

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Senior citizen gaming: more than just buffets

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https://www.emerald.com/insight/content/doi/10.1108/17554210911002183/full/html

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Senior citizen gaming: more than just buffets | Emerald Insight

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Senior citizen gaming: more than just buffets - Author: Sze‐Wei Steve Wu, James Wortman

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The Profile and Motivations of Elderly Women Gamblers

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The Profile and Motivations of Elderly Women Gamblers

# data[].attributes.body
https://digitalscholarship.unlv.edu/grrj/vol5/iss1/3/

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Disciplines

Gaming and Casino Operations Management | Gaming Law

Document Type

Original Research Article

Abstract

Survey research was conducted to determine the profile and motivations of elderly women gamblers. The survey results indicate there is potential to increase revenues by appealing to this segment. Those that do visit casinos, do so primarily for the entertainment and excitement it provides. Furthermore, as a group, elderly women gamblers are disciplined and do not suffer from compulsive gambling problems.

Recommended Citation

Tarras, J., Singh, A., & Moufakkir, O. (2000). The Profile and Motivations of Elderly Women Gamblers. UNLV Gaming Research & Review Journal, 5(1). Retrieved from https://digitalscholarship.unlv.edu/grrj/vol5/iss1/3

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# data[].attributes.attachment_link.title
The Profile and Motivations of Elderly Women Gamblers

# data[].attributes.attachment_link.description
Survey research was conducted to determine the profile and motivations of elderly women gamblers. The survey results indicate there is potential to increase revenues by appealing to this segment. Those that do visit casinos, do so primarily for the entertainment and excitement it provides. Furthermo…

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Design and Evaluation of a Second Screen Communication and Gaming Platform to Foster Teleparticipation of the Socially Isolated Elderly

# data[].attributes.subject
Design and Evaluation of a Second Screen Communication and Gaming Platform to Foster Teleparticipation of the Socially Isolated Elderly

# data[].attributes.body
https://link.springer.com/chapter/10.1007/978-3-319-26345-8_1

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Abstract

Research studies show that life events such as the transition between working life and retirement, the loss of a life partner, as well as sudden changes in living arrangements potentially increase the risk of social isolation among elderly people. While ICT has had a huge impact on everyday communication and social participation, online services still remain inaccessible to the older generation mostly due to technical barriers resulting from little experience in the use of communication technology. This paper discusses the process behind designing, developing, and testing of a second screen communication and gaming platform in order to foster teleparticipation of the socially isolated elderly. The platform supports intuitive gameplay and live videoconferencing through a prototype of the turn-based card game Schnapsen, which is very popular in German-speaking countries. The technical equipment required for home installation is inexpensive, functions mainly on ICT already available in households, and is easily adaptable to future content. User tests showed that even first-time tablet users could quickly understand the playful interaction concept and soon started to engage in real-time video conversation.

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References

1. Cattan, M., White, M., Bond, J., Learmouth, A.: Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. Ageing Soc. 25(1), 41-67 (2005). Jan

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2. Nef, T., Ganea, R.L., Mri, R.M., Mosimann, U.P.: Social networking sites and older users-a systematic review. Int. Psychogeriatr. 25(7), 1041-1053 (2013)

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Acknowledgments

This contribution presented, is supported by the Benefit programme of the Austrian Research Promotion Agency under grant agreement No. 840701 ( BRELOMATE).

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St. Pölten University of Applied Sciences, Matthias-Corvinus-Strasse 15, 3100, St. Pölten, Austria

Jakob Doppler, Gernot Rottermanner, Sabine Sommer, Johannes Pflegerl & Peter Judmaier

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Correspondence to Jakob Doppler .

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Doppler, J., Rottermanner, G., Sommer, S., Pflegerl, J., Judmaier, P. (2016). Design and Evaluation of a Second Screen Communication and Gaming Platform to Foster Teleparticipation of the Socially Isolated Elderly. In: Wichert, R., Klausing, H. (eds) Ambient Assisted Living. Advanced Technologies and Societal Change. Springer, Cham. https://doi.org/10.1007/978-3-319-26345-8_1

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# data[].attributes.attachment_link.title
Design and Evaluation of a Second Screen Communication and Gaming Platform to Foster Teleparticipation of the Socially Isolated Elderly

# data[].attributes.attachment_link.description
Research studies show that life events such as the transition between working life and retirement, the loss of a life partner, as well as sudden changes in living arrangements potentially increase the risk of social isolation among elderly people. While ICT has had a...

# data[].attributes.headline
BRELOMATE - A Distributed, Multi-device Platform for Online Information, Communication and Gaming Services Among the Elderly

# data[].attributes.subject
BRELOMATE - A Distributed, Multi-device Platform for Online Information, Communication and Gaming Services Among the Elderly

# data[].attributes.body
https://link.springer.com/chapter/10.1007/978-3-319-41264-1_37

# data[].attributes.attachment_link.readable_text
Abstract

While inexpensive mobile devices and services become the primary means of online communication the elderly are prevented from participating due to technical difficulties and common barriers. Among the older users communication and entertainment are considered key aspects to alleviate loneliness. Elderly people are at high risk of facing social isolation with rising age. This article proposes a distributed, multi-device platform called BRELOMATE to promote social participation and online communication. Firstly the system architecture and a prototypical gaming service with integrated video-conferencing are presented. Secondly the user centered design process and the results of a first user study are shown.

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1. Doppler, J., Rottermanner, G., Sommer, S., Pflegerl, J., Judmaier, P.: Design and evaluation of a second screen communication and gaming platform for fostering teleparticipation of the socially isolated elderly. In: Wichert, R., Klausing, H. (eds.) Ambient Assisted Living, vol. Ambient. Springer International Publishing, Frankfurt (2016)

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2. Eiffe, F.F.: Soziale Lage lterer Menschen in sterreich. Technical report, Band 11, Bundesministerium fr Arbeit, Soziales und Konsumentenschutz, Wien (2012)

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3. Nef, T., Ganea, R.L., Mri, R.M., Mosimann, U.P.: Social networking sites and older users - a systematic review. Int. Psychoger./IPA 25(7), 1041-1053 (2013)

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Acknowledgements

The authors would like to thank all focus group participants. This work is supported under grant agreement No. 5629694 (BRELOMATE 2) from The Austrian Research Promotion Agency.

Author information

Affiliations

1. Institute for Creative Media Technologies, St. Pölten UAS, Austria

Jakob Doppler, Christian Gradl & Gernot Rottermanner

2. Ilse Arlt Institute on Social Inclusion Research, St. Pölten UAS, Austria

Sabine Sommer

Corresponding author

Correspondence to Jakob Doppler .

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© 2016 Springer International Publishing Switzerland

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Doppler, J., Sommer, S., Gradl, C., Rottermanner, G. (2016). BRELOMATE - A Distributed, Multi-device Platform for Online Information, Communication and Gaming Services Among the Elderly. In: Miesenberger, K., Bühler, C., Penaz, P. (eds) Computers Helping People with Special Needs. ICCHP 2016. Lecture Notes in Computer Science(), vol 9758. Springer, Cham. https://doi.org/10.1007/978-3-319-41264-1_37

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# data[].attributes.attachment_link.title
BRELOMATE - A Distributed, Multi-device Platform for Online Information, Communication and Gaming Services Among the Elderly

# data[].attributes.attachment_link.description
While inexpensive mobile devices and services become the primary means of online communication the elderly are prevented from participating due to technical difficulties and common barriers. Among the older users communication and entertainment are considered key aspects to alleviate loneliness. Elderly people are at high risk of facing social isolation with rising age.

# data[].attributes.headline
KINOPTIM: A Tele-rehabilitation gaming Platform for Fall Prevention in the Elderly Community

# data[].attributes.subject
KINOPTIM: A Tele-rehabilitation gaming Platform for Fall Prevention in the Elderly Community

# data[].attributes.body
http://www.scienpress.com/Upload/IJHRI/Vol%202_1_4.pdf

# data[].attributes.headline
The Robot ALIAS as a Gaming Platform for Elderly Persons

# data[].attributes.subject
The Robot ALIAS as a Gaming Platform for Elderly Persons

# data[].attributes.body
https://link.springer.com/chapter/10.1007/978-3-642-37988-8_21

# data[].attributes.attachment_link.readable_text
Abstract

Entertainment is an important aspect of social robots in an AAL context. Especially for elderly people, a robot can be the right platform for entertaining games. This paper describes the robotic platform ALIAS as a gaming platform. In the project ALIAS, a robot is equipped as a communication platform for elderly people. One aspect of the project is to provide cognitively stimulating games using a natural human-machine interface. Therefore, a computer game with multiple interaction channels is integrated on the robot ALIAS. The robot has a touchscreen with a graphical user interface where the game Tic-tac-toe can be played. Additionally, the game can also be controlled by speech commands, whereby a speech dialogue system is employed. In order to enrich the human-machine dialogue, the robot uses face detection to control its gaze behaviour and look at its conversational partner. This demonstration scenario can be seen as a first approach to evaluate a multimodal user interface using haptics and speech in conjunction with a cognitive dialogue system.

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These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Acknowledgements

This work was supported by the project AAL-2009-2-049 "Adaptable Ambient Living Assistant" (ALIAS) co-funded by the European Commission and the German Federal Ministry of Education (BMBF) in the Ambient Assisted Living (AAL) programme.

Author information

Affiliations

1. Lehrstuhl für Mensch-Maschine-Kommunikation, Technische Universität München, München, Germany

Jürgen Geiger, Thomas Leykauf, Tobias Rehrl, Frank Wallhoff & Gerhard Rigoll

2. Jade University of Applied Sciences, Oldenburg, Germany

Frank Wallhoff

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Correspondence to Jürgen Geiger .

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© 2014 Springer-Verlag Berlin Heidelberg

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Geiger, J., Leykauf, T., Rehrl, T., Wallhoff, F., Rigoll, G. (2014). The Robot ALIAS as a Gaming Platform for Elderly Persons. In: Wichert, R., Klausing, H. (eds) Ambient Assisted Living. Advanced Technologies and Societal Change. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37988-8_21

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# data[].attributes.attachment_link.title
The Robot ALIAS as a Gaming Platform for Elderly Persons

# data[].attributes.attachment_link.description
Entertainment is an important aspect of social robots in an AAL context. Especially for elderly people, a robot can be the right platform for entertaining games. This paper describes the robotic platform ALIAS as a gaming platform. In the project ALIAS, a robot is...

