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1 Seoul International School “Games as an effective way to cure early stages of dementia in ageing societies” Christine Yi 1 Instructor Sookyoung Kim 2 August 1, 2021 ____________________________________ 1 christine.yi22@stu.siskorea.org, Seoul International School 2 Cretion000@gmail.com, Cretion Academy

2 Abstract This research paper will delve into the topic of dementia that threatens the ageing people all over the world. Various research is used to describe how people with dementia often experience memory loss, repeat themselves and ask the same questions again and again and forget recent events. According to a study conducted in 2020, the risk of deterioration can be reduced in the earlier stages of dementia by providing aid to the cognitive function, such as memory problems. Dementia is known to complicate a person’s daily tasks. Since no actual cure has been created to prevent the disease, studies have been made reduce the risks that could arise as well as diagnosing the disease before it deteriorates. Thus, this paper will portray a new type of therapy for the disease, which is games that have become quite popular and bring out the most positive results opening the road to a whole new type of treatment of dementia. Various research studies have been used in representing the data. The conducted research was analyzed and used to aid in the explanation of the topic at hand. Playing “tetris” and computer tests, slows down the decline in mental abilities and the development of dementia in the ageing people. It turned out that the old people who played the telephone version of “tetris” lost their memory much more slowly and thought more vividly than their peers from the control group. Memory games, for example, memorizing a figure on the screen, showed similar positive results. It is the first therapy that has been shown to be effective in reducing the risk of developing dementia. Thus, this researcher will further prove that just a few hours of this kind of training will be beneficial for the next ten years of a person’s life. I. Introduction

3 For the longest time, dementia has been threatening the ageing people across the globe. Medications as the main cure continue to fail and yet are used as the only prevention and help against the disease. Dementia serves as a catalyst not only in the rising of physical issues but psychological as well. It is a disease that put great pressure not only on the patient but his whole family. When the brain ages, structural changes occur. The size of brain neurons decreases, and the volume of the brain decreases as the neural network decreases. When the volume of the brain decreases, memory decreases and behavioral reactions slow down. This is because brain neurons cannot move as quickly as before. In general, it is known that 30-50% of brain neurons are lost in old age compared to young age. In particular, as the number of neural networks connecting brain cells and cells decreases, it leads to memory loss and information processing ability decline. The reduction of neurotransmitters in the brain is also a phenomenon of brain aging. As the production of neurotransmitters decreases, the rate of brain nerve response decreases. The decline in cognitive ability with age is also related to brain aging. Especially, in the early to milder stages of dementia, cognitive impairments are often the most disabling and distressing features for the individual and their family. However, recent research demonstrates that the brain cells are also regenerated. In other words, reducing brain cell damage and promoting regeneration can slow brain aging. So, interventions to assist with aspects of cognitive functioning, such as memory problems, and associated functional limitations are therefore important in the milder stages of dementia as they may allow the person greater independence and can potentially minimize the risk of 'excess disability'. In mild to moderate dementia, there is a significant decline in the ability to carry out instrumental activities of daily living. Thus, in the absence of a cure there is increasing focus on risk reduction, timely diagnosis, and early intervention is garnering attention such as games, as a new form of dementia therapy, stand out from various therapeutic methods and

