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Since the creation of the earliest video games in the 1970s, a number of studies have been conducted to investigate how cognitive skills are involved in these electronic games. Within the field of neuropsychology the first video games represented an interesting tool for the implementation of rehabilitation programmes as they provided tasks that addressed multiple cognitive skills. The ease of use and the aesthetic attractiveness of video games motivated this choice. Some studies were conducted with healthy elderly people to assess the impact of video games on cognitive and motor skills. However, these video games were not very flexible and tasks resulted rather repetitive leading to their abandonment as a rehabilitation tool for many years. During the last years, improvement in video games technologies has facilitated the development of applications with contents and ergonomics more appropriate to older adults than predecessors’ video games. In the area of AD care there is an increasing interest for the last generation video games as a means for delivering cognitive stimulation in a pleasant way. Nevertheless it seems important to assess their usability before assessing their clinical benefits. We have conducted a usability study of two sport video games of the Wii console from NintendoTM. The aim of this project was to determine if older adults with cognitive impairment could learn to play the two video games and to control their movements with the wireless controller (i.e., Wiimote). Tests sessions were also conducted with the purpose of exposing some design issues of the system that can complicate its use by our target users. A secondary objective was to examine how particular neuropsychological deficits could modulate usability of these games. One group consisted of older adults with mild-to-moderate AD according to NINCDS-ADRDA [36] diagnosis criteria. Another group consisted of older adults with Mild Cognitive Impairment (MCI) according to the Petersen et al. diagnosis criteria [42]. A thrid group consisted of healthy elderly. All subjects were aged between 75 and 90 years. Participants were recruited through a day care centre. Explanation of the study was provided and a consent form was signed prior to their attendance to the test sessions. User-test protocol consisted of: One introductory session and four 4 test sessions at a rate of one-hour session per week. In the introductory session neuropsychological assessment was conducted. In this session participants also created their own avatar for the game purposes, a task that was used to instruct them in the use of the Wiimote. In the test sessions participants were asked to play two games of bowling and two games of tennis in an alternating way (B-T-B-T). The screen and the player were video recorded at each test session with two camcorders. Material included the video game console Wii from NintendoTM, the Wiimote, the tennis and bowling WiiSports games, a 46-inch plasma screen, two (2) camcorders and a behavior-analysis software. To collect performance and behavioral data we used the video recordings that were analyzed subsequently with the behavior-analysis software. A five-point Likert scale was used to assess user preferences. The preference scale was administered twice, once at the end of the first test session and once again after the fourth test session. This choice was made with the purpose of evaluating whether familiarization with the video games had an influence on the subject's preference measures. Data analysis concerned only the first and the last test session. Results showed that all the participants independently of their cognitive status could use the wireless controller and learn to play the two games. However individuals in the AD and the MCI groups needed more assistance, from verbal prompts to physical help during the first sessions. As expected the number of manipulation and timing errors was more important in these two groups than in the healthy elderly group. Concerning performance measures, we could observe that in general for all the participants the number of timing errors and help requests decreased from the first session to the last one in the bowling game. In the tennis game the number of correct actions increased and the number of timing errors and of help requests decreased. The tennis game was considered more difficult to play than the bowling game, in part due to the precise coordination that it requires. With reference to the preference measures, we observed that the evaluation was more positive in the second evaluation than in the first one. A number of usability problems needing some special considerations were noticed. The graphic display presents at certain moments too much information that is difficult to treat by users with cognitive deficits (e.g., scores, arrows to guide the movements, instructions on how to make an action, etc). Errors due to manipulation concerned mainly the use of the Wiimote buttons, such as finding the correct button at the beginning of each session because of memory impairment. Finally the posture required for playing these sports games and the use of the Wiimote may not be suitable for frail elderly (e.g., fatigue, hand tremor, articulation pain, etc.). One of the positives outcomes of this experience was the improvement throughout the sessions in performance measures that we observed for most of the participants. In the case of patients in the AD and the MCI groups, this finding is consistent with preserved procedural memory abilities involved in both cognitive and motor skills. On the contrary, for the same participants coordination difficulties (i.e., timing errors) could be explained by the involvement of executive control, responsible of planning capacities and mental flexibility, among others. We noticed that timing errors corresponded to specific moments where the participant had to inhibit some kind of motor response and to generate another (e.g., press and release a button). This study confirmed the importance of usability testing with end-users before introducing mainstream technologies to older adults suffering from cognitive impairment. In the field of AD care, technology for leisure and stimulation should be introduced in a simple and understandable way. It was also concluded that simplicity and facility to learn are two fundamental criteria of interface design when a public with cognitive deficits is targeted. Regarding usability testing methodology, these results confirm the advantages of conducting repeated sessions with persons with AD. We could observe a positive evolution not only in performance measures but also in preference measures. Multiple usability sessions allow users with cognitive impairment to get familiar with technological devices, to learn how to use them, and to have a positive experience with them—especially when this process concerns games and entertainment technologies. This experience also corroborates the role of motivation and of a supporting social environment in how a person learns to use new technologies.
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