GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 1, Number 6, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2012.0046

Review

Health Benefits of Digital Videogames for Older Adults: A Systematic Review of the Literature Amanda K. Hall, MHSE, MS,1 Enmanuel Chavarria, MS,1 Vasana Maneeratana, PhD,2 Beth H. Chaney, PhD, MCHES,1 and Jay M. Bernhardt, PhD, MPH1

Abstract

Objective: This article is a systematic review conducted of the research literature on digital videogames played by older adults and health outcomes associated with game play. Findings from each study meeting the inclusion criteria were analyzed and summarized into emergent themes to determine the impact of digital games in promoting healthy behaviors among older adults. Materials and Methods: A systematic review of the research literature was conducted through multiple academic databases for works, published between the years 2000 and 2011, looking at digital videogame interventions with adults 65 years of age and older. Multiple combinations of search terms and Boolean operators relevant to digital videogames and older adults were queried. A criteria matrix was created to code and evaluate studies. Results: Thirteen studies met specific criteria for inclusion and were analyzed in the final review. Significant mental, physical, and social health factors, type of digital game platform, study design, and measurements are among emergent themes summarized from the reviewed research literature. Significant mental health outcomes of digital game interventions were found in the majority of the reviewed studies, followed by physical and lastly social health outcomes in older adults. Conclusions: A majority of the studies revealed significant positive effects on health outcomes associated with digital videogame play among older adults. With current advancements in technology, including advanced motion sensing, digital game platforms have significant potential for positive health impact among older populations. More robust and rigorous research designs are needed to increase validity and reliability of results and establish stronger causal relationships on the health benefits of digital videogame play for older adults.

Introduction

L

ife expectancy in the United States has increased substantially in the 21st century, owing, in part, to the advancements in medical sciences and technology.1 As a result, older individuals represent the fastest growing segment of the U.S. population.2 Currently, Americans 65 years of age and older account for 13 percent of the U.S. population.3,4 This trend is expected to continue and reach 20 percent by the year 2030.3,4 Additionally, adults 65 years of age and above are at an increased risk of developing more than one chronic disease, and this risk increases with age.4,5 Of this group, nearly 84 percent live with one or more chronic disease(s).4 Moreover, chronic diseases tend to affect their health-related quality of life (HRQOL) factors more deeply than other population segments.4 HRQOL includes the quality of physical, mental,

and social attributes of a person’s life.6–8 A person’s HRQOL can be jeopardized by illness, resulting in decreased HRQOL.6–8 Therefore, activities and interventions that promote healthy behaviors are imperative for fostering healthy aging, preventing chronic disease, and improving HRQOL. In recent years, the digital videogame industry has expanded and integrated itself into the health market with games such as Nintendo ‘‘Wii Fit’’ (Nintendo of America, Redmond, WA), the ‘‘Dancetown’’ Fitness System (Dancetown, Pittsburgh, PA), and other games to engage players (aka ‘‘gamers’’) in health-promoting activities.9 Consequently, interactive games (i.e., exergames) and health-based games have emerged to utilize gaming as a strategy to change health behavior.10 According to the Pew Internet & American Life Project, 23 percent of adults 65 years of age and older actively play

1 Center for Digital Health and Wellness, Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, Gainesville, Florida. 2 Center for Applied NanoBioscience and Medicine, College of Medicine, Basic Medical Sciences, University of Arizona, Phoenix, Arizona.

