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Rosa M., Souza M. (2021) Monitoring social functioning using board games – 2 case studies with cognitive decline, Journal of Aging & Innovation, 10 (3): ARTIGO ORIGINAL: Rosa M., Souza M. (2021) social functioning using board games – 2 124 - Monitoring 138 case studies with cognitive decline, Journal of Aging & Innovation, 10 (3): 124 - 138

 ARTIGO ORIGINAL

Monitoring social functioning using board games – 2 case studies with cognitive decline Monitorizar a função social através do jogo de tabuleiro – 2 estudos de caso com declínio cognitivo Monitoreo de la función social a través del juego de mesa: 2 estudios de casos con deterioro cognitivo Marlene Cristina Neves Rosa1, Micael da Silva e Souza2

1 – PhD, Polytechnic Institute of Leiria, School of Health Sciences, ciTechCare - Center for Innovative Care and Health Technology. https://orcid.org/0000-0001-8276-655X 2 – PhD, Department of the Civil Engineering, University of Coimbra, Portugal (CITTA).

Corresponding Author: marlene.rosa@ipleiria.pt Author Note This manuscript had no specific funding sources; The authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work

ABSTRACT Aim: This study aimed to test Board Games as a performance-based method to monitoring social functioning in people with cognitive decline and dementia. Method: A pilot board game-based session was implemented in 2 study cases. Junk Art was the game chosen for testing, including serious adaptations (Part I, free exploration of game components; Part 2, implementation of game rules) for recreation of social behaviours related to daily experiences and older personal memories. Session was video recorded and players’ interactions with the game system were accounted to characterise individual participation profile and differences between players’ participation profile. Results: A female (Player 1 (P1) - 89yrs; mild cognitive deficit) and a male (Player 2 (P2) - 71yrs; moderate stage of dementia) participated in this study. Contrarily to P2, the P1 demonstrated a quite balanced performance between Part 1 and Part 2, e.g., P1 - 51.5% Social interaction vs P2 - 65.5% Social interaction between players. In total, P1 had 68 interactions, while P2 had only 29 interactions. Conclusions: The Junk Art was able to detect players with higher cognitive impairment, demonstrating potential for evaluating social functioning, including number of social interactions, of memories recall and creativity thinking.

Key words: diagnostic; game; aged

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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ARTIGO ORIGINAL: Rosa M., Souza M. (2021) Monitoring social functioning using board games – 2 case studies with cognitive decline, Journal of Aging & Innovation, 10 (3): 124 - 138 RESUM0 Objetivo: Este estudo teve como objetivo testar os jogos de tabuleiro como uma metodologia de avaliação de performance para monitorização do funcionamento social em pessoas com declínio cognitivo e demência. Método: Uma sessão piloto baseada num jogo de tabuleiro foi implementada em 2 estudos de caso. Junk Art foi o jogo escolhido para teste, incluindo adaptações sérias (Parte I, exploração livre dos componentes do jogo; Parte 2, implementação das regras do jogo) para a recriação de comportamentos sociais relacionados a experiências diárias e memórias pessoais mais antigas. A sessão foi gravada em vídeo e as interações dos jogadores com o sistema de jogo foram contabilizadas para caracterizar o perfil de participação individual e as diferenças entre o perfil de participação dos jogadores. Resultados: Participaram do estudo uma mulher (Jogador 1 (P1) - 89 anos; déficit cognitivo leve) e um homem (Jogador 2 (P2) - 71 anos; demência moderada). Ao contrário de P2, o P1 demonstrou um desempenho bastante equilibrado entre a Parte 1 e a Parte 2, por exemplo, P1 - 51,5% de interação social vs P2 - 65,5% de interação social entre jogadores. No total, P1 teve 68 interações, enquanto P2 teve apenas 29 interações. Conclusões: O Junk Art foi capaz de detetar jogadores com maior comprometimento cognitivo, demonstrando potencial para caracterizar o funcionamento social, incluindo o número de interações sociais, de evocação de memórias e pensamento criativo.