# data[].attributes.headline
Active Video Gaming to Improve Balance in the Elderly

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Active Video Gaming to Improve Balance in the Elderly

# data[].attributes.body
https://ebooks.iospress.nl/doi/10.3233/978-1-60750-766-6-159

# data[].attributes.attachment_link.title
IOS Press Ebooks - Active Video Gaming to Improve Balance in the Elderly

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The combination of active video gaming and exercise (exergaming) is suggested to improve elderly people's balance, thereby decreasing fall risk. Exergaming has been shown to increase motivation during exercise therapy, due to the enjoyable and challenging nature, which could support long-term adherence for exercising balance.

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Systematic review of Kinect applications in elderly care and stroke rehabilitation

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Systematic review of Kinect applications in elderly care and stroke rehabilitation

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https://jneuroengrehab.biomedcentral.com/articles/10.1186/1743-0003-11-108

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Abstract

Abstract

In this paper we present a review of the most current avenues of research into Kinect-based elderly care and stroke rehabilitation systems to provide an overview of the state of the art, limitations, and issues of concern as well as suggestions for future work in this direction. The central purpose of this review was to collect all relevant study information into one place in order to support and guide current research as well as inform researchers planning to embark on similar studies or applications. The paper is structured into three main sections, each one presenting a review of the literature for a specific topic. Elderly Care section is comprised of two subsections: Fall detection and Fall risk reduction. Stroke Rehabilitation section contains studies grouped under Evaluation of Kinect's spatial accuracy, and Kinect-based rehabilitation methods. The third section, Serious and exercise games, contains studies that are indirectly related to the first two sections and present a complete system for elderly care or stroke rehabilitation in a Kinect-based game format. Each of the three main sections conclude with a discussion of limitations of Kinect in its respective applications. The paper concludes with overall remarks regarding use of Kinect in elderly care and stroke rehabilitation applications and suggestions for future work. A concise summary with significant findings and subject demographics (when applicable) of each study included in the review is also provided in table format.

Introduction

The median age of the general population is projected to significantly rise in the upcoming years [ 1]. As the elderly population grows in age and size, an increased patient population-based stress will be placed on already overloaded clinics and hospitals. Major contributors to this increase are need of care for the elderly who are healthy to stay healthy (such as physical exercise, fall detection and fall risk reduction) and need for rehabilitation after stroke, for which age is a significant risk factor. The demand for technologically advanced methods of elderly care, which can be accessed at any time and used in a private, home-based setting while still providing rehabilitation instructions and progress tracking, is expected to expand. The Kinect is the forerunner in commercially available hardware upon which development of these methods can be built while simultaneously maintaining affordability for large-scale disbursement [ 2]. In this paper we present a review of the most current avenues of research into Kinect-based elderly care and stroke rehabilitation systems to provide an overview of the state of the art, limitations, and issues of concern as well as suggestions for future work in this direction. Figure 1 presents the structure of the manuscript, essentially, how studies included in this review are grouped together into relevance-based subsections. Elderly Care is comprised of two subsections: 1) Fall detection and 2) Fall risk reduction. Stroke Rehabilitation contains: 1) Evaluation of Kinect's Spatial Accuracy, and 2) Kinect-based Rehabilitation Methods. We have allocated a third section titled 'Serious and exercise games' for studies that are indirectly related to the first two sections and present a complete system for elderly care or stroke rehabilitation in a Kinect-based game format. A concise summary with significant findings and subject demographics (if applicable) of each study included in the review is also provided in a table format Tables 1 and 2), to facilitate readers' access to more detailed information for studies of interest. The remainder of the Introduction section provides a brief overview of each of the three main sections of the paper.

Manuscript Structure. Structure of the manuscript summarizing how studies included in this review were grouped together into relevance-based subsections. The Applications in Elderly Care section is comprised of two subsections: 1) Fall detection and 2) Fall risk reduction. The Applications in Stroke Rehabilitation section contains: 1) Evaluation of Kinect's spatial accuracy and 2) Kinect-based rehabilitation methods. We have included a third section titled 'Serious and exercise games' for studies that we believe are indirectly related to the first two sections and present a complete system for elderly care or stroke rehabilitation in a Kinect-based game format. There are many applications of the Kinect in rehabilitative and assistance-based research that, while extremely important, fall outside the scope of this systematic review.

Table 1 Overview of studies categorized under the section applications of Kinect in elderly care

Table 2 Overview of studies categorized under the section applications of Kinect in stroke rehabilitation

Users of the Kinect are able to intuitively interact with a computer through various gestures and postures. This natural method of human-computer interaction allows for the development of specialized forms of elderly care applications and medical alert support systems. These alert systems focus on reducing the probability a fall incident will occur; a leading cause of injury, emotional distress, and financial burden to the elderly [ 7- 17]. Current prototype alert support systems of fall detection and/or risk reduction show tentative promise of becoming successful tools to extend elderly independent life through accurate fall detection [ 18- 22] and automated gait assessment [ 23- 26].

Ideally, all stroke rehabilitation exercises would be performed with therapist-assisted daily practice; however, the demand this would create for therapists make it logistically impractical and quite expensive. Kinect-based stroke rehabilitation applications have the potential to reduce this impracticality through guided interactive rehabilitation and virtualized therapists. The accuracy of the Kinect for clinical use to this end is strong [ 27- 32], supporting the potential for full realization of the latter virtualization paradigm which could make pseudo-therapist assisted home-based rehabilitation a reality [ 33]. The various Kinect-based rehabilitation methods noted in this review hold great potential not only for supporting accurate completion of rehabilitation [ 34], but also possibly enhancing clinical record keeping and future medical diagnostic methods [ 35].

The Kinect also provides a platform for the development of stimulating game-based applications in both elderly care and stroke rehabilitation. Serious games offer patients rehabilitation environments which help motivate successful completion of otherwise dreary or demanding rehabilitation regimens [ 36], whereas the aim of exercise games (also termed "exergames") is to create stimulating methods of maintaining an active lifestyle tailored to the specific physiological and psychological requirements of the elderly and disabled while providing the benefits of physical exercise routines [ 37- 46].

Methods

Inclusion criteria

All peer-reviewed journal and conference proceedings articles published in English, directly (e.g., fall detection) or indirectly (e.g., gait assessment) related to elderly care and stroke rehabilitation and conducted within one of the subfields presented in the previous section, and also in Figure 1, were included in this review.

Exclusion criteria

As the volume of literature regarding the usage of the Kinect in the fields of interest was not anticipated to be extraordinarily large, but instead not yet aggregated, exclusion criteria for this review was minimal: studies which did not go through a peer-review process for publication or were published in a non-English language, were not directly or indirectly related to elderly care or stroke rehabilitation, or were out of the scope of the subfields mentioned previously, and also in Figure 1, were excluded from the review.

Information databases & search methodology

The following electronic bibliographic databases were searched: IEEE/IET Electronic Library, PubMed, ACM Digital Library, Computer Science Index, Safari Tech Books Online, and ISI Web of Science. Articles were located using the keyword kinect and derived combination sets of the following: stroke, rehabilitation, gesture, posture, clinical, geriatrics, elderly, ageing, aged, alert, fall, gait, exergame, and serious game. No date range or other limits were imposed during the search. Titles and abstracts of all articles were scanned for relevance and a complete list of possible inclusions was compiled with citation information retained in a LaTeX bibliography file. All relevant papers were then closely examined and if a tagged journal paper was deemed a more complete study of a tagged conference paper, the journal version was included and the conference version was discarded. The literature review was concluded on August 1st, 2013.

Data collection and presentation

As the topic of this review spans two overarching categories including multiple, not directly inter-related subcategories, data was collected, and is presented, on a by-topic basis through included charts and graphs as well as in-line text.

Contingency bias

Initially, we planned to assess study quality with the Downs and Black check-list [ 47]; however, based on the observation that current systems developed utilizing the Kinect are often at an immature 'proof of concept' state, this approach was deemed unfruitful. As the Kinect is a newly emerging care and rehabilitation tool, discussing the possibility of various biases within individual papers was determined to be out of the scope of this survey. To this end, all within-scope peer-reviewed studies, including unverified and/or only anecdotally supported, are included in this review.

Results

Study results during PRISMA phases. Visual representation of the article search and inclusion/exclusion process during different phases of the conducted review process.

Kinect applications in elderly care

In this section we provide a review of applications of Kinect in elderly care grouped under two categories: 1) Fall Detection and 2) Fall Risk Reduction. Technologically advanced alert support systems are a potential avenue of assistance for the independently living elderly person, and these systems could also then be leveraged to produce affordable in-home telerehabilitation methods of care [ 48]. With falls being a main cause of injury and mortality for the elderly [ 7- 17, 49] development of robust, affordable, and widely dispersible in-home fall detection and risk reduction alert systems is needed and there is significant interest in applications of Kinect to address this need. We refer the reader to Table 1 for a more detailed summary of the studies covered in this section.

Fall detection

As fall detection systems are typically employed in living environments, variables such as distance from the sensor and illumination are major challenges for current video-based strategies to overcome. Nevertheless, Zhang et al. [ 19] presented a method of fall detection that continues to perform well in the lack of normal lighting as well as when the participant was beyond the range of depth sensing of the Kinect through RGB video and image processing methodologies. The reported rate of successful fall detection utilizing this method on simulated events performed by five participants was as high as 98%. Similarly, Lee et al. [ 20] put forth an algorithm capable of monitoring in shadow filled or completely dark environments. This system used three unique features: bounding box ratios, normalized 2-D velocity variations from the centroids, and Kinect-gathered depth information in order to overcome the error introduced by shadows during moving object tracking. An overall accuracy of 97% with a minimal false positive rate of 2% was reported when applying the system to an unspecified ground-truth dataset.

Another current trend of research in RGBD camera-based fall detection support systems is the development of robust systems that can perform unthwarted by occlusion caused by static or mobile scenery. The following three methods aim to overcome this pitfall by utilizing a 3D bounding box, pre-occlusion velocity data analysis for falls which end in an occluded state, and the orientation of a participant's derived "spine" in respect to a ground plane.

First, Mastorakis and Makris's [ 21] bounding box method utilized a participant's width, height and depth instead of a more standard method of skeletization; calculations derived from a center of mass; or specific measurements of predetermined body points. This approach enabled the system to function fully, without data pertaining scene objects; however, one drawback to this system is that it does not differentiate between bounding boxes created for valid participants and those created for scene objects. If an object falls over, a false positive will occur.