4 pave the way for dementia treatment. Hence, if the right kind of support is offered at the right time, shifts to substantial levels of need may be delayed or prevented. In recent research, hippocampus-associated memory has shown drastic improvements from the pre- and post-tests. The degree of improvement was tied to both the amount of exploration of the game such as Minecraft world and the complexity of the structures built within he game. (Levis et al., 2001) According to a study done in 2020, the risk of ‘excess disability’ can be reduced in the earlier stages of dementia by intervening with the disease to aid the cognitive functioning, such as memory problems. It is an acknowledged notion that instrumental activities required for a person to carry on with daily tasks become quite limited in the cases of milder and restrained dementia. Thus, due to the lack of a cure to even prevent the diminishing brain functions, scientists and doctors concentrate on reducing any risks that could arise as well as diagnosing the disease before it deteriorates. As a new type of therapy for the disease, games have become quite popular and bring out the most positive results opening the road to a whole new type of treatment of dementia. (Ning et al., 2020) II. The Game as a cognitive stimulation program important for mild to moderate dementia Indeed, the best that current drugs can do, in most cases, is to slightly slow down the cognitive decline. Consequently, until satisfying treatment methods are found, our aging societies will have to adapt and attend to the needs of an ever-growing number of demented patients; non-pharmaceutical approaches can help with this issue. There was consistent evidence from multiple trials that cognitive stimulation programs benefit cognition in people with mild to moderate dementia over and above any medication effects. Cognitive stimulation therapy was found to be as clinically and cost effective as the acetylcholinesterase inhibitors;

5 reminiscence therapy is also recommended in national guidelines. The aim of behavioral intervention is to improve or at least maintain the individual’s cognitive function, enable the person to continue to perform usual activities of daily living, and/or address behavioral symptoms that often accompany memory impairment (e.g., depression, wandering, sleep, agitation, or aggression). (Ferreri, 2015) Especially individuals with early-stage dementia appear to perform more poorly in more than one cognitive domain, leading to a more substantial interference in daily activities and independent function which may negatively affect the quality of life of patients and their caregivers. Man et al. investigated the effectiveness of a computer-based memory-training program versus the same program administered by paper and pencil, in people with questionable dementia. (Stone, 2020) The results demonstrated that, although both programs improved participants’ memory performance, the computer memory training improved more cognitive abilities of participants than the paper and pencil training. First of all, it is an effective and convenient method. In particular, paper and pencil cognitive training has been reported to be more effective when it is administered in groups. However it is not possible in COVID times to meet person to person. Moreover, it offers self-paced, individualized training, which sets the initial level of task difficulty according to the baseline competency of participants and gradually adjusts it as their performance improves. Another issue under consideration, though, is that most of the cognitive-training programs depend on the therapist and many sessions are required. As such, they might not be ideal when it comes to patient comfort. For this reason, more recent studies suggest the use of computer training as opposed to traditional training with the use of paper and pencil. (Stone, 2020) In the research of “Beneficial Effect of Multidomain Cognitive Training on the Neuropsychological Performance of Patients with Early-Stage Alzheimer’s Disease”, the

6 activity index of the entire brain and the average value of the concentration index of the frontal lobes (F3, F4) increased. Thus one can conclude that a computer concentration training program used specifically for the ageing people with dementia whose simple brain functions are slowly degrading can prevent further deterioration of the loss of concentration. Therefore, 'brain training' games are popular with people in the early stages of dementia and those that are worried about their memory. These games will specifically help prevent dementia, and some studies have shown that it can help aspects of memory and thinking. Considering the development of computer technology and apparent limitations of board games in dementia care, electronic games (also called video games) have been considered as an alternative for dementia instead of board games. (Nousia et al., 2018) In order to interfere with the process through games, the brain triggers concentration, memory and simple motor skills which is the best training technique for early stages of dementia. Studies show that people with dementia greatly benefited from the games in terms of perception, balance, and an overall progressive effect on BPSD. In the case of what types of games to be used, video games are not the limit. Board games are a great substitute and both video and board games have a great variety that could concentrate on increasing progress in one aspect or another for dementia patients. Overall, video games tend to increase a patient’s initiative better than board games due to the special effects used for games, such as music, sound effects, visual effects, and quest rewards. In addition to this, games increase the serotonin hormones that increases the happier mood in the patients. As the study claims, “the flexibility of individualized deployment, the broad range of effects, and the entertainment value suggest that game-based intervention is among the best choices to people with dementia.” (Jiaying Zheng, 2017) Despite the various games that keep on growing in the market, dementia specific games are still a novelty. In order for these games to also freely enter the market, health care

