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Published on 30.12.16 in Vol 2, No 1 (2016): December

Preprints (earlier versions) of this paper are available at, first published Jun 20, 2016.

This paper is in the following e-collection/theme issue:


    Feasibility of Using a Game-Based Cognitive Assessment for Older Adults in Emergency Care

    1Interactive Media Lab, Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada

    2Knowledge Media Design Institute, Faculty of Information, University of Toronto, Toronto, ON, Canada

    3Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada

    4Primary Care Research Unit, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    5Clinical Epidemiology Unit, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    6Department of Emergency Services, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Corresponding Author:

    Tiffany Tong, MASc

    Interactive Media Lab

    Department of Mechanical and Industrial Engineering

    University of Toronto

    5 King's College Road

    Toronto, ON, M5S 3G8


    Phone: 1 416 978 7581

    Fax:1 416 978 7581



    Background: Developed nations are currently facing a demographic shift towards a higher proportion of elderly people and increasing age-related health concerns. Elderly adults often enter into the health care system through emergency services. As a result, emergency departments (EDs) are an opportune environment for cognitive screening to improve patient outcomes. Existing methods are not designed for use in EDs and require administration by a trained test administrator. As an alternative, we suggest serious games as screening tools that can be self-administered or used with minimal assistance in emergency care. The use of validated and reliable serious games can encourage more efficient and engaging cognitive screening.

    Objective: Our objective was to investigate the feasibility and usability issues identified in the process of evaluating the validity and reliability of a game-based cognitive screening tool administered on an interactive tablet, for use by elderly adults in emergency care.

    Methods: We carried out a study in a hospital ED to evaluate the validity of the serious game with elderly adults over the age of 70 years (N=146). Validity was assessed in terms of the correlation of game performance with outcomes of current assessment methods. Comparative assessments included the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and the Confusion Assessment Method (CAM). We also assessed the reliability of our game-based assessment tool in a hospital ED for a large subset of the patients who underwent a revised protocol involving follow-up sessions at a minimum of every 8 hours (n=127). In both studies, research personnel (RP) administered the standard cognitive assessments and then asked the patients to play the serious game. Recruitment for the reliability study overlapped with our validation study, with 56 potential overlap cases.

    Results: In our validation group, 141 of 146 patients consented to play the serious game. Performance on the serious game correlated significantly with the MoCA (r=–0.339, P<.001), MMSE (r=–0.558, P<.001), CAM (r=0.565, P<.001), and other cognitive assessments. In our reliability study of 127 adults, we obtained data from 126 people. We observed good test-retest reliability with Pearson correlation r values between 0.5 and 0.7. 
These results supplement findings from our validation study that the assessment was correlated with MMSE, MoCA, and CAM scores. Usability feedback suggested that the game was too easy and the need to use a stylus for users with dry skin. All patients were able to play the serious game administered on a tablet either independently or with minimal assistance from RP. In the latter case, RP would assist by holding the tablet as some patients found it heavy.

    Conclusions: This research demonstrates the feasibility, validity, and reliability of using a game-based cognitive assessment in a clinical setting. Elderly users in an ED can use our screening tool by improving on the usability of the system by incorporating their feedback in our design process. This research shows that appropriately designed serious games can be self-administered or used with minimal assistance in a clinical setting repeatedly for each person.

    iproc 2016;2(1):e35



    This poster was presented at the Connected Health Symposium 2016, October 20-21, Boston, MA, United States. A photo of the poster is displayed as an image in Figure 1 and as a higher resolution image in Multimedia Appendix 1.

    Figure 1. Poster.
    View this figure

    Multimedia Appendix 1


    PDF File (Adobe PDF File), 1MB

    Edited by T Hale; submitted 20.06.16; peer-reviewed by CHS Scientific Program Committee; accepted 02.08.16; published 30.12.16

    ©Tiffany Tong, Chelsea DeGuzman, Mark Chignell, Mary Catherine Tierney, Jacques Lee. Originally published in Iproceedings (, 30.12.2016.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in Iproceedings, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.