The second method was developed by Rougier et al. [ 22] and utilized two forms of data: centroid height relative to floor level and the velocity of a moving body. This method allowed for fall detection through use of the former method when there are no significant occlusions, and through utilization of the latter method when the subject is fully occluded after a fall.

The third method, presented by Planinc et al. [ 18], is a fall detection system that relied on a calculation of a participant's "spine," and its orientation with respect to the ground plane. This "spine" is not directly related to the physiological spine, but instead is derived from an analysis of full-body 3D data collected with a Kinect. It can then be assumed that scenarios where this spine rapidly transforms from a state of perpendicular to the ground plane to parallel, and does not return to perpendicular within a specified amount of time, can be considered as a potential fall event.

Fall risk reduction

Creation of successful algorithms to directly analyze and predict fall potential through real-time Kinect-based systems is a tantalizing, and potentially possible, idea; however, to date, no direct fall prevention algorithms have yet been demonstrated. The existing studies along this line of research are comprised mainly of gait assessment and pre-emptive in-home fall-prevention training exercises, and while gait-based and pre-emptive exercise methods are, at best, only indirectly related to true fall prevention methodologies, they nonetheless have strong potential to contribute to the enabling of accurate fall detection and prevention in the future.

Gait assessment to reduce fall events

The studies in this section represent differing approaches in current Kinect-based automated gait assessment methodology research. Stone and Skubic [ 23, 24] conducted a comparison of the Kinect with a ground-truth Vicon system. Gabel et al. [ 25] and Parajuli et al. [ 26] each separately demonstrated that a wide range of full-body biomechanical parameters, such as core posture or angular velocities of limbs, were accurately acquirable using The Kinect. Stone and Skubic [ 23, 24] also performed a successful real-world pilot study of their automated gait analysis system in a functional assisted living facility.

Stone and Skubic [ 24] collected and compared gait related data using the Kinect, a dual web-camera system, and a ground-truth Vicon motion capture system. Not only was the Kinect reported to have sufficient accuracy for clinical gait assessment, it provided significant improvements in foreground capture and overall computational requirements when compared to the low-cost web camera system.

Gabel et al. [ 25] developed a method of full body gait analysis through the use of Kinect-based data and a multiple additive regression tree algorithm [ 51, 52]. The system monitored the time of the stride, stance, and swing phases of a gait cycle, as well as angular velocities of arm movements; however, measurements of lower limb angular velocities and core posture were also noted to be possible. Prediction of kinematic measurements using these algorithms resulted in a difference of stride measurements between the two systems of 35-71 ms and a correlation coefficient of angular velocity readings between the Kinect and a gyroscope of greater than 0.91 for both arms. Furthering these findings, Parajuli et al. [ 26] demonstrated that variables of Kinect-based posture and gait recognition can also be accurately acquired (up to 99%) through the use of the specific biomechanic and algorithmic parameters of: height/shoulder width, arms' coordinates, and c-support vector machine scaling (for an optimal hyper-plane [ 53]).

Translating Kinect-based gait assessment application from only system accuracy and biomechanic parameter readings to real-world applications, Stone and Skubic [ 23] developed a system which yielded the simultaneous creation of accurate, autonomous daily in-home gait data profiles of multiple residents of an assisted living facility. These profiles were then examined and reported as containing sufficient parameters for diagnostic use.

Limitations of Kinect-based elderly care

As the Kinect is a relatively new piece of hardware, establishing the limitations of the sensor within specific application scenarios is an ongoing process. Nevertheless, we provide a list of current limitations of Kinect that we noted based on our review of applications in elderly care systems.

1. 1.
Current Kinect-based fall risk reduction strategies are derived from gait-based, early intervention methodologies and thus are only indirectly related to true fall prevention which would require some form of feedback prior to a detected potential fall event.

2. 2.
Occlusion in fall detection algorithms, while partially accounted for through the methodologies of the various systems discussed, is still a major challenge inherent in Kinect-based fall detection systems. Current strategies focus on a subject who stands, sits, and falls in an ideal location of the Kinect's field of vision, while authentic falls in realistic home environment conditions are more varied, therefore the current results should not be taken as normative.

3. 3.
The Kinect sensor must be fixed to a specific location and has a range of capture of roughly ten meters. This limitation dictates that fall events must occur directly in front of the sensor's physical location. While it has been noted that a strategically placed array of Kinect sensors could mitigate this limitation [ 32, 54], a system utilizing this methodology has not yet been implemented and evaluated.

4. 4.
Without careful consideration of the opinions of a system's proposed user base, concerns regarding ubiquitous always-on video capture systems, such as the Kinect, may inhibit wide-scale system adoption. During the review, it was noted that research related to the reception of alert support systems is at an early phase, likely due to in-home hardware previously being cumbersome and expensive. With the Kinect having the potential to be widely disbursed in in-home setting monitoring systems, this avenue of research has become more viable and relevant [ 55- 57].

Kinect applications in stroke rehabilitation

Evaluation of Kinect's spatial accuracy

The following studies focus on evaluating the accuracy of the Kinect, and when placed under scrutiny, the Kinect has been found, in general, to carry significant potential for a cost-effective motion capture system for rehabilitation. Chang et al. [ 27] and Loconsole et al. [ 30] specifically examined accuracy of Kinect in recording upper extremity movements, whereas a whole-body postural evaluation approach was taken by Clark et al. [ 28], Fern et al. [ 31], and Obdrzálek et al. [ 29]. Furthermore, in an attempt to remove the variability introduced through human subjects during accuracy evaluations, Pedro et al. [ 32] utilized a robotic arm. As the volume of accuracy evaluation studies focusing on specific postures or scenarios is large, we refer the reader to Table 2 for more detailed reports and accounts of these individual studies. In the remainder of this section, we provide a summary of most prevalent results of Kinect accuracy evaluation studies.

Research related to the Kinect's ability to accurately capture upper extremity movements is consistently reported as sufficient for clinical use with regards to the elbow and wrist joint tracking; however, mixed results have been reported for the shoulder. Loconsole et al. [ 30] leveraged a setup containing real, rather than solely virtual, objects, and while some accuracy variation in all joint trajectories was noted depending on the object's distances on the Z axis (towards the object from the camera) and X axis (horizontal, sideways from the camera), all tests - including those for the shoulder joint trajectories - resulted in readings of within 2 cm of the correct/baseline values. This was reported as well within the limits of rehabilitation needs. Chang et al. [ 27]; however, observed acceptable wrist and elbow joint tracking, but the shoulder trajectory readings were found to be widely inconsistent. The authors attribute these inconsistencies to differing methods of motion capture and joint estimation between the ground-truth OptiTrack system and the Kinect. On the other hand, even with these inconsistencies, when participants were asked to utilize external rotation of the shoulder during game play, the system successfully identified all non-external rotation movements performed as incorrect.

In order to simplify the method of verifying the Kinect's accuracy for rehabilitation and to avoid the influence of various errors introduced by human biomechanics, Pedro et al. [ 32] utilized a 'points of interest' approach rather than a whole-body kinematic analysis. Under this methodology, the Kinect readings had good repeatability in both X and Y axes, whereas repeatability worsened as the distance to the 'point of interest' (Z axis) increased. Data gathered in this study showed that the average of the standard deviation of spatial error increased quadratically with distance; however, even with this limitation it was noted that the Kinect retained a sufficient level of accuracy at manufacturer recommended distances for use in rehabilitation applications.

In an attempt to further improve accuracy of Kinect, including lessening occlusion error or enhancing fine motor control capture, the use of the Kinect together with various inertial sensors has sparked interest. Hussain et al. [ 63] made use of Kinect-monitored manipulation of specially designed intelligent objects (i.e a can, a jar, and a key-like object embedded with inertial sensors) for fine motor control diagnostics of the hand and wrist. This allows for a virtual environment to monitor the location and kinematics of both the user and the objects manipulated by the user. A variety of hand-held objects very similar if not identical to those prototyped by Hussain et al. are utilized in current, widely used stroke impairment classification tests [ 64]. Data fusion systems of this type have the potential to enable low-cost home-based stroke impairment quantification tests for both gross and fine motor skills.

As noted by Obdrzálek et al. [ 29], the Kinect does not perform well at skeletizing positions under significant participant occlusion, or non-participant object interference. When compensation for this deficiency is required for more specific applications, skeletization based on a fusion of Kinect-gathered and worn inertial sensor data show promise for accurate data collection. Bo et al. [ 65] used inertial motion sensing units composed of 2-axis gyrometers, 3-axis accelerometers, and the Kinect (using Primesensor NITE Middleware) to support accurate Kinect-based data capture with significant occlusion-based error reduction. This error reduction was accomplished by utilizing Kinect readings, when available, as a method of inertial sensor calibration, and inertial sensor estimations when Kinect readings are unavailable due to occlusion.

Kinect-based rehabilitation methods

The ultimate goals of validating Kinect's accuracy for rehabilitation are diagnostics (quantifying motor function improvement level of patients) and development of home-based rehabilitation protocols. In this section, we provide a summary of studies that focused on Kinect's applications to pursue these goals, and their results on provisionary physical and mental benefits.

Virtual reality-based rehabilitation offers a a highly interactive system with many documented benefits specifically to stroke patients [ 66], and a large variety of Kinect-based approaches of stroke rehabilitation have recently come to the forefront. From Da Gama et al. [ 67] Pastor et al. [ 68], and Yeh et al.'s [ 69] virtual exercise guide and game-based rehabilitation systems, to Shiratuddin et al.'s [ 70] interactive visuotactile 3D virtual environment, and Frisoli et al.'s [ 71] multi-modal architecture for brain-controlled interface-driven robotic upper limb exoskeleton, there is a broad range of potential Kinect-based applications.

Hints of various multidisciplinary directions Kinect-based research is expanding toward can be seen in the more intricate applications of the Kinect presented by Frisoli et al. [ 71] and Shiratuddin et al. [ 70]. Frisoli et al. proposed a Kinect-based, multi-modal architecture for a brain-controlled interface-driven robotic upper limb exoskeleton with a goal of providing active assistance during reaching tasks for stroke rehabilitation. At the level of action planning, the patient's intention to move towards an object is acquired through a Kinect-based vision system that identifies and tracks physical objects, and an eye-tracking system. At the level of action, brain activity is analyzed during motor imagery and controls the exoskeleton accordingly. Experimental results demonstrated that operating the exoskeleton movement through brain-computer interaction was successful with a classification error rate of 89.4 ± 5.0%. Shiratuddin et al. also proposed a unique framework which utilizes non-contact natural user interfaces, such as the Kinect, in an interactive visuotactile 3D virtual environment rehabilitation system.