Palavra-chave: diagnóstico; jogo; idoso

Introduction Social functioning, which is the way individuals associate and interacts with others, is a core domain of people with dementia (Boer et al., 2008). In fact, these individuals often lose their interest in previous value hobbies, they also lose emotional self-control, which negatively affects the course of close relationships (Evans & Lee, 2013). Lower social functioning can be one of the first signs of progression in dementia and an important clinical criterion to adapt and personalise specific therapies (Bennett DA, Schneider JA, Tang Y, Arnold SE, 2006), therefore this is a central factor in dementia monitorisation. Although the importance of social functioning for detecting progression in dementia, there is only one specific instrument to measure this ability, which is the Social Functioning in Dementia scale (SF_DEM) and this needs to be completed in a face-to-face interview with the person with dementia or their family caregiver, being classified as a self-report or proxy-report measure (Sommerlad, Singleton, Jones, Banerjee, & Livingston, 2017). In contrast to self-reported and proxy-reported measures, a performance-based measure assesses the necessary abilities to perform goal-directed activities including initiation, planning, problem identification, problem-solving and sequencing processes, using direct observation and more realistic perception of patient’s difficulties and needs (Harvey, Velligan, & Bellack, 2007). Given the impracticality of conducting observations in the natural environment, the performance-based measures should be developed on wellspecific simulated scenarios and interactions. These interactions are videotaped for subsequent coding by trained raters (Harvey et al., 2007).

According to their general

properties, games are able to simulate common daily experiences of social interactions and scenarios, stimulating players to link with their partners and providing shared experiences (Mccallum, 2012).

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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As a summary, new performance-based measures to assess social functioning in people with dementia and cognitive decline are needed and game-based assessment methods might have potential in this field. Therefore, the aim of this study is to test Board Games Activities as a performance-based method for monitoring social functioning in people with cognitive decline and dementia.

Materials and Methods An exploratory descriptive study was conducted after Ethical Approval by Portugal Alzheimer Foundation. Included participants had 60 years old or over; were not bedridden; had cognitive decline or dementia diagnosis in a non-advanced status (Mini-mental state examination >10) (Perneczky et al., 2006). Severe impairments in status-conscious, diagnosis of global aphasia or vision severe limitations were exclusion criteria for this study. A previous meeting was conducted with invited participants and respective caregivers in order to present information, as clear as possible, about study methodology. All procedures performed in this study were following the ethical standards of the Institution Ethical Committee and are in accordance with the 1964 Helsinki Declaration. The informed consent was obtained after this meeting, if both patient and caregiver would agree to participate. Two study cases were included and sociodemographic data were obtained (gender, age, occupation, mini-mental state examination, cognitive status classification). A pilot assessment session of 40 minutes was implemented, including 2 participants around a table, facing each other.

Protocol for this pilot session followed the Design, Play and Experience (DPE) framework (Winn, 2009), considering a design adaptation of a modern board game in order to achieve the serious games objectives (Castronova & Knowles, 2015), in this case related to the simulation of common daily experiences of social interactions and scenarios.

Modern board games are popular because they are providing innovative collective payable face-to-face playable experiences. These new games, through presential object manipulation, stimulate socialization and cooperation between players (Zagal, Rick, & Hsi, 2006), providing engaging experiences through manipulation of the game components and even the game related chores (Xu, Barba, Radu, Gandy, & Macintyre, 2012). Within the modern board game gender (Sousa, M., & Bernardo, 2019) eurogames are the most innovative, providing elegant mechanics and simple rulesets that provide compelling gameplay (Rogerson & Gibbs, 2016) (Woods, 2012), enjoyable to all ages. Eurogames are also known because they explore specific themes though relative simple models where players decisions are meaningful, providing a conscious gameplay where players can express personal perspectives through their gameplay and related materiality in face-to-face activities (Dias, Sousa, & Rosa, 2020).

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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Junk Art (Cormier & Lim, 2016) was the modern board game explored in this study, a party and dexterity game with evident eurogame design inspirations but that maintain low complexity among the modern board game gender. This game contains more than 60 big plastic colourful components inspired in junkyard objects.

In the present study, the implementation of Junk Art was seriously adapted to assess a high diversity of abilities that are usually decreased in people with dementia or cognitive decline and affects social competence, such as: creativity or divergent thinking (Palmiero, Di Giacomo, & Passafiume, 2012), verbal and non-verbal expression (Rousseaux, Sève, Vallet, Pasquier, & Mackowiak-Cordoliani, 2010) or recall of memories (Son, Therrien, & Whall, 2002). The protocol of the session and then designed to enable the natural occurrence of these abilities and it was divided in two different parts: (i) Part 1 - the first 20 minutes of free exploration of the game components, with no competitive rules; (ii) Part 2 – the last 20 minutes included the implementation of game rules, requiring strategy/competition in the choice of game components (format, colour) and on their coupling to build the tallest tower.

The DPE framework (Winn, 2009) was adapted to produce a new framework called Redesign, Play Experience (RPE) considering the need to adapt the game to the two activities parts and introducing the facilitator role to explain and guide the player during the play if necessary and to interpret the game experiences. Because analog games do not have the automatic rules enforcement like digital games (Sato & Haan, 2016) a facilitator is mandatory to make the game flow, which is also useful to make ongoing adaptations and to help debriefing (Lederman, 1992) the game experiences with a direct communication channel to the players.