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DIGITAL VIDEOGAMES AND HEALTH OF OLDER ADULTS digital videogames, and this rate is increasing.11,12 Moreover, older adults play digital videogames more often than any other segment of the population.11 Additionally, a recent study conducted and funded by The LEAGE (LEArning Games for Older Europeans) project found that older adults, across three European countries, enjoyed the challenge and social interaction components of digital videogames, which met their demands for fun leisure activities.13 Therefore, because of the increased availability of interactive digital videogames on the market and the percentage of adults engaging in game play, researchers have begun to examine the health benefits of using digital videogames.14 A 2008 literature review by Baranowski et al.15 on digital games and health behavior change reported positive health gains through game play. Game design features, such as health-related dialogue, knowledge gains, and goal-oriented tasks, resulted in health behavior changes.15 Other studies have found diverse health behavior outcomes of digital game play that increased physical activity among various population studies.16,17 A large number of these studies and reviews primarily focused on health outcomes of digital game interventions among younger populations, but little is still known about similar outcomes among populations 65 years of age and older. Therefore, given the aging of the U.S. population, the prevalence of chronic diseases among older adults, the large number of health-based digital videogames available to consumers, and the increasing percentage of older adult gamers, there is a need for a critical examination into the current state of research on HRQOL benefits (i.e., mental, physical, and social health benefits) of digital videogame play among adults 65 years of age and older. This systematic review of the peer-reviewed literature (1) reports on interventions using digital videogames to promote healthy behaviors among adults 65 years of age and older and (2) analyzes health outcomes related to mental, physical, and/or social attributes associated with digital videogame play among adults 65 years of age and older.

403 used in favor of more specific terms (i.e., health terms) to ensure studies were properly assessed based on inclusion or exclusion criteria. Every article compiled through this primary exploration and monitor procedure (n = 194) was included for further investigation. One hundred sixty-four articles were excluded after the screen of titles and abstracts. This initial large number of exclusions was due to the broad search terms used. Additionally, many of these 194 articles and studies were not interventions but reports, commentaries, or studies involving clinical procedures and findings. Further exclusion included the removal of studies that did not include both male and female participants in their intervention and those that did not solely use digital videogame play in their intervention. The latter relates to the rationale that generalizability of the studies’ results can be hindered in not having equal distribution of gender or in results being attributed to intervention methods other than digital videogame play. After these initial exclusions, 30 studies underwent a full text assessment. From these 30 studies, 17 were excluded for a variety of reasons, including failing to explicitly measure and report participants’ health outcomes (n = 7),18–24 participants’ mean age was less than 65 years (n = 7),25–31 case studies, acting as opinion or editorial pieces (n = 2),32,33 or serving only as secondary sources of information, where full results were not reported within the scope of

Materials and Methods Search procedures The literature surveyed were peered-reviewed, English language publications and included subjects related to evaluating health outcomes associated with digital videogame play exclusively among an older adult population. The scope of the review included studies with male and female participants with a mean age of 65 years and older, participating in digital videogame play in all locales, and studies that measured mental, physical, or social benefits of digital videogame play. Literature databases included PubMed, CINAHL, PsycINFO, Ageline (EBSCOhost web), SPORTDiscus, and Web of Science. Only articles published from 2000 to current day were included. The literature search was performed in the winter of 2011. Key terms used in an array of arrangements with Boolean operators to conduct searches were ‘‘digital games,’’ ‘‘video games,’’ ‘‘digital video games,’’ ‘‘computer games,’’ ‘‘virtual games,’’ ‘‘older adults,’’ ‘‘gerontology,’’ and ‘‘aged.’’ MeSH terms were used in PubMed. The thesaurus available in CINAHL, PsycINFO, and Ageline SPORTDiscus was used to ensure that relevant key words were properly searched in each database. Initially, broad search terms were

FIG. 1.

Literature review flow diagram.

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HALL ET AL.

the study (n = 1).34 After accounting for conditions outlined by the above exclusion criteria, 17 studies were not summarized for this review. The final 13 journal articles were research studies assessing health outcomes of digital videogame play on adults 65 years of age and older. These 13 studies were fully analyzed, and the gathered data were organized. Emergent themes were recognized and summarized, and a matrix is described under the data extraction section. Figure 1 delineates the systematic review process of the research literature process. Data extraction Using the methodology described by Garrard,35 a matrix was constructed using data extracted and compiled from the selected 13 studies. Each study in the final selected sample of 13 was coded on several categories. Additionally, two researchers independently coded each study to test for interrater agreement. Table 1 describes the categories chosen for coding and analysis, along with reasons. Results After the systematic inclusion process described in Figure 1 was implemented, in total, 13 studies met all inclusion and exclusion criteria. Table 2 includes the findings of the systematic review of the research literature. Although the search parameters included years 2000 through 2011, all of the selected studies fitting the inclusion and exclusion criteria were published between the years 2008 and 2011.