These initial benefits, system ideas, and hints toward future research demonstrate a strong potential for fruitful Kinect development, as well as enhancing previously developed widely used out-patient rehabilitation services [ 72]. These initial studies, by and large, present positive results; however, the potential impact Kinect-based rehabilitation may have on future paradigms is only currently emerging and it is difficult to predict how widespread such systems will become. Their use depends largely on their success in practical implementation, validation of benefits and acceptance by users.

Limitations of Kinect-based stroke rehabilitation

The current stage of Kinect-based rehabilitation literature is lacking in reported functional and validation data because a majority of systems are only at a proof of concept stage. The following over-arching limitations have been derived from the current state of the literature:

1. 1.
While initial Kinect-based comparisons with research grade motion capture systems demonstrated highly correlated trends and reasonable accuracy, a majority of evaluation studies focused only on sets of gross movements that are advantageous for Kinect. Evaluation of more realistic and/or specific diagnostic movement sets are still needed.

2. 2.
The Kinect is unable to accurately assess internal joint rotations of the shoulder and instead utilizes a much less clinically viable single-point estimation. Use of the Kinect for specific shoulder-based functionality requirements have yet to be shown to be clinically viable.

3. 3.
Rehabilitation goals which include fine motor skills can not be captured by the Kinect alone; however initial studies suggest fusion systems of Kinect and inertial sensors can be a feasible alternative.

4. 4.
Kinect systems are usually not suitable for severely disabled patients, as gross movements that remain extremely small in their entirety are difficult for the Kinect to accurately capture.

Serious and exercise games

Historically, virtual reality rehabilitation has always been a promising field with an infeasibly high price tag for mass implementation [ 73]. Tanaka et al. [ 2] note that recent research, focused on hardware and software, has lead to Sony's Eyetoy, Microsoft's Kinect, and Nintendo's Wii becoming the top three market contenders as tools for low-cost virtual reality rehabilitation platforms. This initial comparison study concluded that the Kinect is the forerunner of these top three tools, citing three main reasons: 1) the Kinect provides the most natural form of human-computer interaction; 2) the Kinect is the most feasible technology for a widely dispersed system of elderly exergaming as it utilizes vision-based data capture and requires no extraneous hardware, and 3) the freedom of controller-free data acquisition and ease of developer access to the Kinect platform required for the development of novel and high quality rehabilitation systems and exergames.

The benefits of focused physical tasks and exercise to stroke victims and the elderly have a rich and well documented history [ 37- 46]. Growing out of this solid foundation, Kinect-based gaming has notable potential to create a low-cost and enjoyable exercise setting while simultaneously gathering quantitative data related to rehabilitation progress, general caloric expenditure, and aerobic activity [ 74, 75]. Current Kinect-based gaming research consists of exergames and serious games. Exergames (a term for exercise games) aim to combine natural human movements and the entertainment of video games to promote elderly exercise and enable built-in unobtrusive diagnostics, whereas serious games intend to simultaneously rehabilitate motor-impaired users while evaluating patient progress and monitoring for potential patient injury. In this section, we provide a review of studies and their results involving use of Kinect in serious and exercise game applications. Again, we refer the reader to Tables 1 and 2 for more comprehensive summaries of articles focusing on this topic.

Design considerations

In their comparison of elderly preferences between button-based, mixed button/gesture-based, and gesture-based controllers for game play, Pham et al. [ 79] observed that Kinect-based controller-free design carries the benefit of being the preferred choice of the elderly. Three main findings were reported: 1) older participants preferred less or no physical controlling devices (42% prefered gesture-only, 25% preferred mixed, 8% preferred button-only, and 25% had no preference); 2) the requirement of larger physical movement of the Kinect did not stop it from being the most attractive system, and 3) older adults perceived the need to develop their knowledge and skill further for complete use of the Kinect.

Arntzen et al. [ 80] examined the physical and cognitive requirements of game design targeted for elderly players based off of interviews and a literature review. The resulting design considerations for controller-free game development were compiled to define seven categories: 1) visual; 2) hearing; 3) motion; 4) technological; 5) acceptance; 6) enjoyment, and 7) emotional response. Furthermore, they suggested an iterative approach to game development, in which a preliminary assessment should be done with patients using traditional games, and results of the assessment should inform refinement and definition of requirements. Once a game prototype is developed, another assessment should be conducted on the usability of the system by those with age related cognitive and/or physical disabilities. Gerling et al. [ 81] also proposed an iterative method of game development and noted that while age-related visual, hearing, and motion impairments can be accounted for during design, it is advisable to conduct multiple stages of user-feedback driven design prototypes in order to accommodate more specific impairments as well as to ensure user approval in the cognitive categories of technological acceptance, enjoyment, and emotional response.

McNiell et al. [ 82] offered suggestions for future rehabilitation game development based on previous work and a literature survey. They highlighted that the response to failure and poor performance, in any game, is integral to its use by a player base, and hence should be taken as an important consideration. They suggested that including appropriate positive and encouraging feedback mechanisms are necessary tools to overcome the discouragement that system unfamiliarity and poor motor skills will inevitably cause during use of a serious or exercise game.

Jiang et al. [ 83] suggested a number of heuristics for selecting Kinect-based gesture patterns specific to patients with upper extremity impairments. The guidelines for appropriate gesture selection were derived using a human-based approach which constructs the gesture lexicon based on studying how potential users interact with each other rather than what would be easy for the system to recognize. These guidlines included the following: (1) Select gestures that do not strain the muscles; (2) Select gestures that do not require much outward elbow joint extension; (3) Select gestures that do not require much outward shoulder joint extension; (4) Select gestures that avoid outer positions; (5) Select dynamic gestures instead of static gestures; (6) Select vertical plane gestures where hands' extension should be avoided; (7) Relaxed neutral position is in the middle between outer positions, and (8) Select gestures that do not require wrist joint extension caused by hand rotation.

Exercise games

The Kinect is not unique in its ability to provide vision-based data capture capable of supporting gaming paradigms; however, current research grade multiple camera motion capture systems are typically expensive, difficult to set up, and require a knowledgeable operator. The Kinect does not suffer from these challenges, and with its low-cost, leading the emergence of natural gaming paradigms and development of targeted exercise games (the term "exergames" is also commonly used) in a variety of areas.

Gerling et al. [ 85] conducted two studies to examine the use of Kinect as a human-computer interface for older adults. In the first study, an evaluation of elderly participants' performance using a set of gestures developed with the aid of a physical therapist was performed. Based on the resulting limitations observed in movement patterns, an exergame was designed targeting institutionalized elderly participants. The second study then investigated how participants responded to the derived game-based gestures, and concluded that Kinect-based gaming has a positive effect on users emotional well being. Sun et al. [ 86] developed a Kinect-based exergame which allowed players to participate in interactive balance exercises with visual feedback, and explored how Kinect-based balance training exercises influence the balance control ability and the tolerable intensity level of a player. The game would move various body-outline shapes toward the player's avatar, and the player would then have to imitate the body-outline shape in order to pass through it without touching the outline. As differing player experience evaluation methods resulted in different findings, it was concluded that care must be taken while deciding on which evaluation methods are to be employed within game design. Chiang et al. [ 87] examined the health benefits of somatosensory video games specifically related to reaction time and hand-eye coordination on institutionalized older adults confined to wheelchairs. "Follow the Arrow", "Matchmaker", and "Mouse Mayhem" -three previously developed games- were modified for the Kinect and then utilized to gather participant related data. A significant decrease in the mean and standard deviation times from start to target were noted in the experimental group (which received Kinect-based training) while the control group lacked any observable improvement. Chen et al. [ 88] presented a study which attempted to quantify the health benefits of Kinect-based somatosensory video games to older adults with disabilities. Various physical benefits were noted throughout the study; however, mental benefits, in general, showed no significant differences between experimental and control groups.

Each of these systems concluded with overall positive results and demonstrated that Kinect-based gaming can significantly improve quality of life using a variety of measures, such as participant's emotional state [ 85], physical function, level of body pain [ 88], visual performance skills, reaction time, and hand-eye coordination [ 87]. A caveat to these positive results can be seen in that evaluation methods based specifically on player experience can result in notably different outcomes. Thus exergames for training purposes strongly building on player experience as a metric should be designed with care [ 86]. Also, to understand the efficacy of somatosensory video game intervention, more rigorous examination needs to be conducted in order to strengthen these initial results.

Serious games

The physical changes that accompany ageing affect a wide range of functions, including sensory-perceptual processes, motor abilities, response speed and cognitive processes [ 89]. Research on the efficacy of serious games to retain and rehabilitate optimal abilities have been limited mainly to qualitative studies with small sample sizes and focusing on a variety of controllers and inertial sensor systems [ 33]. This limitation can also be seen in the literature for current Kinect-based serious games, as the majority of studies have not yet moved beyond initial game design and development.

For many stroke patients, balance and weight shift management constitute a risk of secondary injury [ 90]. Lange et al. [ 91] prototyped a serious game based on their Flexible Action and Articulated Skeleton Toolkit (FAAST) which enabled a Kinect-based system to run Jewel Mine; a balance rehabilitation game which encourages the user to reach outside of their base of support. Based on discussion and technical support from Lange et al., Huang et al. [ 92] proposed a smart glove extension to their system for concurrent hand and upper limb rehabilitation by requiring a player to actually grasp the virtual gems and place them into a receptacle instead of just hitting them. Also utilizing the fusion of a Kinect sensor and a haptic glove, Sadihov et al. [ 93] developed three minigame applications to offer a variety of game play, motor requirement, and difficulty options: 1) a table wiping game; 2) a meteor deflection game, and 3) a rope pulling game. This methodology of developing multiple minigames for maximum variety of play and motor tasks was also employed by Borghese et al. [ 34] in the development of Animal Feeder, which offered training for dual task management, and of Fruit Catcher, a game which required reaching and weight shift techniques to be employed without movement of the feet. Borghese et al.'s system also carries the potential to utilize Kinect-obtained information about a patient to both fine tune rehabilitation game parameters and to assess patients' improvement.

Throughout all of these developed systems, one thread of consistency is the positive reception by players and initial rehabilitation results. The overall view in the literature related to serious games is positive; however, the level of current confidence is almost unanimously recognized as tentative and needing further study.