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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Figure 1. RPE framework adaptation to the experiment with the adapted version of Junk Art.

The entire session was video recorded for data analysis (Figure 2), considering the methods for evaluating events and percentages of time during gameplay in which the players interact with the game system by doing and having different behaviours (Berland & Lee, 2011) (Guhe, MarkusLascarides, 2012) (Masuda & Dehaan, 2015)(Xu et al., 2012), in this case related to the object manipulation to help identify daily experiences and older personal memories.

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Figure 2. Implementation of Junk Art seriously adapted to assess social functioning in people with dementia and cognitive decline.

Data analysis Two independent ratters with experience in taking care of people with dementia were dedicated to the video analysis of this session.

They were trained to account the following parameters: (i)

the number of connections with real life, as an outcome to interpret the ability to remember something (e.g., recall of memories);

(ii)

the number of judgments or advisements between players and number of verbal and non-verbal expressions are an outcome of level of social interaction between players;

(iii)

the amount of interactions with game components are an outcome of players’ creativity.

These criteria were accounted for each player, namely the number of interactions for player 1 (NP1) and for player 2 (NP2). Differences between NP1 and NP2 and the % of participation for each Player in Part 1 (Formula 1) and in Part 2 (Formula 2) were calculated. The % of players’ participation was used to characterise the Individual Participation Profile.

Formula 1

[Individual Participation Profile of P1/P2] = N interactions Part 1 /total interactions

during the entire session for each player*100; JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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ARTIGO ORIGINAL: Rosa M., Souza M. (2021) Monitoring social functioning using board games – 2 case studies with cognitive decline, Journal of Aging & Innovation, 10 (3): 124 - 138 Formula 2

[Individual Participation Profile of P1/P2] = N interactions Part 2/ total interactions

during the entire session for each player*100; Absolute numbers of players’ interactions (NP1; NP2; NP1-NP2) were used to characterise differences between players’ participation profile in Part 1 (Formula 3 and Formula 4) and in Part 2 of game session (Formula 5).

Formula 3

[Differences between players’ participation profile in Part 1] = NP1 social interaction - NP2

social interaction Formula 4

creativity

[Differences between players’ participation profile in Part 1] = NP1 memories recall and

- NP2 memories recall and creativity

Formula 5

[Differences between players’ participation profile in Part 2] = NP1 social interaction - NP2

social interaction

Results A female aged 89 years old, presenting a mild cognitive deficit and a male aged 71 years old, presenting a moderate stage of dementia participated in this pilot session (Table 1).

Gender (M;F) Age (years) Occupation Mini Mental Examination (Total) Cognitive classification M, male; F, female;

Player 1 F 89 School teacher State 27

Player 2 M 71 Factory manager 20

status Mild cognitive Moderate deficit dementia

stage

of

Table 1. Demographic (gender, age) characterisation of Player 1 and Player 2 included in board game’s session.

Characterisation of individual participation profile The performance of P1 in Part 1 (23.5% Memories recall and creativity + 25.0% Social interaction between players) and in Part 2 of the session (51.5% Social interaction between players) was quite balanced. The performance of P2 was quite asymmetric between Part 1 (20.7% Memories recall and creativity + 13.8% Social interaction between players) and Part 2

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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of the session (65.5% Social interaction between players). In fact, most of interactions of P2 happened in Part 2 of the session (Table 2; Figure 3).

Figure 3. Percentage (%) of individual participation in Part 1 and Part 2 of game’s session.

Differences between players’ participation profile In total, P1 had 68 interactions, while P2 had only 29 interactions, with the following differences: in Part 1 of the session the P1 had more 10 interactions in memories recall and creativity processes and more 13 social interactions (Figure 4); in Part 2 of the session, P1 had more 16 social interactions (Figure 5). An important difference between players was found in the higher number of non-verbal expressions (specifically expression of dissatisfaction / discomfort) for P2 (N = 15), compared to P1 (N = 7) during Part 2 of the session (Table 2).

Figure 4. Differences between players’ participation in Part 1 of the game’s session.

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Figure 5. Differences between players’ participation in Part 2 of the game’s session

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Table 2. Characterisation of individual participation profile (Player 1 and Player 2) and differences between players’ participation profile in Part 1 of the game’s session (when stimulating social interactions and memories recall and creativity) and in Part 2 (when stimulating social interactions during strategy/competitive rules).