Summary of findings on significant key health outcomes Significant key health outcomes of digital videogame interventions reviewed varied considerably. The majority of studies addressed multiple health domains. Measures of studies with reported significant P values at the Pp0.05 level were recorded. Significant mental health positive outcomes (e.g., working memory, depression) were concluded in 10 of the 13 reviewed studies. Significant physical health positive outcomes (e.g., balance, mobility) were measured in six of the 13 studies. Significant social health positive outcomes (e.g., social interaction, social support) were noted in two of the 13 studies. Taken together, statistically significant positive health outcomes were found on multiple measures of physical, mental, and/or social variables. When compared with baseline, significant mental health positive outcomes, such as cognitive improvement, were reported in multiple digital videogame interventions, which used measures such as working memory, focused attention, fluid intelligence, scales for dementia, scales for depression, information processing, enjoyment of physical exercise, and balance confidence to assess cognitive improvement. The most frequently reported significant health outcome among digital game interventions for older adults were mental health outcome factors. Table 2 describes all mental health outcome findings. Physical health outcome measures were the second most common factors reported by researchers in the reviewed studies. The review of the research literature found that

Table 1. Matrix Category and Reason for Selection Category Author(s), title, journal Year of study Theoretical foundations Purpose of study Measures of study Study design Setting of study (context) Content (physical, mental, social) Description of sample  Sample size  Mean age (SD)  Gender (%) Game information  Game title  Purpose of game  Tailored (yes/no)  Platform  Duration of play Significant key health outcomes (physical, mental, social) Duration of intervention (weeks) Frequency

Reason for selection To search for any recurring authors or journals in which the type of research is found To search for particular years in which the type of research initiated or was popular To look for any particular theories used by the majority of researchers in the topic To determine what purposes guide most researchers’ experiments To determine what measures do most researchers utilize in conducting their study on the topic. To determine whether a particular type of study design was used most by researchers To determine if a particular setting was most used by researchers Used as a reference to determine whether particular studies found significant results on the content reported To assess the characteristics of participants and total number of participants used most by researchers to evaluate study designs and findings, 65q of Medicare eligibility

To evaluate the types of games and platforms used across studies to determine if certain games were more effective than others in linking game play to health outcome measures

To examine and compare statistically significant findings on instruments and assessments used To assess the length of interventions with study findings To assess the dose of interventions with study findings

SD, standard deviation; 65q, adults aged 65 years of age or older.

DIGITAL VIDEOGAMES AND HEALTH OF OLDER ADULTS several studies reported significant improvements on balance, physical mobility, strength, and pain. Most studies assessing physical health outcomes used the Nintendo Wii console, which can incorporate the Wii Balance Board to assess balance. Table 2 describes all physical health outcome findings. The review of the selected research literature found that few studies (two out of 13) measured social health outcomes. Both studies reported significant increased social interaction of digital videogame play assessed with measures such as perceived feelings of social participation and social support. Social health outcomes were measured less frequently than mental and physical health outcomes. Table 2 describes all significant social health outcomes. In summary, nearly all studies found statistically significant positive health outcomes, in their respective hypothesized directions, affirming change in at least one significant key health outcome. The exception was Bainbridge et al.,36 who hypothesized significant physical and mental health outcomes associated with digital videogames; however, the particular study found no statistically significant key health outcomes. Bainbridge et al.36 surmised that their lack of finding statistically significant results was due to a small sample size (n = 6), the limited capacity of the Wii system to store participant information, and the absence of a control group in the study design. Although a few of the participants did reduce their fall risk as measured by the Berg Balance Scale, overall statistical findings did not reach statistical significance.36 It is notable that Bainbridge et al.,36 Yamaguchi et al.,37 and Bell et al.38 used total or group sample sizes of less than 10 participants to run the data analyses and evaluate findings. The validity of findings using sample sizes of less than 10 subjects is not considered statistically relevant, and future replications of these study designs with increased sample sizes can adequately verify findings. Summary of findings on study features The review of the selected research literature found that study designs varied widely among the 13 selected digital videogame interventions. The majority of studies used a pretest and post-test design, and two were pilot studies.39,40 Furthermore, only one study reviewed conducted a randomized control trial.41 A theoretical foundation for the reviewed interventions was only found in one study.41 The settings for the studies were fairly similar with a few exceptions. The most common research setting was a facility specializing in elderly care; however, each study had a slight variation in the term used to describe its facility depending on the type of services provided to the residents. The three exceptions were a laboratory, a college sports center, and a hospital outpatient center. Although the studies included participants of both genders, a highly disproportionate number of females participated in all of the reviewed studies. The number of participants in each study ranged between six participants to 121 participants, and the mean number of participants was 32.31 (standard deviation [SD] = 28.67). The mean age of participants across the studies in the selected research literature was 75.38 (SD = 6.84) years. Duration of interventions ranged between 1 to 12 weeks, with a mean of 7.13 weeks (SD = 3.30).