7 professionals, game developers, scientists, patients among many others have to collaborate to further create more dementia based games. Research shows the specific points that should be considered for the dementia games, such as “the effect of different duration and intensity of the game-based intervention, or their frequency need to be measured so as to decide the optimal frequency and duration of a game-based intervention.” (Nousia et al., 2018) III. The important factor of Game for mild to moderate dementia When dementia is only beginning to develop, it is important to note that any sort of practice activities do not have to be prearranged. Various types of actions can be practiced using simple daily tasks. Patients with dementia are helped with choosing their own clothes to wear, how to hold a toothbrush, among various other mundane tasks. (Baeklund, 2021) In general, patients with dementia tend to be like children and get defensive when it comes to any situation that they are not comfortable or familiar with. They have a fear of failure when a new task is given to them which may result in further mistakes. For such reasons, I designed a gameplay where failure is either impossible or very unlikely due to the simplicity of the task at hand. Moreover, if it does happen, its importance is systematically toned down. Furthermore, any task involving computers is often seen as utterly complicated. Therefore, being able to do even the simplest thing. No matter how easy we make the game, patients will still feel empowered when playing it. So key design point of it is human interaction, based on their memories and daily activities. “Smart Ageing, a life scene game that simulates the daily life scene guides the elderly to complete the specific living task to test or exercise their cognitive abilities, such as executive functions, divided attention, long/short-term memory, and spatial orientation and attention.” (Yang, 2010)

8 IV. Important Symptoms of Dementia 1. Short-term Memory Loss: Constantly Pose Reminders with Visual Cues like Photographs People with dementia often experience memory loss, repeat themselves and ask the same questions again and again and forget recent events. This happens since dementia is an issue in the brain. Thus, the damage can cause issues with any part of the brain, especially with creating and trying to recall memories. With time, demented patient will have longer period of time that he does not remember anything, which in turn also affect their daily life. At the beginning, visuals such as photographs and other pictures can trigger retrieval of certain memories. For the most part, patients to retain memory of talking and performing simple tasks, but they will not remember full episodes.. (Stone, 2020) a) Atrophy of the Hippocampus 2. Loss of Sense of Direction Recent memories and spatial recall, which is “the ability to remember different locations or where something is in relation to something else,” are two of the first things that the elderly with cognitive decline lose. Thus, a patient might lose all recollection of their destination and how to get their or why they were going there in the first place.

9 According to the study, “they also tend to have a small hippocampus, a region of the brain involved in navigation.” (Stone, 2020) b) Atrophy of the Entorhinal Cortex c) Impaired Spatial Memory The entorhinal cortex and hippocampus are key components of the brain’s spatial memory network and are affected from the initial stages of Alzheimer’s disease. In 2014, Professor John O'Keefe of UCL was jointly awarded the Nobel Prize in Physiology or Medicine for “discoveries of cells that constitute a positioning system in the brain”. Essentially, “this means that the brain contains a mental 'satnav' of where we are, where we have been, and how to find our way around.” O’Keefe and Nadel proposed that the “hippocampal formation also contained information regarding direction and distance allowing construction of a cognitive map of the environment. A key component of this internal satnav is a region of the brain known as the entorhinal cortex. This is one of the first regions to be damaged in Alzheimer's disease, which may explain why 'getting lost' is one of the first symptoms of the disease. The entorhinal cortex is the primary network hub to the hippocampus, with medial and lateral subdivisions conveying spatial and object-related information.” (Stone, 2020)

10 3. Difficult to Find Instructions or Sequences Atrophy of the Lobes a) “Frontal lobe-struggling with decision-making, planning or organizing As the damage spreads to the frontal lobes, someone with Alzheimer's may struggle with decision-making, planning or organizing, so it becomes more difficult to follow or interpret things (such as following a new recipe). Damage to the frontal lobes can make it hard to pay attention for very long, switch between tasks or do more than one thing at a time. A person with damaged frontal lobes may become easily distracted or easily lose focus, particularly if they are given too much information all at once.” (Stone, 2020) b) “Temporal Lobe-damage here can disrupt a person’s ability to understand spoken and/or written language. Damage to this area may disrupt a person’s ability to understand spoken and/or written language. The parietal lobes contain the primary sensory cortex, which controls sensation (touch, pressure). Behind the primary sensory cortex is a large association area that controls fine sensation (judgment of texture, weight, size, and shape). Damage here would also