Discussion Findings from the present study suggest that modern board games, such as Junk Art, can be used as a performance-based tool for characterisation of social profile of people with cognitive decline and dementia, and can be used as a method to identify needs and adjust therapy. The use of these games should have some guidance framework, and departing from the DPE it is possible to create a redesign game flexible process, called Redesign, Play and Experience (RPE) with the presence of facilitators to overcame the nature of board games systems and implement a simple ongoing debriefing support to players.

For example, in the present study, it was possible to understand that player 1 is able to adjust to the entire session, responding in a similar way to challenges of creativity and memory (Part 1 of the session), as well as to more competitive dynamics (Part 2 of the session). In contrast to player 1, player 2 demonstrates unbalanced responses to the two parts of the session, with less participation and interaction in part 1 and better performance when he was involved in competitive dynamics, including specific rules.

In fact, the profile identified by players’ performance in this study is in accordance with the results of a previous systematic review focused on the relationship between dementia and the progressive declining in creativity (Palmiero et al., 2012). For example, and according to this assumption, the implementation of Junk Art tested in the present study, was able to detect that players with higher cognitive impairment (Player 2, moderate stage of dementia) had more JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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difficulties in producing an original product (Creation by handling game’s components: P1=6.9% vs P2=13.2%).

The implementation of the Junk Art also allows us to identify different levels of memory function between Player 1 and Player 2. In the present study, one of the most common tests was used to classify the levels of cognitive impairment of the included players, which was the Mini-Mental State Examination. However, this test has been demonstrating the inability to measure working memory or the recognition of personal experiences (Arabi, Aziz, Abdul Aziz, Razali, & Wan Puteh, 2013). In this context, the Junk Art revealed the potential for evaluating memory based on the payers’ performance in a simulated context, by counting the personal memories according to the parameter “Talking about the personal meaning of the components of the game” (P1 = 7; P2 = 4).

Through the experimental test of Junk Art game, it was possible to match the different parts of the session (Part 1 and Part 2) with two different learning models, both commonly discussed in people with dementia: Part 1 of this game has an equivalence with explicit learning models, where specific instructions and aims are explained to participants; in turn, Part 2 of this game has an equivalence to the implicit learning model, in which instructions are given and the specific aim to be achieved is specified (Pohl, McDowd, Filion, Richards, & Stiers, 2001). It is known that implicit learning, unlike explicit learning, is preserved in people with dementia in more severe stages (Ardila, Bernal and Rosselli, 2018), which may explain the poorer performance of Player 2 in Part 1 of Junk Art implementation (van Tilborg, Kessels and Hulstijn, 2011).

Data on the present study demonstrated some surprising results for Player 2 (N=19 social interactions in Part2), considering his score on Mini-Mental State Examination (score=20; moderate stage of dementia).

These surprising results might be explained by the

implementation of innovative game-based methodologies. These methodologies follow the new recommendations to assess active learning performance and the ability to co-construct significant social and collaborative opportunities by including rich communicative environments (Duff, Hengst, Tranel, & Cohen, 2008). This trend totally contradicts the specific model of conventional instruments (e.g., the Mini-mental State Examination), which are often individualcentred and focused on specific individual impairments (Hengst, Duff, & Dettmer, 2010).

The present study presents an exploratory case study methodology, mainly because there is a lack of detailed preliminary research (Mills, Durepos, & Wiebe, 2010), especially dedicated to the characterisation of social functioning in people with dementia using a game-based methodology. The following step for Junk Art validation as a measure for social functioning in

JOURNAL OF AGING AND INNOVATION, DEZEMBRO, 2021, 10 (3)  ISSN: 2182-696X  http://journalofagingandinnovation.org/ DOI: 10.36957/jai.2182-696X.v10i3-8

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people with dementia should be the development of a content validity study. This study may start by the appreciation of each of the items assessed, using this experimental game-based methodology RPE and the respective judgment by a group of professional experts and a representative group of the target population (e.g., a group of caregivers)(Boateng, Neilands, Frongillo, Melgar-Quiñonez, & Young, 2018).

Conclusion This study demonstrated that modern board games can be implemented with serious adaptations, developing a proper framework (RPE), for measuring social functioning in people with dementia or cognitive decline. The Junk Art method implemented in this study was divided in two different challenges based on two different learning models (implicit and explicit learning models) and demonstrated the ability to characterise different levels of social functioning in people with dementia (e.g., worse difficulties in creativity thinking in people with more severe dementia). Thinking on the clinical acceptance of this experimental game-based methodology, future research should move forward for content-validity studies, proving its validity to assess active learning performance, as recently recommended in dementia research.

Acknowledgments The authors would like to thank the patients that participate in this pilot session as well as to their caregivers. We are also grateful to the support of Alzheimer Portugal association in the patients’ recruitment process.

Funding Sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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