405 The frequency of the interventions ranged between one time per week to seven times per week, with a mean of 2.56 (SD = 1.57). Duration of game play interventions ranged from 20 to 90 minutes, with a mean of 38.50 (SD = 20.55) minutes of play across all studies in the selected research literature. Three of the reviewed studies did not specify the number of minutes of game play of their intervention. Table 2 describes the study features associated with the selected research literature. Summary of findings on digital videogames and platforms The review of the selected research literature found that game titles used by studies widely varied, yet the Nintendo Wii was the most commonly used console as well as computers. Most games used in the reviewed literature were related to scoring due to elicited physical movement or scoring based on completing cognitive tasks such as problem solving through memory usage. The review of the selected research literature found only one study that incorporated a game that was specifically designed for an older audience, ‘‘Dancetown,’’ which promotes physical activity.42 One exception was the Nintendo DS handheld console used to test mental health effects in patients.43 One study used a unique threedimensional virtual reality platform called Phantom Omni, which was designed for use in stroke rehabilitation.44 Besides the latter study, the majority of studies did not incorporate participant-tailored games and instead incorporated games designed for a general audience. Discussion The aging of the U.S. population and the prevalence of chronic health conditions both spur a market built on finding innovative solutions, such as digital health initiatives to counteract rising healthcare costs and deficiencies.4,45 Digital health projects include the refinement and creation of interactive digital videogame platforms for promoting healthy activities and ultimately increasing HRQOL. The latter contributes to the need and opportunity to assess and review the current state of studies of health outcomes of digital videogame play by older adults. From 2008 to the present, researchers have just begun to empirically question the health benefits that digital games can present to an aging population. Because studies varied in purposes, measures, and instruments used to assess health outcome measures, future researchers should seek to use consistent measures to assess physical, mental, and social attributes of game play in older adults to facilitate better cross-study effect comparisons. Digital and virtual games are successfully being used for rehabilitation therapies. For example, Broeren et al.44 reported that healthcare providers are using virtual reality technology to create simulated environments in controlled settings to treat stroke patients. These environments simulate real life tasks and provide feedback, which helps stroke patients regain upper arm extremity functionality.29 Additionally, digital games are being studied as effective ways to improve physical strength in patients with issues such as balance weakness or upper extremity dysfunction.9,46 However, only one of the reviewed studies looked at videogames

Table 2. Gaming for Health in Older Adults Literature Review Matrix

Reference

Year Theoretical of study foundations

Broeren et al.44

2008 Not stated

Basak et al.55

2008 Not stated

Rosenberg et al.39

2010 Not stated

Studenski et al.42

2010 Not stated

Brem et al.43

2010 Not stated

Hsu et al.46 2011 Not stated

Peretz et al.56

2011 Not stated

Torres57

2011 Not stated

Bell et al.38

2011 Not stated

Williams et al.40

2011 Not stated

Bainbridge et al.36

2011 Not stated

Yamaguchi 2011 Not stated et al.37

Szturm et al.41

Purpose of study

Measures of study

Study design

VR system used to assess and promote performance in persons affected by stroke Assess executive control processes of older adults