11 mean exhibiting increasingly poor judgment such as wearing inappropriate clothes for the season and having difficulty handling money.” (Stone, 2020) Mild atrophy of both the frontal and parietal lobes and the left medial temporal area (Coronal MRI scan shows absence (left) and presence (right) of atrophy of the medial temporal lobe in a healthy elderly subject and a patient with AD) c) Episodic Memory: Losing or Misplacing a Valuable Object. “Temporal lobes are essential to memory, especially episodic memory. If damaged, this can easily lead to frequently losing or misplacing valuable objects. In order to intake new knowledge and remember where we set down things like car keys, we must encode new information and retrieve it later. Alzheimer’s disease commonly damages the temporal lobes, making it difficult to store and recall a recent ‘episode’ and an inability to remember names when introduced to someone new.” (Stone, 2020) 4. Long-term Memory Loss: Forgetting Phone Numbers In the case of early to mid-stage dementia, the patient loses long-term memory instead of just the short-term. As Alzheimer's disease covers more and more area of the brain, additional areas and lobes fall under the influence as well. “The cortex overall becomes thinner (so memories from further in the past are

12 lost) and the brain gradually shrinks to the point at which the sufferer no longer remembers his or her own name, nor address or phone number. Alzheimer’s and other dementias can affect long-term memory in two different ways. A person can have difficulty storing the information in the long-term memory, and they also can have challenges retrieving it.” (Stone, 2020) Atrophy of the Amygdala “The amygdala is affected early in Alzheimer’s disease (AD), but generally later than the hippocampus. So, a person with Alzheimer's will often recall emotional aspects of something even if they don't recall the factual content. They may, therefore, respond more according to how they feel about a place or person than in a more logical way.” V. The Important Factors of Game Play for Mild to Moderate Dementia As early as the 1970s, digital games have been a significant form of entertainment, and in the 1980s the first studies regarding their use by the elderly were carried out. Some of the various initiatives resulted in favorable effects of video games on some psychological parameters. Research revealed an increase of self-reported well-being in the experimental group after a Tetris training program (5 hours a week during 5 weeks). Likewise, another researcher noted that the ageing patients that underwent care for a longer period of time greatly

13 improved after eight weeks of playing video games. These specific patients especially showed better results in their self-esteem while the control group had no such results. A similar effect was depicted with the elderly people aged 60 to 85 once they were shown what a computer is and were taught how to use it as a part of a senior citizens program. Such simple changes brought about boosts in self-esteem and feelings overall, as well as improvement in the motor skills, such as “switching, working memory, visual short-term memory and reasoning.” Putting these results into perspective, one can note that video games can serve as methods to prevent or slow down physical and cognitive deterioration in the elderly as well as boost their self-confidence. Thus, more and more of such methods are being adopted by various institutions. (Ferreri, 2015) 1. Key Facts for Making Games for those with Dementia Photography Dementia patients often exhibit a systematically defensive attitude regarding anything unfamiliar. They are always afraid to fail or break something when confronted with a new task. For such reasons, it is important to use photographs or images to increase familiarity as they can see the items pictured in their daily life. Photographs of actual places and things work much better than cartoons. Photographs should clearly represent the item being illustrated rather than be ‘artistic’. (Jiaying Zheng, 2017) Color Usage of high contrast color schemes improves readability, especially for important interface components. In fact, research has shown that vivid color