Limitations of current Kinect-based serious and exercise games

The limitations specific to Kinect-based serious and exercise gaming applications, considering the requirement of clinical data capture for specific limb movements; specific player-base-desired design considerations; varying levels of limb impairment, and previously defined serious and exergame-based requirements, can be summarized as the following:

1. 1.
Any games designed specifically for diagnostic usage are limited to non-occluding movements. This implies that standard stroke impairment level tests requiring extensive occluding movement sets may be untenable for a Kinect-based system to capture.

2. 2.
Diagnostic potential for extremities is limited to gross movements, as fine movements of the hand and foot are currently outside the Kinect's capture sensitivity.

3. 3.
Games targeted at rehabilitation may be prone to "cheating" (e.g. excessive, unnatural and counter-productive trunk-based compensation).

4. 4.
Appropriate response to failure and poor performance, if not accounted for during game design, can inherently limit positive outcomes due to demotivation/discouragement resulting in less frequent/consistent use of the system.

5. 5.
The current benefits of Kinect-based gaming have only tentatively been studied with mainly short term and small sample sized studies. Data to date should be seen as initial results, and not normative.

Discussion

As Kinect-based elderly care and stroke rehabilitation research is in its infancy, a majority of the data acquired is qualitative with a focus on self-report and personal opinion. Compounded with this observation is the fact that the data is derived only from small groups of participants, it is anything but normative and should be viewed as tentative initial results. Filling the deficiencies of quantitative and large population based research thus remains a potentially fruitful and necessary avenue of future work. The current applications of Kinect in elderly care seem to be at a more mature state than those of stroke rehabilitation; however, even with the current deficiency, we believe that the Kinect carries the potential to become a future cornerstone of widely dispersed care and rehabilitation systems.

With regards to fall detection and fall risk reduction applications, each of the current technologies of panic buttons, audio sensors, body-fixed systems, 2D and 3D video capture systems comes with inherent physical and financial limitations. While the Kinect does not render any of these technologies obsolete, and comes with its own limitations, its unique aspects may enhance current systems, or potentially be the foundation for newly developed functionalities.

1. 1.
The autonomous nature of the Kinect allows for fall detection without requiring a user to physically trigger a panic button system, or the wearing of cumbersome physical devices, which can often be forgotten.

2. 2.
The Kinect comes with built in directional sound capture capabilities, possibly enabling it to be used as, or in unison with, current audio sensor-based systems. This is a functionality of the Kinect not yet studied.

3. 3.
The added third dimension depth field measurement offered by the Kinect requires less overhead than current methodologies, and enables the development of more accurate methods of fall-related image processing to be developed.

4. 4.
The low-cost, marker-less, and widely dispersible nature of an already commercially available gaming system immediately enables the current clinical virtual reality-based rehabilitation methodologies to be rapidly relocated to individual home settings.

While questions such as participants with what level of impairment most strongly benefit from using the Kinect, how to build an ideal exercise routine for preventative or rehabilitation needs, which is the most performant fall detection algorithm, or how to most efficiently leverage all the various capabilities of the Kinect are still unanswered, the overarching conclusions of this review point toward the Kinect as a promising technology for a wide range of elderly care and stroke rehabilitation applications and need for studies involving larger participant pools to establish reliability and validity.

Remarks and suggestions for future work

We have compiled the following list based on our review of the current state of Kinect-related elderly care and stroke rehabilitation literature. It contains our remarks as well as suggestions for relevant future research.

1. 1.
A majority of applications in elderly care and stroke rehabilitation require a robust and easily manipulated user interface which at present cannot be readily found in current commercial systems. When developing exercise games, serious games, and applications of Kinect-based rehabilitation, it is vitally important to remember that repurposing a technology initially intended for a younger and healthier audience requires careful adherence to new design strategies focused on both the physiological and psychological requirements of aging and injured users. Therefore we suggest that multidisciplinary research teams involving engineers as well as clinicians, human factors experts and cognitive psychologists would be best positioned to tackle the challenges that such game development efforts would entail.

2. 2.
A critical validation step for Kinect-based applications to both fields is a focused experimental evaluation of the accuracy and latency of the motion capture data obtained from Kinect in comparison with a research grade motion capture device and statistical evaluation of this data for specific diagnostic potential. The effects of distance from the Kinect sensor on gathered data is another important consideration. In order to verify that the Kinect has the potential to make therapy financially accessible and medically beneficial to a large population of elderly and stroke patients, more targeted studies involving relevant rehabilitation and preventative exercise movements, are needed.

3. 3.
Kinect applications may have the potential to simultaneously achieve care or stroke related goals while capturing real-time, clinically viable data for injury risk evaluation. The real-time data gathering aspect of the Kinect has yet to be satisfactorily examined as a majority of documented work focuses solely only providing assistance or motivation to the user while ignoring this important potential function.

4. 4.
As alert systems potentially gather data in an always-on fashion even what might normally be considered mundane activities can then turn into potential privacy infringements. Because of this potential problem, the reception and concerns of the elderly related to always-on systems require a thorough and careful examination.

5. 5.
Game content specifically designed for aging and/or injured users must simultaneously allow for high standards of captivating game play and long-term enjoyment potential while maintaining seamless methodologies of adaptation and monitoring of players needs, which are critical characteristics of a successful low-cost home-based rehabilitation paradigm.

6. 6.
Generic game play may be unsuitable for many patients with secondary disabilities not solely defined by motor function. Strategic adaptation schemas for game play are necessary traits as complex demands for speech, memory, or cognition patterns significantly reduces the potential for games with large and diverse player bases.

7. 7.
The stimulating aspect of exergames and serious games, while being beneficial in patient motivation, should be closely monitored as to provide an exercise or rehabilitation environment that discourages overexertion injuries in both individual movements and length of play.

8. 8.
Assumptions of rehabilitation success should not be based on in-game score improvement as arbitrary scores do not necessarily correlate with actual functional improvement, and evaluation methods based specifically on player experience can result in notably different outcomes, therefore using player experiences or in-game scores as metrics should be avoided.

Conclusions

In this paper, various applications of the Kinect in the fields of elderly care and stroke rehabilitation have been examined. We have classified these applications into the groups of (1) Fall Detection, (2) Fall Risk Reduction, (3) Evaluation of Kinect's Spatial Accuracy, (4) Kinect-based Rehabilitation Methods, and (5) Serious and Exercise Games - serious games for stroke rehabilitation and exercise games for the elderly. While only in its initial stages of development, the Kinect already shows notable potential in making therapy and alert systems financially accessible and medically beneficial to a large population of elderly and stroke patients; however, some significant technological limitations still present are: a fixed location sensor with a range of capture of only roughly ten meters; a difficulty in fine movement capture; shoulder joint biomechanical accuracy, and fall risk reduction methodologies that only utilize indirect, gait-based pre-emptive training. The directions for future work are vast and have promise to enhance elderly care; stroke patient motivation to accurately complete rehabilitation exercises; rehabilitation record keeping, and future medical diagnostic and rehabilitation methods. Based on our review of the literature, we have reported a summary of critical issues and suggestions for future work in this domain.

Authors' information

OC received his B.S. and M.S. degrees in Mechanical Engineering in 2004 and 2006 respectively, from Istanbul Technical University, Turkey. He completed his Ph.D. in Mechanical Engineering in 2011 at Rice University and was a Research Assistant at the Mechatronics and Haptic Interfaces (MAHI) Lab from 2006 to 2011. He was an Assistant Professor at San Francisco State University from 2011 to 2013. He is currently an Assistant Professor at Colorado School of Mines and Director of the Biomechatronics Research Laboratory. He was a recipient of the best paper award at the IEEE World Haptics Conference in 2011. His research interests include robotic rehabilitation, biomechatronics, robotics, haptics, human sensorimotor control system, motor adaptation and learning.

DW received his B.A. in Music from the University of Georgia in 2009 and his M.S. in Computer Science from San Francisco State University in 2013. Between 2012-2013, he was a Research Assistant in the School of Engineering's Biomechatronics Research Laboratory. His research interests include computer vision, human-computer interaction, biomechatronics, robotic rehabilitation, and kinematic modeling.

Abbreviations

CVA:

Cerebrovascular accident

RGBD:

Red-green-blue-depth

FAAST:

Flexible action and articulated skeleton toolkit.

References

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Acknowledgements

This work was supported in part by a Center for Computing for Life Sciences (CCLS) research grant at San Francisco State University. The authors would like to thank the anonymous reviewers for their constructive and insightful comments and suggestions.

Author information

Affiliations

1. Department of Computer Science, San Francisco State University, San Francisco, 94132, USA

David Webster

2. Department of Mechanical Engineering, Colorado School of Mines, Golden, 80401, USA

Ozkan Celik

Corresponding author

Correspondence to Ozkan Celik.

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Competing interests

No financial or non-financial competing interest exists for either of this paper's authors.

Authors' contributions

OC conceived the review paper idea. Both DW and OC participated in designing and structuring the literature search and resulting review paper structure. DW conducted the literature search, as well as the drafting of the manuscript. OC guided the literature search and drafting of the manuscript. Both authors read and approved the final manuscript prior to submission.

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Webster, D., Celik, O. Systematic review of Kinect applications in elderly care and stroke rehabilitation. J NeuroEngineering Rehabil 11, 108 (2014). https://doi.org/10.1186/1743-0003-11-108
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Keywords

Elderly Care

Game Development

Inertial Sensor

Stroke Rehabilitation

Motion Capture System

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Systematic review of Kinect applications in elderly care and stroke rehabilitation - Journal of NeuroEngineering and Rehabilitation

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Abstract In this paper we present a review of the most current avenues of research into Kinect-based elderly care and stroke rehabilitation systems to provide an overview of the state of the art, limitations, and issues of concern as well as suggestions for future work in this direction.

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Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review

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Virtual Reality Rehabilitation and Exergames—Physical and Psychological Impact on Fall Prevention among the Elderly—A Literature Review

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Faculty of Health Sciences, Jagiellonian University Medical College, 33-332 Krakow, Poland

Department of Rehabilitation, Lesser Poland Orthopedic and Rehabilitation Hospital, 30-224 Krakow, Poland

Author to whom correspondence should be addressed.