Perception of VR, manual ability (BBT and ABILHAND), executive function and attention (TMT-B), kinematics (UE test) Cognitive ability, executive control, and visuospatial skills

Assess feasibility, acceptability, and shortterm efficacy and safety of exergames (combined game play with exercise) Assess efficacy of adapted interactive dance videogame

Mood (QIDS), health-related QoL Pilot, follow-up study (MOS, SF-36), cognitive functioning (RBANS), adherence (personal logs). Vital signs (pulse, BP, BMI), physical function (performance test), self-reported QoL

Assess cognitive performance due to videogames

Central information processing (Kurtest fur Allgemeine Intelligenz), health-related QoL (12-item short form health survey), mental stability (Neuroticism-ExtroversionOpenness-Five Factor Inventory) Assess effects of adding Physical performance (Nursing simulate game play to Home Physical Performance Test), standard exercise physical activity enjoyment regimen for residents of (PACES), pain intensity and pain long-term care facility bothersomeness (NRS), AROM, and perceived change (GPRC) Assess whether Cognitive ability (measured by Ncognitive training can CPC) and Nexade result in cognitive gains for older adults Assess effects of Cognitive ability, cognitive videogames on the portion of ADAS; self-concept, elderly pertaining to ICAC; QoL, WHOQOL cognitive ability, selfconcept, and QoL

2011 Biofeedback Assess feasibility and training benefits of physical therapy via interactive videogame paradigm

Balance, balance confidence, and limits of stability were assessed via Berg Balance Scale, Activitiesspecific Balance Confidence Scale, MDRT and COP excursion measurements. General cognitive function measured using (HDS-R); visuospatial and constructive function measured using Kohs block-design tests; behavioral changes measured using MOSES Berg Balance Scale, Timed ‘‘Up & Go’’ Test, Activities-specific Balance Confidence Scale, Clinical Test of Sensory Interaction and Balance, all used to assess reactive balance controls and environmental interaction

Content (physical, mental, social)

Description of sample

Sample size

Mean age (years)

Gender (%)

Physical, 22 (11 mental control, 11 treatment)

68.0

F (78%), M (22%)

Mental

69.1 control, 70.1 treatment

F (74%), M (26%)

Residential Physical, 19 (all facility, mental treatment senior centers participants)

78.7

F (68%), M (32%)

Single group, pre-/post-test design

Senior centers

Physical, 25 (all mental treatment participants)

80.1

F (83%), M (17%)

10-day longitudinal study

Hospital (bedside)

Mental

Randomized, single-blind crossover trial

Long-term care facility

Physical, 34 (19 mental Group I, 15 Group II)

80.0

F (71%), M (29%)

Hospital outpatient facility

Mental

67.8

F (67%), M (33%)

Residential homes for elderly

Mental

78.3

F (77%), M (23%)

80.8

F (76%), M (24%)

Pre-/post- test design with a control group Pre-/post- test design with a control group

Randomized double-blind interventional study Pre-/post- test, 3 groups (experimental, passive control, and active control groups) design Assess effects of Wii on QoL, CASP-19; social Repeatedquality of life, social relationships via Social Provisions measures design relationships, and Scale; confidence to prevent falls confidence in the ability via M-FES to prevent falls Assess benefits ‘‘Wii Fit’’ Balance is measured via the Berg Single group may have on balance for Balance Scale pre-/post-test older adults design

Assess whether ‘‘Wii Fit’’ Balance Board leads to improvements in balance in older adults with perceived balance deficit Assess effects on cognitive function due to use of enjoyable sports videogames

Setting of study (context) Facility for communitydwelling persons Laboratory

Assisted living facilities

39 (20 control, 19 treatment)

32 (16 control, 16 treatment)

121 (66 control, 55 treatment)

43 (15 treatment, 17 passive control, 11 active control) Physical, 21 (8 Group mental, 1, 6 Group social 2, 7 control)

66.1 F (62%), treatment, M (38%) 68.9 control

Independent Physical retirement communities or skilled nursing facilities College sport Physical, center mental