14 cues can help enhance the short-term memory performance of Alzheimer Disease patients. Pastel colors can be used, but they are difficult to distinguish for the ageing eye and strong vibrant colors are easier to remember. Contrast sensitivity is the most consistent visual deficit in people living with dementia. Highlight important elements. Usage of prominent color contrast to add clarity to the environment; for example, chairs should be a contrasting color to the floor. Sinks and toilets must contrast with the wall and floor, and table settings must contrast with the table or tablecloth. Soft white can be used as base color. Colors in the red to yellow zone of the color spectrum are more easily identifiable by people living with dementia than colors in the blue to green shades. Warm-color environments, such as oranges, reds and earth-tones consisting of long wavelengths have been proven to stimulate the nervous system. (Jiaying Zheng, 2017) Yellow is another stimulating color, which is used in activity areas to increase brain wave activity. Stimulating colors are good for Alzheimer’s patients as they can trigger memories and cognitive function. Red is also a highly stimulating color, which is often used in activity areas to increase brain wave activity and stimulate the production of adrenaline. Red increases brain activity, so if you want to get a dementia patient’s attention, use red. Lime green is particularly useful with Alzheimer’s for visual attention. A high light reflecting value (LRV) between different surfaces is essential, with a minimum of 30 points of difference providing the required contrast. Blue and green have a resting, calming effect. Other organizations studying the impact of color on individuals with diemthia’s disease have characterized pink as having an uplifting effect, decreasing aggressive tendencies. (Jiaying Zheng, 2017)

15 Graphic Text should not overlay pictures or photographs. Everything on the screen should be very large and highly contrasted to be easy to comprehend and keep the eye candy to a minimum to avoid distracting users with unnecessary frills. To keep lowering the cognitive weight of our system, I designed extremely simple, image-based graphical elements. Avoid animated or blinking icons unless necessary for content. (Jiaying Zheng, 2017) Text Use sans-serif fonts because the letter shapes are generally more readable on digital screens. On-screen speech bubbles to explain game scenarios may increase cognitive load and cause the patient to lose interest in the game. Use at least Arial size 14 font. There is no single color that works best for everyone, but many people find yellow or cream paper with black font can provide a good color contrast. Ensure plenty of white space between sections and avoid italics, which are more difficult to read. Use bold text to emphasize something. (Jiaying Zheng, 2017) Music Musical memories are often preserved in the brains of Alzheimer's disease sufferers because key brain areas linked to musical memory are relatively undamaged by the disease. Interestingly, the regions identified to encode musical memory correspond to areas that show substantially minimal cortical atrophy (as measured with magnetic resonance imaging), and minimal disruption of glucose-metabolism (as measured with 18F-fluorodeoxyglucose

16 positron emission tomography), as compared to the rest of the brain for a large majority of patients. Musical sensitivity, in particular regarding songs discovered during childhood, is one of the very last cognitive capabilities to disappear. (Ferreri et al., 2013) Musical Memory Region Data indicates that music for dementia patients can boost mood, reduce agitation and improve focus. Familiar tunes and lyrics can be recognized across all stages. When participants listened to familiar music, there was a much more extensive pattern of activation of several areas of the brain, including those involved with emotion and the processing of language, movement and memory. “What we found was there was improvement in brain functional connectivity, changes in brain activation and also improvements in memory scores, which told us that by exposing the brain repeatedly to this familiar music, people were actually improving cognitively and there was evidence that their brain was also changing,” said Dr. Corinne Fischer, director of the memory disorders clinic at St. Michael's Hospital. Verbal memory is the ability to remember what you read or hear. It includes your ability to hear or read a word, sentence or paragraph and then recall it when needed. The critical new point of Dr. Fischer’s study was to also track the brain activation response during the encoding phase where improved word recognition coincides with music that provides rich and helpful contextual cues useful for subsequent item recognition. This suggests that