Academic Editors: Youngho Lee and Elena Amaricai

Received: 24 March 2021 / Revised: 15 April 2021 / Accepted: 27 April 2021 / Published: 30 April 2021

The present review is aimed at the effectiveness of virtual reality (VR) and exergames in the prevention of falls among the elderly. Falls become a significant problem in the aging population and lead to psychological, social, and physical impairment. Prevention of falls is crucial to the well-being of the elderly population and is one of the challenges of contemporary rehabilitation. Recently, in view of the threat of the SARS-CoV-2 pandemic, contactless methods of rehabilitation, including telerehabilitation, appear as valuable rehabilitation tools. This review is based on the PRISMA guidelines and was carried out in five databases: PubMed, Medline, Web of Science, Scopus, and PEDro. Twenty-one randomized controlled trials, focused on the application of VR and exergames in the prevention of falls, were included. This review suggests that VR training in rehabilitation appears to be a promising complement to traditional techniques of physiotherapy to improve specific physical outcomes. VR and exergames could be considered as a complement of standard physiotherapy and its possible continuation at home for elderly. However, further high-quality studies, with carefully designed protocols and proper blinding, are needed. View Full-Text

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Piech, J.; Czernicki, K. Virtual Reality Rehabilitation and Exergames-Physical and Psychological Impact on Fall Prevention among the Elderly-A Literature Review. Appl. Sci. 2021, 11, 4098. https://doi.org/10.3390/app11094098

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Piech J, Czernicki K. Virtual Reality Rehabilitation and Exergames-Physical and Psychological Impact on Fall Prevention among the Elderly-A Literature Review. Applied Sciences. 2021; 11(9):4098. https://doi.org/10.3390/app11094098

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Piech, Joanna, and Krzysztof Czernicki. 2021. "Virtual Reality Rehabilitation and Exergames-Physical and Psychological Impact on Fall Prevention among the Elderly-A Literature Review" Applied Sciences 11, no. 9: 4098. https://doi.org/10.3390/app11094098

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# data[].attributes.attachment_link.title
Virtual Reality Rehabilitation and Exergames-Physical and Psychological Impact on Fall Prevention among the Elderly-A Literature Review

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The present review is aimed at the effectiveness of virtual reality (VR) and exergames in the prevention of falls among the elderly. Falls become a significant problem in the aging population and lead to psychological, social, and physical impairment. Prevention of falls is crucial to the well-being of the elderly population and is one of the challenges of contemporary rehabilitation.

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An Analysis of Elderly Gamers' Trip Characteristics and Gambling Behavior: Comparing the Elderly with Their Younger Counterparts

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An Analysis of Elderly Gamers' Trip Characteristics and Gambling Behavior: Comparing the Elderly with Their Younger Counterparts

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https://digitalscholarship.unlv.edu/grrj/vol10/iss2/5/

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Keywords

Elderly; age groups; casino gaming; market segmentation.

Disciplines

Gaming and Casino Operations Management | Gaming Law

Document Type

Original Research Article

Abstract

The purpose of this study was to examine trip characteristics and gambling behavior of the elderly and compare them with those of other age groups. Visitors to two large Midwestern commercial land-based casinos completed a follow-up telephone survey. Of the 32 represented variables, II indicated a significant difference between age groups: Elderly gamblers were the least likely to engage in other recreational activities besides gambling. They were the least likely to obtain information about the casino and the least likely to use the Internet for this information. They preferred to visit casinos on weekdays, and indicated an interest in buying weekday package trips that include stops at several casinos. With regards to overall trip spending and gambling behavior, there is no statistical significance indicating that the elderly behave any different from their younger counterparts.

Recommended Citation

Moufakkir, O. (2006). An Analysis of Elderly Gamers' Trip Characteristics and Gambling Behavior: Comparing the Elderly with Their Younger Counterparts. UNLV Gaming Research & Review Journal, 10(2). Retrieved from https://digitalscholarship.unlv.edu/grrj/vol10/iss2/5

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elderly; age groups; casino gaming; market segmentation.

# data[].attributes.attachment_link.title
An Analysis of Elderly Gamers' Trip Characteristics and Gambling Behavior: Comparing the Elderly with Their Younger Counterparts

# data[].attributes.attachment_link.description
The purpose of this study was to examine trip characteristics and gambling behavior of the elderly and compare them with those of other age groups. Visitors to two large Midwestern commercial land-based casinos completed a follow-up telephone survey.

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Determinants of Gambling Disorders in Elderly People—A Systematic Review

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Determinants of Gambling Disorders in Elderly People—A Systematic Review

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https://www.frontiersin.org/articles/10.3389/fpsyt.2019.00837/full

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EA 7479 SPURBO, Department of Addiction Disorders, Université de Bretagne Occidentale, Brest, France

Addictive Disorders Unit, University Hospital of Nantes, Nantes, France

EA 4275, Faculté de Médecine de Nantes, Nantes, France

EA 7479, Department of Family Practice, Université de Bretagne Occidentale, Brest, France

ERCR SPURBO, Department of Family Practice, Université de Bretagne Occidentale, Brest, France

Background: Despite the growth in the number of studies on gambling disorders (GDs) and the potentially severe harm it may cause, problem gambling in older adults is rarely apparent in literature. Driven by the need to overcome this limitation, a broad systematic review is essential to cover the studies that have already assessed the determinants of GD in the elderly.

Objectives: The aim of this systematic review is to understand the determinants related to GDs in elderly people.

Methods: A total of 51 studies met the inclusion criteria, and data were synthesized.

Results: Three major types of determinants were identified in this review: individual, socio-financial and environmental.

Conclusions: This review explored the determinants influencing GDs in older people. The findings are relevant to academics, policymakers, patients, and practitioners interested in the identification and prevention of GD in older people.

Introduction

Rationale

Gambling is a popular activity among older people and this is cross-cultural ( 1). Gambling participation is increasing significantly among the elderly and it is becoming a particularly widespread and regular recreational behavior among this population ( 2). In the United States, the participation rate in gambling among older people, over the preceding year, increased from 23% to 50%, between 1975 and 1998 ( 3, 4). Older adults generally possess positive attitudes towards gambling activities ( 5). Gambling is considered a harmless form of entertainment, whereas it was considered a vice in the first part of the 20th century ( 6). The rates for older adults' participation in gambling, in the preceding year, ranged from 26.6% to 85.6% ( 7- 10). The prevalence of problem gambling among older people ranges from 0.3% to 10.4% in studies of those over 55 years of age ( 3). Among those over 60 years of age, Subramaniam et al. found a life-long prevalence of problem gambling of between 0.01% and 10.6% in a systematic review ( 1).

In literature, a great deal of research has focused on a younger age group and on the " classic " problem gambler, especially the middle-aged man ( 2, 11). A broad range of risk factors for GD in young adults has been documented, including sociodemographic characteristics (male gender, younger age, low socioeconomic status) ( 12, 13), gambling habits (early exposure, availability) ( 14) or individual vulnerabilities such as negative life events, personal psychiatric/addictive comorbidity ( 15), or familial history of GD or substance use disorders ( 16, 17). More specifically, many studies on GD in adults investigated cognitive distortions which are related to an inability to control or to stop gambling ( 18, 19). Craving is an urge to participate in gambling and decreased cognitive control was identified in GD which correlated in fMRI with impaired activity in the prefrontal cortex ( 20). Reward system dysfunction was also identified in adults with GD, compared with a control group, with striatal presynaptic dysfunction ( 21). This point is interesting in that Dreher at al. directly demonstrated a tight coupling of midbrain dopamine synthesis and reward-related prefrontal cortex activity; they provided direct evidence for an alteration of this regulatory relationship in healthy older humans ( 22).

Vulnerable populations, such as elderly people, remain rare subjects in literature. However, regular gambling habits may cause potentially very serious harm: financial, social, familial, and other problems, even suicide ( 11, 23). Previous reviews on gambling disorders (GDs) have not focused exclusively on older people, and most of the studies had been conducted in North America: United States or Canada. Very few had been conducted in Europe.

Focusing on GDs in older adults is important, especially in order to characterise GD specificities in older adults. Several authors agree that the associated harm within this age group requires special attention ( 1).

Objective

In summary, this systematic review aims to provide a broad, cross-cultural picture of the determinants of GDs in older adults. Accordingly, we reviewed both qualitative and quantitative studies that included older patients with GD.

Methods and Materials

Protocol, Registration, and Eligibility Criteria

The current systematic review focuses on elderly individuals with GDs and is based on qualitative and quantitative studies that describe clinical particularities. The PRISMA statement for reporting systematic reviews was adopted. The protocol had not previously been registered for this review. Inclusion criteria were coded by both authors reaching an agreement regarding the coding process and were: (a) including clinical samples of GD in those aged 65+; (b) containing quantitative and/or qualitative data; (c) being published in a peer-reviewed journal; (d) being available as a full text in one of the following languages (spoken languages of the authors): English or French.

Information Sources and Search Strategy

Existing papers were identified by searching the academic databases PubMed and PsycINFO, from March to May 2018, published from January 1990 to February 2018. Both authors drew up a list of agreed English keywords for the systematic search: Gambling (MeSH term) OR "Gambling disorder" OR "problem gambling" OR "Pathological gambling" AND "Aged (MeSH term)" OR Aged 80+ (MeSH term) "elders" OR "older adults" in the title, abstract or keywords. Inclusion and exclusion criteria are presented in Table 1.

Table 1 Inclusion and exclusion criteria.

Study Selection and Data Collection Process

At the first stage, 867 articles were identified with the key words Gambling (MeSH term) OR "Gambling disorder" OR "problem gambling" OR "Pathological gambling" AND "Aged (MeSH term)" OR Aged 80+ (MeSH term) "elders" OR "older adults". At the second stage, duplicated papers were excluded. The selection of papers for the systematic review was based on the inclusion and exclusion criteria previously described. Following the search strategy presented in the flow diagram in Figure 1, the inspection of article titles and abstracts concluded with the inclusion of a total of 51 papers. We included studies or literature reviews in the English or French languages, which concerned older people (over 50 years of age) specifically, in clinical settings, and those which concerned gamblers (with or without problems). We excluded neurocognitive studies and experimental studies. (See inclusion and exclusion criteria- Table 2). We excluded studies on the general population, even when such studies included older people up to 85 years of age. Older gamblers represented a small part of these populations and so no specific analysis was carried out on these subgroups in general population studies.

Figure 1 Prisma diagram.

Table 2 Article synthesis.

Data Extraction and Quality Assessment

Considering the exploratory nature of this systematic review, and in order to have a broad understanding of GD in the elderly, the studies were not filtered according to their quality and both qualitative and quantitative studies were taken into consideration. Given the high levels of heterogeneity of the data across studies, as regards research methods, data were synthesized qualitatively through a summary table and a narrative synthesis using these categories: (1) the individual determinants; (2) the structural determinants; (3) the environmental determinants.