22

83.9

F (82%), M (18%)

6

75.0

F (87.5%), M (12.5%)

Single group pre-/post-test design

Nursing home

Physical, mental, social

9

88.9

F (66.6%), M (33.3%)

Randomized control trial

Geriatric hospital

Physical, 27 (13 mental control, 14 treatment)

Prospective, cross-sectional pilot study, pre-/ post-test design

NA; median given, inclusion criterion 65–85 years

F (70.4%), M (29.6%)

ABILHAND, Assessment of Manual Ability; ADAS, Alzheimer Disease Assessment Scale; AROM, active range of motion; BBT, Berg Balance Test; BMI, body mass index; BP, blood pressure; CASP-19, Control, Autonomy, Self-realization, Pleasure-19; COP, Center of Pressure; F, female; GPRC, Global Perceived Rating of Change; HDS-R, Hasegawa’s Dementia Scale-revised; ICAC, Clinical Self-Concept Inventory; M, male; MDRT, Multi-Directional Reach Test; M-FES, Modified Falls Efficacy Scale; MOS, Medical Outcomes Study; MOSES, Multidimensional

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Table 2. (Continued) Game information

Game title

Purpose of game

Tailored (Y/N)

Platform

Duration of play

Significant key health outcomes (physical, mental, social)

Not specifically stated To manipulate virtual objects by using upper extremities

Yes

Phantom Omni

45 minutes Physical: time and hand-path ratio for VR task (P < 0.05)

‘‘Rise of Nations’’

Using strategy to control land

No

PC computers and eMAC

1.5 hours

‘‘Wii Sports’’

Physical movement to simulate actual games (‘‘Bowling,’’ ‘‘Baseball,’’ ‘‘Tennis,’’ ‘‘Golf,’’ and ‘‘Boxing’’)

No

Nintendo Wii

‘‘Dancetown’’

Pressing correct arrow to the beat of music

Yes

Screen and dance 30 minutes Physical: narrow walk time P = 0.0260, Short pad Physical Battery Performance P = 0.0071. Mental: self-reported health P = 0.02, SF-36 Mental Component P = 0.0180, self-reported balance confidence P = 0.0129 Nintendo DS 45 minutes Mental: working memory increased P = 0.004, handheld console fluid intelligence increased P = 0.006, information processing increased P = 0.03

Mental: ability to quickly switch between two tasks (sessions 2 and 3), F(1, 34) = 6.78, P = 0.01; improved focus of attention in the visual short-term memory task, F(2, 16) = 4.02, P = 0.04; and memory load cost decreased (session 3 versus session 2), F(1, 36) = 5.49, P = 0.02 35 minutes Mental: QIDS-16, t = 3.24, P = 0.004, SF-36 Mental Health Composite Score t = 2.57, P = 0.014, and Cognitive Functioning (RBANS) t = 2.41, P = 0.028

‘‘Dr. Kawashima’s Using cognitive ability to correctly Brain Training: How perform tasks Old Is Your Brain?’’

No

‘‘Wii Bowling,’’ part of ‘‘Wii Sports’’

Swing to knock down pins, simulated bowling

No

Nintendo Wii

20 minutes Physical: Nursing Home Physical Performance Test P < 0.001, pain bothersomeness P = 0.015, AROM P = 0.007. Mental: Physical Activity Enjoyment Scale, enjoyment of activity P = 0.014

‘‘CogniFit Personal Coach’’

Complete 21 different training tasks for points

Yes

PC computers

20–30 minutes

‘‘QBeez,’’ ‘‘Super Granny 3,’’ ‘‘ZooKeeper,’’ ‘‘PenguinPush,’’ ‘‘Bricks,’’ and ‘‘Pingyn’’ ‘‘Wii Bowling,’’ part of ‘‘Wii Sports’’

Problem solving, using work memory and recognition

No

PC computers

Not Mental: cognitive portion of ADAS specified t(14) = 3.505, P = 0.003, r = 0.68 (unlimited play)

Simulate bowling game

No

Nintendo Wii

‘‘Wii Fit’’ Balance Board

Completing balance activities by moving forward, backward, and side to side on Wii Balance Board