17 music-related memory processes rely on specific neural mechanisms and that music can positively influence both episodic encoding and retrieval of verbal information. (Thompson, 2005) Language Use unambiguous, straightforward, and clear language. Demented patients have reduced capacity for encoding written information, so it is necessary that information is presented in a way minimizes confusion. Damage to the frontal lobe also makes it difficult for them to concentrate for long periods of time, especially when too many pieces of information are presented at once. Therefore, all instructions must be presented one piece at a time in a logical order. The same applies when asking questions. Questions directed towards dementia patients should include no more than two choices. For example, the question “Would you like carrots or peas?” only offers two options – carrots and peas – to choose from. This is done purposefully to adapt to the reduced attention and focus abilities of the demented population. Task Difficulty Dementia patients are often characterized by lack of motivation and lack of engagement. Repeated difficulty carrying out a task can add to these symptoms by serving as a reminder of the progression of the disease. Therefore, to provide demented patients with a motive to start the games, initial task difficulty must be lowered to the point where failure is either impossible or highly unlikely due to the simplicity of the tasks. After few rounds of highly simple tasks, difficulty levels should be gradually increased to achieve the

18 games’ purpose of cognitive learning, as psychology research in learning has proven “the opportunity to engage in difficulties to be extremely successful in learning”. 2. The Role of Gaming No matter how easy we make the game, patients will still feel empowered when playing it. So, observation is crucial: our last key design point is human interaction: Patients interact with caregivers, family and others. The frequency of play for each game should be adapted to each subject, although in general, it is recommended that games are played between 2-4 times per week. (Jiaying Zheng, 2017) VI. Game Design for Early Stage Dementia 1. Quiz Game Games have been found to be effective in treating early-stage dementia. To help patients restore their memories and cognitive ability, quiz games are focused on daily activities. All the quiz memory games are based on the observation of pictures. The specific gaming tasks include identifying colors of pictures, and learning the content or positions of pictures, to train their various cognitive abilities, among them, rapid reactions, discernment skills, and long/short-term memory. Digital games are especially good at simulating daily life scenes, and can assist and guide the elderly to complete specific life tasks to test or exercise their cognitive abilities, such as executive functions, divided attention, long/short-term memory, and spatial orientation and attention.

19 Getting Ready a) It is a game that reminds the subject of important dates, places around the house, what is in the kitchen, how to use items in each room, and how to dress according to the season. It stimulates the frontal lobe to improve decision-making, planning, and organizing and increase short-term memory. Visit to a Shopping Mall To increase memory retention and cognitive ability, a quiz focuses on a daily event using real pictures of a department store. A player might be asked, for example, to purchase a gift for a son or daughter, buy recipe ingredients, etc. During shopping, whatever the activity, whether buying clothes or something else, the patient must do the task and then complete the payment process, which further exercises the player’s planning skills and practical abilities. Such games also help the person bond with family. Find the Way “Find the Way” is a game that stimulates spatial memories through searching tasks, which engages recognition of places and helps build a sustained attention span. The player must plan which actions to perform, and in what order. By using a map, patients can try to find a particular place, position themselves appropriately, look for the right direction to go, and have subsequently have their entorhinal cortex stimulated. Birthday Party No longer being able to identify otherwise familiar faces is a common symptom of dementia. This game enhances people’s episodic memory and ability to recall names and faces as well as match photos with names despite viewing from different angles.

20 The game will help people who no longer recognize who they are or who others are, and utilize the brain more. 2. Digital Games Find the hidden object in all the clutter! Short-term memory loss is a hallmark symptom of dementia. The hippocampus is one of the first areas damaged by dementia, and it is this area of the brain that is responsible for developing new memories. The creeping shrinkage of the hippocampus explains why memory problems become more persistent as dementia progresses to its later stages. This means that the size of the hippocampus is very important in maintaining a patients’ memory. Mental stimulation of various kinds has been proven effective in maintaining the hippocampus size. Accordingly, a game like Memory Repeat is entertaining memory training that can slow down memory loss in dementia patients. 1. Read the name of the object written inside the blue box. 2. Look for the object among the clutter of different objects. 3. The number of objects in the clutter increases at higher game levels. Instructions Playing games is now a technique for dementia sufferers to help them learn new skills and acquire new information. Through digital games for elderly patients, I have incorporated errorless learning scenarios within an active learning paradigm. This has become a widely accepted practice in rehabilitation and dementia treatment, as it has been found to maximize successful retrieval opportunities. Based on these theories of effective treatments that I have