Results

Study Selection and Characteristics

In this review, the first group of 867 papers was identified by searching for the keyword in the scientific database. As described in the flow diagram ( Figure 1), 670 papers were excluded because they were replicated records or because the topic was not GD in elderly people. One hundred thirty-eight were assessed for eligibility, 87 full texts were excluded because they did not describe clinically elderly persons with GD. A total of 51 studies met the inclusion criteria. The publication dates ranged from 1990 to 2018 and contained clinical samples of elderly persons with GD. Selected articles are listed in Table 2.

Risk of Bias Within Studies

Selection Bias

The definition of older adults significantly differed in literature: 12 articles specified those over 50 or 55 years of age ( 3, 9, 10, 24- 32); 16 articles, those over 60 years of age ( 1, 2, 5, 33- 45); 16 articles, those over 65 years of age ( 32, 46- 60), and 7 over 70 years of age ( 8). Methodologically, these differences in age criteria bring difficulties in comparing and analyzing data from the literature.

Evaluation Bias

Gambling becomes a problem when gambling behavior becomes persistent, recurrent, and leads to clinically significant difficulties ( 61). The diagnostic criteria for pathological gambling are constructed and validated for the middle-aged adult in employment. Several criteria lose their specificity in ageing subjects: loss of social activities, damage to career, and harm to those close to them, are far less relevant to retired people who are alone or isolated for reasons other than those related to gambling behavior ( 62).

Cultural Bias

A large majority were conducted in North America (USA or Canada), Australia, or Singapore but only a few articles concerned Europe (six articles).

Synthesis of the Results

Articles are presented in Table 2. 3 Themes were mainly identified ( Figure 2)

Figure 2 Themes identified the review.

This review focuses on: ( 1) individual determinants, ( 2) structural determinants, ( 3) environmental determinants of GD in the elderly.

Individual Determinants

Gender influences gambling habits. Women over the age of 60 have a risk of problem gambling that is equivalent to, or even higher than, that of men in the same age group ( 20). The prevalence of at-risk or problem gamblers (between 1 and 4 in the criteria for pathological gambling) is high among women over 65 years of age ( 20).

Age at gambling initiation is a risk factor for more frequent and more severe gambling behavior, as well as for pathological gambling in later life ( 3, 21). However, where a more advanced age is concerned, most studies found that the prevalence of problem gambling declined with age beyond 60. Ladd et al. conducted a study among gamblers over 65 years of age and found problem gamblers were significantly younger than non-problem gamblers ( 22).

Comorbidities

In elderly subjects with gambling problems, more significant medical or psychosocial comorbidities are reported than in non-gamblers or non-problem gamblers ( 1). These connections are multifactorial. Gambling is a sedentary activity, which can lead to medical problems ( 23) or, conversely, it can attract people who already have difficulty moving around for medical reasons. People with alcohol use disorder or tobacco use disorder, whose general health is impaired, may seek relaxation or excitement from readily available gambling opportunities ( 1). Moreover, the practice of gambling is in itself a stress factor. Several studies have shown neurophysiological changes (hyper-reactivity of the autonomous system in response to gambling-related stimuli) and neurochemical changes (elevated levels of cortisol, norepinephrine, and dopamine during casino gambling sessions). These changes may increase the risk of chronic pathologies ( 51).

Older adults with a life-long history of problem gambling had experienced significantly more medical problems in the previous year ( 1). Problem gambling is associated with chronic medical illness ( 24). Pietrzak et al. showed that, among medical morbidities in older adults with PG, angina and arthritis were overrepresented ( 25) and both reduce the physical abilities of older adults. Problem gambler status is significantly associated with a lower quality of life, in medical, social, and emotional terms, compared with social gamblers or non-gamblers. They have a more negative perception of their general and psychological state and a more pessimistic view of their future state of health ( 26, 27). Desai et al. ( 32) showed, in data from the NESARC (National Epidemiologic Survey on Alcohol and Related Conditions), that subjects over 65 years of age, with a history of problem gambling during the year, had significantly more alcohol use disorders and were more frequently tobacco dependent ( 24). Life-long problem gambling was associated with substance use disorders (alcohol, illicit substances), but also with psychiatric disorders: mood disorders (depression, dysthymia, mania, hypomania) and anxiety disorders or avoidant personality disorder ( 25, 28). In older adults, cognitive impairment may also reduce the ability to decide to stop gambling ( 29), especially in cognitive impairment which involves the frontal cortex (as in frontotemporal lobar degeneration).

Specific attention should be paid to the complex and varied relationship between gambling and Parkinson's disease (PD) and dopaminergic medication ( 30). Impulse control disorders (ICDs), such as compulsive gambling, and also buying, sexual, and eating behaviors, are a serious, recognized complication in PD which occurs in up to 20% of PD patients over the course of their illness and especially in those with the highest risk profile ( 31).

Social and Financial Determinants

Several studies identify socio-professional, financial, and educational status as risk factors for problem gambling ( 1, 23). This connection is not found in all studies ( 22) but it should be taken into account, particularly with regard to the elderly. Older people are especially vulnerable to gambling related problems due to loss experienced in their personal life: loss of role, loneliness, social isolation, and a lower or fixed income. The change in professional status with retirement can have a direct influence on a gambler's behavior. A decline in income in retirement can be a factor which precipitates the passage from social gambling behavior to problem gambling. Gamblers may wish to make up for a loss of income through winnings from gambling by increasing their participation ( 26, 37). The money-making motivation, combined with the search for excitement, have been identified as predictors of risk and problem gambling among slot-machine gamblers over the age of 60 ( 38). In addition, the failure to adjust their betting in proportion to their lower income in retirement may also lead to difficulties.

Determinants Correlated to Gambling

Cognitive Distortions

Cognitive distortions, found in younger adults ( 63), have also been identified in older adults. In a multi-ethnic Asian sample of gamblers, Subramaniam et al. identified the following themes in the perception of gambling: skill, near miss, concept of luck, superstitious beliefs, entrapment, gambler's fallacy, chasing wins, chasing losses, and the belief that wins exceeded losses. These gambling-related cognitions played a role in the maintenance and escalation of gambling ( 39).

The type and structural characteristics of gambling may enhance cognitive distortions. Lottery video terminals and slot machines have used a computer and virtual reels to determine the odds. Since the end of the eighties, a clustering technique has been used to create a high number of near misses ( 64). What the gamblers see on the machine does not correspond to reality and it induces a misperception of the probability of winning; gamblers take the near miss as an indication of their improving skills which leads to gambling behavior being sustained ( 65).

It could be interesting to analyse older problem gamblers' cognition to identify strategic prevention targets. A reduction in gambling cognitive distortions was identified as being one of the best predictors of recovery ( 66).

Motives for Gambling

Eighty percent of older gamblers are looking for entertainment and enjoyment ( 5, 67). Thirty-eight percent say they gamble to distract themselves from everyday problems, and combat boredom but also loneliness ( 32, 34, 58). Studies in North America show that older people frequently visit gambling locations (casinos) to make social connections ( 2). Living alone and/or being separated, divorced or socially isolated are factors associated with problem gambling ( 1).

Access to stimulating activities for leisure and pleasure are likely to be reduced with age and some people may not be able to participate in activities they had previously enjoyed ( 1, 54). One hypothesis is that gambling fills a void in the lives of older people and may be a form of substitute for social support ( 33).

The fight against negative emotional states ( 68), linked to loss or grief, is one of the factors motivating gambling activity ( 3, 67). However, gambling is not always a problem: improving cognitive skills is one of the motives for gambling. A general population study has even shown that people who had gambled during the past year had better subjective health than those who had not gambled ( 69).

Type of Gambling

Casino trips are the first outside activity offered to institutionalized elderly people ( 67). Over 65s account for 39%-45% of all casino users. In terms of casino use, the prevalence of pathological gambling ranges from 6.7% (never) to 19.1% (at least once a month) in a study conducted among non-institutionalized elderly subjects ( 33).

The use of gambling varies among older subjects according to the characteristics of the type of gambling practiced. The perception of harm associated with gambling products is high in the general population; casino and EGMs are identified as very, or extremely, harmful by the general population. According to TSE et al. in 2013, problem gamblers over the age of 55 tend to play continuous or limitless games such as slot machines, online games or even scratch games, while those without a gambling problem tend to play discontinuous, inexpensive and time-limited games such as lotteries. However, there are few studies so far on the structural characteristics or the different types of games (pure chance games or those involving skill) which are popular with the elderly ( 3).

The Availability of Gambling Opportunities

One of the factors highlighted by this increase in gambling behavior is the expansion of the legal gambling market, especially with developments in Internet gambling. The global gambling market was estimated to be worth 430 billion US dollars in 2012 (Global Gambling and Gaming Consultants). Several studies have highlighted the links between the availability and proximity of gambling opportunities and excessive gambling practices ( 8, 70). A study on socio-cultural factors among gamblers over 60 years of age showed that, in problem gambling populations in need of care, the age at initiation and the desire to gamble were much higher in the United States than in Brazil ( 53). One of the authors' hypotheses is that the availability of gambling, as a result of each state's legislation, is much more significant in the USA than in Brazil. The legislative framework for gambling can thus have a direct impact on gambling practices ( 53), especially among vulnerable people.

Gambling is part of a growing industry driven by powerful multi-national corporations. There is an intensification in marketing strategies which target older people ( 26). Older adults are an especially desirable demographic for the gambling industry because they fill the floors during off-peak hours. Casinos aggressively direct marketing towards them, offering discounts on meals, free drinks, and guarantees to win and, sometimes, medication discount coupons. Some gambling locations also offer transportation for people coming to the casino ( 71). A recent study showed that, among older adults, using bus tours to access gambling venues was associated with an increased risk of problem gambling ( 28, 60).

Loyalty strategies are being implemented by many casinos in France which offer a "VIP" upgrade to gamblers. The gambling opportunities offered at casinos are described as the ideal solution for the "needs of seniors", and several countries are trying to raise awareness of this intrusive marketing campaign which targets vulnerable, elderly people ( 67, 72).

The targeted gamblers most susceptible to these offers (bus tours) tend to be retired women, over 75 years of age ( 28, 60). Older women seem to be more vulnerable to gambling marketing strategy and, more particularly, to electronic games machines ( 73). Specific gambling characteristics in older adults are synthetised in Table 3.

Table 3 Specificities of gambling characteristics in older adults.

Discussion

In a large majority of studies, gambling in older people is compared with gambling in a younger population in employment. Through the analysis of the selected articles, clear gambling specificities in older adults were identified: first, individual specificities; second, social and financial specificities; and third, those correlated with gambling.