No

Nintendo Wii

Not specified (until 10 frames completed) 20 minutes

‘‘Wii Fit’’ Balance Board

Completing balance activities by moving forward, backward, and side to side on Wii Balance Board

No

Nintendo Wii

‘‘XaviX Hot-plus’’

Grab coin when it appears to float out of screen or moving legs to music, both to score points

Yes

Television screen Not and tangible specified accessories such as soft bowling balls

‘‘Under Pressure,’’ ‘‘CMemory Match,’’ ‘‘Balloon Burst’’

Move weight to get object directed in right spot, or user shifts weight in order to select correct card, or user shifts weight in order to burst balloon.

Yes

Mental: focused attention P = 0.01, sustained attention P = 0.01, memory recognition P = 0.02, mental flexibility P = 0.05

Duration of intervention Frequency (weeks) 4

3 times/ week

4–5

15 sessions

12

3 times/ week

12

2 times/ week

1

7 sessions

8 (4 using Wii)

2 times/ week

12

3 times/ week

8

1 time/ week

8

1 time / week

4

3 times/ week

6

2 times/ week

Physical: visuospatial and constructive function measured using Kohs block-design tests, P = 0.02. Mental: HDS-R, P = 0.002. Social: MOSES, P = 0.054

10

1 time/ week

FSA Pressure mat 45 minutes Physical: Berg Balance Scale, P = 0.001; connected to Clinical Test of Sensory Interaction and laptop computer Balance, Loss of Balance sponge surface, P = 0.007. Mental: Activities-specific Balance Confidence Scale, P = 0.02

8

2 times/ week

Social: CASP-19, Group 2 item 8, P = 0.030; Social Provisions Scale, Group 3 item 1, P = 0.030; Group 2 item 3, P = 0.045, Group 1 item 14, P = 0.048. Mental: M-FES, Group 2 item 8, P = 0.047 Physical: Berg Balance Scale t(21) = –9.861, P < 0.01

30 minutes Physical and mental outcome measures were not found to be statistically significant for Berg Balance Scale and Activities-specific Balance Confidence Scale (3 subjects decreased their fall risks by 6–12%).

Observation Scale for Elderly Subjects; N, no; NA, not available; N-CPC, Neuropsychological Examination–‘‘CogniFit Personal Coach’’; NRS, Numeric Rating Scale; QIDS, Quick Inventory of Depressive Symptoms; PACES, Physical Activity Enjoyment Scale; QoL, quality of life; RBANS, The Repeatable Battery for Assessment of Neurocognitive Status; SF-36, Short Form 36; TMT-B, The Trail Making Test, part B; UE, upper extremity; VR, virtual reality; WHOQOL, World Health Organization Quality of Life Questionnaire; Y, yes.

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408 as an intervention to promote physical activity, and more studies are needed to confirm these findings in older adults.42 Furthermore, game platforms are being tested as possible fall risk assessment tools by therapists.22,24 Preliminary evidence points to the physical health benefits associated with the use of digital videogame play by older adults and as rehabilitation tools used by healthcare providers. The use of digital videogames to improve cognitive processes of older adults has also been investigated. Clinical findings support the notion that after 65 years of age, the brain experiences variable structural and cognitive functional declines.47 Thus, digital videogames may prove to be an effective treatment to sharpen mental processes as people age.47,48 Rosenberg et al.39 found significant positive changes in depressive symptoms of older adults with subsyndromal depression. Overall, the reviewed studies found positive effects of game play on mental health status. Research on increased social interaction and social support was pursued by a small number of researchers.38,46 However, these studies showed promising results for increasing verbal communication and expression of positive feelings, which are supported by the literature as key elements of social interaction.38,49 Positive outcomes relating to social support were found among groups formed and meeting regularly during digital videogame play interventions.46 The latter study suggests that the phenomenon be further investigated through future studies. Therefore, future studies in the area of digital videogame play by older adults should incorporate a construct for assessing social support, to confirm current findings and to test for validity of results stemming from research on social support. Only a single study based its research on a theoretical foundation.41 Evidence-based research supports the use of behavioral theory to inform health promotion programs for changing health behavior.10 Therefore, the current state of research on health-based games demonstrates a need to include behavioral determinants utilizing a model for health behavior prediction. Additionally, more comprehensive and thorough experimental designs are also needed to increase reliability and validity of results stemming from the research. To decrease variations between studies, intervention times can be aligned based on frequency and duration of intervention. From our findings, we suggest the norm of intervention duration to be in the vicinity of 7 weeks and frequency of intervention at around two or three times per week. Because the majority of participants studied were females, parallel studies related to gender are necessary in order to draw definitive conclusions on the various classes of health outcomes associated with digital videogame play in the older generation. The reviewed studies varied in the number of participants, and many studies experienced high participant attrition rates. Therefore, researchers looking to study the effects of gaming on older adults in future studies should plan for a greater number of participants to strengthen statistical significance of their findings and to counter possible high attrition rates. The Nintendo Wii console was found to be the most chosen digital videogame platform on which games were played for interventions. The Nintendo Wii works primarily on motion sensing and has been the industry leader in sales for several years. Today, Nintendo Wii faces stronger competition from PlayStation 3’s PlayStation Move with PlayStation Eye from