21 discussed above, it is clear that early stage dementia sufferers have excellent opportunities to actively stimulate their thought processes, memory, spatial orientation, and attention. Watch and repeat the ever-growing sequence of flashing lights! Short-term memory loss is the hallmark symptom of dementia. One of the first areas damaged by the disease is the hippocampus, the area of the brain responsible for developing new memories. Given that decreased hippocampal volume correlates with memory loss, leading research has demonstrated the effectiveness of mental stimulation in maintaining hippocampal volume. Accordingly, Memory Repeat is entertaining memory training to decelerate the atrophy of the hippocampus in dementia patients. Instructions 1. Watch and listen for the first signal (a button will light up, accompanied by a tone) 2. Repeat the signal by clicking on the same button 3. The computer will replay the first signal, then play a second one 4. Repeat the two signals in the same order in which they are played 5. Memorize and repeat the chain of signals that grow longer and longer with every round Scramble One of the first symptoms experienced by dementia patients is the inability to find the right words for familiar objects and faces. Damage to the temporal lobe makes it difficult for the person to search for the right word when talking or singing, even if they

22 understand the meaning of the words. Scramble targets the temporal lobe by providing practice opportunities to identify objects and retrieve the correct words from memory. Unscramble the letters and spell out the words in the correct order! Instructions 1. Identify the name of the object or person in the photo 2. Click on a letter that is out of order 3. Click on a different letter, and the two letters will swap places 4. Repeat until the word is spelled out correctly Math Genius Math can be difficult, but we can make it fun! The inability to perform simple calculations and understand arithmetic are common symptoms of Alzheimer’s disease. The left parietal lobe, the dominant lobe, is of central importance in calculating and processing numbers. Damage to this part of the brain can lead to difficulties performing tasks with numbers. Math Genius helps patients stimulate their parietal lobes by offering an easy yet enjoyable math experience. Instructions 1. Choose between addition (+), subtraction (-), multiplication (x), or division (÷) 2. Solve the math equation shown at the top of the screen 3. Click on the red box that has the correct number Hidden Shape

23 Difficulty recognizing familiar objects begins as dementia progresses toward the mid-stage. This is caused by damage to the right temporal lobe, an area of the brain that deals with visual information. Damage to this area can also lead to difficulties recognizing familiar faces, but this only happens in the latter stages. Hidden Shape stimulates the right temporal lobe by providing object recognition practice. Instructions 1. Look at the shape and outline of the object’s silhouette 2. Guess the object that the silhouette represents 3. Click on the button that has the correct answer Puzzle Another common symptom of dementia that begins in the early stage is the decline in spatial awareness. The hippocampus, responsible for developing new memories, is also integral to spatial recall. Damage to this part of the brain makes it difficult for the person to remember locations or where something is in relation to something else. Puzzle trains players’ spatial recall and spatial awareness by having them put together pieces o f famous locations and landmarks. Instructions 1. Drag a puzzle piece to the top of the image 2. Move the piece around until it overlaps with the background image 3. The piece will stop moving when it is put in the correct position 4. Repeat until the image is completed

24 This is a new and helpful technique while they are learning a new skill or acquiring new information. In other words, through digital games for elderly dementia patients, I incorporate errorless learning scenarios within an active learning paradigm, which is a widely accepted practice in rehabilitation and dementia treatment, as computer games have been found to maximize successful memory retrieval opportunities. Based on the theory that I suggested here, I believe the early stages of dementia can be arrested by stimulating thought processes, memories, spatial orientation, and attention by playing computer-based games. VIII. Conclusion Despite the notion that dementia has no real cure, research on the topic took a great leap in the recent years. Researchers found that computer games and tests improve overall mood and slow down the loss of mental capacity in older people at high risk of developing dementia. The scientists who conducted all of these studies tried to achieve the same goal - to slow the decline in mental acuity in older years and stop the development of senile dementia. Comparison and combination of their results showed that simple computer games and the simplest tests for attention and memory are best suited for these purposes. For example, the simplest “Tetris” coped well with such a task as the elderly who played the telephone version of this oldest computer game lost their memory much more slowly and thought more vividly than their peers from the control group who were not interested in computer entertainment. Similar results were obtained for another memory game in which elderly gambling addicts had to memorize a figure on the screen and name it correctly sometime after it appeared on a computer display. Such a method of combating dementia, as scientists admit, has limitations, since with those that already developed dementia, the positive effect of computer games is absent or