Individual determinants, concerning gender and age and morbidities could make it possible for caregivers for the elderly to identify GD in this population and offer guidance. Chronic medical illness, ( 32, 43), substance use disorders, but also mood disorders, anxiety disorders or avoidant personality disorder ( 43, 55), cognitive impairment ( 49) or PD ( 49) are risk factors for GDs ( 74). Social and financial determinants are also specific keys to GDs in older adults. Retirement is a moment when some are at risk, particularly at risk of failure to adjust their betting in proportion to their lower income ( 26, 45). Disordered gambling may increase financial problems, including credit card and other debts ( 75). A reduced ability to deal with the damage caused by their gambling is one particular specificity in older adults. Lack of resources to cover the damaging level of gambling expenditure appears to be specific to older adults. They have less time and fewer financial resources to recover from social, financial and, particularly, the medical and psychiatric consequences resulting from disordered gambling. Therefore, the identification of GDs is not initially concerned with medical care and so other types of action could be required to help gamblers to control or to stop their habit. Family support, for example, is very important: a recent study showed that, among older gamblers, family support was essential in helping to implement control strategies for responsible gambling ( 40). To help identify GD in vulnerable older people, Kerber et al. proposed the acronym "CASINO" to help everyone to remember the impact and factors linked to disordered gambling in older adults: Chronic health problems, Affective disorders, Serious risk of suicide, Incarceration, NO money, credit card debts, and financial problems ( 57). This acronym includes individual and social determinants.

One main point of this review is that it underlines the influence of determinants correlated with gambling. Gambling type, as well as gambling-targeted offers and availability, reinforce gambling motivation and cognitive distortions in older people. An editorial in the journal, Nature, underlined recently that gambling in vulnerable populations is a public health concern. They asked: how can research help the unfortunate minority who cross to gambling's dark side? They also drew attention to the lack of scientific studies on the subject and to the lack of debate about society taking control of an industry which profits from compulsive gambling much more than from occasional gambling ( 76). In 2009, Moodie and Hastings pointed out that public health authorities could learn a great deal from tobacco control, in terms of how to respond to gambling ( 77). Caregivers and public health authorities should be aware of specific points concerning gambling practices in older adults. Gambling can be extremely attractive and easily available to the elderly. All gambling marketing variables are adapted to fit older people's needs and vulnerabilities and to increase gambling activity.

Casinos and other gambling locations know how to meet the specific needs of older people. Isolation and boredom are risk factors for GD in older adults. Public authorities and institutions taking care of older people should consider that to delegate the provision of social activities for older people to gambling locations, as defined in literature, may not be an ideal solution and may not demonstrate a responsible or fair attitude towards older people. Social or leisure activities could be developed which are suited to older adults and which would help to limit casino attendance and reduce harm. Gambling locations direct extensively aggressive marketing towards older people.

The extent to which these assisted living facilities should encourage older adults to gamble increasingly and whether they should be liable for increasing the financial risks of the residents are matters to be addressed. The risk is especially important if one fails to identify gambling problems in older adults.

Limitations

Due to the lack, in current literature, of specific analysis on elderly gamblers, literature review, case reports, qualitative, and quantitative studies were included in this systematic review. It induces a high level of heterogeneity of data.

Results of this review are limited by three bias, which limits comparison of data. We identified selection bias in selected studies and cultural bias, as a majority of studies concern North America. An evaluation bias was also identified, it concerned the definition of problem gambling or GD in older people, which differed in articles. It raised problems in comparing and analyzing the existing data.

Implications and Conclusion

A wide variety of treatment options is available for gamblers who seek help and treatment: phone lines (psychiatric emergencies or gambling helpline), associations (e.g., Gamblers Anonymous), outpatient treatment (private therapists, community mental health centers or addictive disorders centers) but also general practitioners and, sometimes, in-patient addiction recovery centers. Very few older people with a GD will seek access to specific treatment programs. Therefore, to reduce harm, especially financial, social, and psychological harm, family and social services have a principal role to play and a protective legislative measure could be discussed. However, policies concerning gambling control are still insufficient for helping vulnerable gamblers to reduce their gambling activities.

According to literature, it seems that older adults are gambling more and more and that the proportion of pathological gamblers is increasing in this age group. The findings of this current review support the need to consider the determinants of gambling in this group. Pathological gambling among older adults is associated with medical, psychiatric, and social comorbidities. The types of motivation for gambling in older adults involve the search for entertainment and the fight against boredom and loneliness. It has the potential to cause extreme harm because of a lack of resources to recover from the negative consequences of gambling. Many studies underline vulnerabilities, especially those linked to the environment and to gambling. Public health authorities and societies should take these findings into account. Gambling policies should help vulnerable gamblers to better control the habit and to reduce harm caused by gambling. There is a need to question the responsibility of public health authorities, as well as the lack of legislation and social measures to control gambling marketing strategies and gambling availability targeting vulnerable people. As with other addictions, responsible governments need to balance tax revenue against a duty of care towards vulnerable members of society ( 78)

Author Contributions

MGL, JC, and MGB carried out the systematic search of bibliographic databases, and reviewed all the articles. MGL, JC, and MGB wrote the article. SL and JR reviewed and revised the article.

Conflict of Interest

MGB and JC declare that the University Hospital of Nantes has received funding from the gambling industry (FDJ and PMU) in the form of a sponsorship that supports the gambling section of the BALANCED Unit (the Reference Center for Excessive Gambling). We guarantee that this review is scientifically independent of the gambling industry operators. There were no constraints on publishing.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Abbreviations

GD, Gambling disorder.

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Determinants of Gambling Disorders in Elderly People-A Systematic Review

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Background: Despite the growth in the number of studies on gambling disorders (GDs) and the potentially severe harm it may cause, problem gambling in older adults is rarely apparent in literature.

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16x9 | The Betting Years: Are casinos exploiting seniors?

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Gambling Participation and Problems among Older Adults:

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Senior gambling in Hong Kong: through the lenses of Chinese senior gamblers – an exploratory study

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Validity and Reliability of Wii Fit Balance Board for the Assessment of Balance of Healthy Young Adults and the Elderly

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https://www.jstage.jst.go.jp/article/jpts/25/10/25_jpts-2013-171/_pdf/-char/ja

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Clinical Use of Nintendo Wii™ Bowling Simulation to Decrease Fall Risk in an Elderly Resident of a Nursing Home

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Clinical Use of Nintendo Wii™ Bowling Simulation to Decrease Fall Risk in an Elderly Resident of a Nursing Home

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https://journals.lww.com/jgpt/Fulltext/2009/32040/Clinical_Use_of_Nintendo_Wii_TM__Bowling.6.aspx?casa_token=hrd6djQuFTQAAAAA:4tmX4LC6lFxrGtpJ4-No7YD69mfO0RNHyFvGv6uMCSKxKeTeA6yWkD6p1A30vrqiUuMaI3QGOoikvS9fGIdQ3Q

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Clinical Use of Nintendo Wii™ Bowling Simulation to... : Journal of Geriatric Physical Therapy

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ls which are the leading cause of injury deaths, as well as the most common cause of nonfatal injuries for older adults in the United States. This case report examines the effect of a novel interactive video game intervention to address balance dysfunction in an elderly resident of a nursing home wh…

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Use of the Wii Fit system for the treatment of balance problems in the elderly: A feasibility study

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Use of the Wii Fit system for the treatment of balance problems in the elderly: A feasibility study

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hhttps://www.academia.edu/77750155/Use_of_the_Wii_Fit_system_for_the_treatment_of_balance_problems_in_the_elderly_A_feasibility_study

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https://www.researchgate.net/profile/Myriam-Lewkowicz/publication/237503651_Enhancing_Interaction_Spaces_by_Social_Media_for_the_Elderly_A_Workshop_Report/links/0c960527ce93ccc799000000/Enhancing-Interaction-Spaces-by-Social-Media-for-the-Elderly-A-Workshop-Report.pdf#page=50

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Physical action gaming and fun as a tool within elderly care - Game over or play it again and again...

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Physical action gaming and fun as a tool within elderly care - Game over or play it again and again...

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https://www.diva-portal.org/smash/get/diva2:479247/FULLTEXT01.pdf

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When Gaming is not Suitable for Everyone: Playtesting Wii Games with Frail Elderly

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When Gaming is not Suitable for Everyone: Playtesting Wii Games with Frail Elderly

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https://d1wqtxts1xzle7.cloudfront.net/6449626/1-with-cover-page-v2.pdf?Expires=1651455400&Signature=a1L8g8Z96PJ7J4TpfHcrlajY2Szcez7jdEj2WU2yvO5kptW2~N0FoWXObCdLASehh--ExXAGfD4mqRYl9M4113aZsVPQ0QoGpXv~2YhpFnuplhA1QUI7lGKDl9OSY2EG0x8xuH1qTXdHySMSm20FPp5JSBUiwLt5R6cUCLgGM5R~gi8WpmKJu8VhWS3L5bNEZqcFHWsSaoqBBDGNSVjO~Eyvdys0G~fUj~pUZMXuh0BBj3UWbglQq2ouz4vg5zD19~kFqQCuurBXJDpBRX8HIjhJSz3VZW4a~1WrK-9Tm7sphToEwEltQZ3r8cpnvDp1uCr2Lp7FrwT2gP0UNSW~3g__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA

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

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

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ORIGINAL ARTICLE

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

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

Antonio Ascolese ¹, Jin Kiat ¹ Imaginary srl, Milan, Italy
² O'Joy Care Services, Singapore
², Lucia Pannese ¹, Luca Morganti ¹

Date of Web Publication

3-Mar-2017

Correspondence Address:
Antonio Ascolese
c/o Imaginary srl, Piazza Caiazzo, 3, 20124, Milan
Italy

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/digm.digm_43_16

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

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.

Platform

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.

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.

Questionnaires

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".

Participants

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].

Procedure

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.

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".

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.

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.

[Figure 1], [Figure 2]

[Table 1]

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Gamifying elderly care: Feasibility of a digital gaming solution for active aging Ascolese A, Kiat J, Pannese L, Morganti L - Digit Med

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ORIGINAL ARTICLE Year : 2016 | Volume : 2 | Issue : 4 | Page : 157-162 Gamifying elderly care: Feasibility of a digital gaming solution for active aging Antonio Ascolese 1, Jin Kiat 1 Imaginary srl, Milan, Italy 2 O'Joy Care Services, Singapore 2, Lucia Pannese 1, Luca Morganti