HALL ET AL. Sony (New York, NY) and the Xbox 360’s Kinect from Microsoft (Redmond).50–52 The newer consoles have more accurate motion sensing and require more realistic physical movement in order to be recognized by the gaming system.53 From this, it is recommended that future studies incorporate as well as compare and contrast current and newer technologies in motion sensing digital videogames. Furthermore, the Nintendo Wii console gives older adults a platform that encourages social interaction and simultaneously stimulates mental and physical activity. The majority of studies were conducted in facilities specializing in geriatric care, which implemented the Nintendo Wii console. This finding suggests that such games can be played indoors and at the leisure of the users, making them appealing to an older adult population. Consequently, the Nintendo Wii was found to be a popular health promotion tool among staff members who care for the elderly.54 However, it is recommended that future studies test current and newer game consoles in other settings, such as in households of older adults, to see if similar health outcomes hold up in settings lacking continuous social support from staff members and researchers. There is a paucity of available research on the types of games preferred by older adults and which games have the greatest health benefits. Only one of the reviewed studies asked participants to rate their enjoyment of the various games they played on a Likert scale.39 Additionally, another study gave participants a choice of games to play but failed to report what games were commonly chosen or which were linked to better health outcome measures.40 Future studies should look at game preferences for sustained use and types of games that provide the greatest health benefits among an older population. Conclusions Findings from this systematic review of the literature describe the current state of research on HRQOL indicators of older adults associated with interactive digital videogame play. Digital games for older adults have been studied for use in rehabilitation treatments, physical activity promotion, mental acuity exercises, and increased social exchanges. The vast majority of reviewed studies revealed positive health outcomes for older adults associated with digital videogame play, especially related to mental and physical health benefits. Evidence suggests that future research on health outcomes associated with digital videogame play by older adults can benefit from more rigorous experimental study designs, an increase in the number of study participants, more equal gender distribution among study participants, and an alignment of trials in regard to frequency and duration of interventions. Strengthening study designs will help increase the amount of valid and reliable empirical and statistically relevant evidence of the possible health benefits due to digital videogame play by older adults. In addition, researchers should test recent innovations and advancements in motion sensing digital videogame platforms to increase the precision of future research. Lastly, we look forward to the clinical benefits derived from studies incorporating the previously stated suggestions and technologies. Acknowledgments The authors would like to thank the Center for Digital Health and Wellness and the Department of Health

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Address correspondence to: Amanda K. Hall, MHSE, MS Center for Digital Health and Wellness Department of Health Education and Behavior College of Health and Human Performance University of Florida 1021 NE 20 Avenue Gainesville, FL 32609 E-mail: [email protected]

Health Benefits of Digital Videogames for Older Adults: A Systematic Review of the Literature.

This article is a systematic review conducted of the research literature on digital videogames played by older adults and health outcomes associated w...
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