25 remains extremely weak in order to reverse negative changes in the brain. Therefore, elderly people should begin such training even before their doctor suspects that they will develop dementia. According to the researchers, both physical exercise trigger many mechanisms in the body, leading to an improvement in its condition, and computer exercises on the plasticity of the brain turn on the right buttons that heal our own computer, the brain. So, recent studies convincingly prove the benefits of computer puzzles: an increase in the integrity of the white matter, neural connections, and the activity of the hippocampus. Thus, the studies of the effectiveness of game for the first time increased production of acetylcholine with regular exercise on a computer. And this is a significant achievement not only for patients with dementia disease, but also for a number of other diseases. \

26 Bibliography Baeklund, P. (2021). Activity ideas for alzheimer’s/dementia residents. https://www.nccdp.org/. Retrieved November 2, 2021, from https://www.nccdp.org/resources/AlzheimersDementiaActivityIdeas.pdf. Ferreri, L. (2015). The influence of music on prefrontal cortex during episodic encoding and retrieval of verbal information: A multichannel fNIRS study. Behavioural neurology. Retrieved November 4, 2021, from https://pubmed.ncbi.nlm.nih.gov/26508813/. Ferreri, L., Aucouturier, J. J., Muthalib, M., Bigand, E., & Bugaiska, A. (2013, January 1). Music improves verbal memory encoding while decreasing prefrontal cortex activity: An fNIRS study. Frontiers. Retrieved November 4, 2021, from https://www.frontiersin.org/articles/10.3389/fnhum.2013.00779/full. Jiaying Zheng, X. C. (2017). Game-based interventions and their impact on dementia: A narrative review . SAGE Journals. Retrieved November 2, 2021, from https://journals.sagepub.com/doi/10.1177/1039856217726686. Levis, S. C., Mahler, S. V., & Baram, T. Z. (2001). The developmental origins of opioid use disorder and its comorbidities. Frontiers. Retrieved November 2, 2021, from https://www.frontiersin.org/articles/10.3389/fnhum.2021.601905/full. Ning, H., Li, R., Ye, X., Zhang, Y., & Liu, L. (2020, May 28). A review on serious games for dementia care in ageing societies. IEEE journal of translational engineering in health and medicine. Retrieved November 2, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279699/.

27 Nousia, A., Siokas, V., Aretouli, E., Messinis, L., Aloizou, A.-M., Martzoukou, M., Karala, M., Koumpoulis, C., Nasios, G., & Dardiotis, E. (2018, July 11). Beneficial effect of multidomain cognitive training on the neuropsychological performance of patients with early-stage alzheimer's disease. Neural Plasticity. Retrieved November 2, 2021, from https://www.hindawi.com/journals/np/2018/2845176/. Stone, J. (2020, December 15). What to do when someone with dementia keeps repeating themselves. Seniors at Home. Retrieved November 4, 2021, from https://seniorsathome.jfcs.org/repetition-dementia/. Thompson, R. G. (2005). Music enhances category fluency in healthy older adults and alzheimer's disease patients. Taylor & Francis. Retrieved November 4, 2021, from https://www.tandfonline.com/doi/full/10.1080/03610730590882819. Yang, H. S. (Ed.). (2010). Entertainment computing - ICEC 2010 - 9th international Conference. Retrieved November 2, 2021, from https://www.springer.com/gp/book/9783642153983.