Developing a Digital Gaming Intervention with Yetitablet® to Improve Older People’s Functioning and Activity in Long-Term-Care – a Feasibility Study

Long-term care (LTC) residents often have many health problems and functional impairments. It has been noticed that physical activity of care dwelling older people is significantly lower than community dwelling older people [1] and older women living in LTC have been observed to spend over 70% of their time sitting or lying during daytime [2]. Lower level of physical activity is associated with more symptoms of anxiety and depression and lower physical performance [3, 4]. Time spent in weight bearing positions and activities is associated with better balance and physical performance while sedentary time is associated with reduced muscle strength, balance, and physical performance [2]. Sedentary time and functional impairments weaken ability to cope with daily activities and the quality of life, and thus cause an increased need for care and caring resources.

One of the promising ways to improve the well-being, functioning and activity of older people is digital gaming which is traditionally used as a leisure activity for younger people. Digital games are played on a digital device such as a tablet computer or a video game console. Nowadays the term serious games is also used, which means that playing has a serious purpose such as exercise, health, or rehabilitation [5]. The effectiveness of digital gaming on the functioning and activity of older people has been studied over the past ten years, and the results have been promising. Digital gaming has been found to improve balance, mobility, and gate [6, 7], promote social interaction [8], and reduce loneliness [9] and depression also on older people with memory disorder [10].

Despite the benefits of digital gaming, the implementation of it in LTC’s everyday life can be challenging. The cost of these games is usually not very high [6] but there might be other barriers for implementation of digital games in LTC. These are for example lack of space, lack of the time required for staff to introduce games to residents and older people's lack of competence in using technology [6, 8]. Healthcare professionals may feel insecure about their own digital skills [11] and attitudes towards new technologies may be rejective, which reduces motivation to adopt new technologies [12]. Also, all the games and devices are not designed for the use of older people [8] and may therefore require quick response, hand-eye coordination, jumping, reaching, or other activities that can be challenging for the older people and require repetition and practice to successfully complete the game.

Mostly used and studied gaming device in LTC environment is Nintendo Wii [13] but in addition, new games and devices are designed and developed for the older people to meet their special needs [14‐16]. There is not much scientific research evidence yet available on the effectiveness of these new technologies on the functioning and activity of older people. Also, the focus of digital game research has been on independently living and healthy older people, so there is a need for game research conducted in the context of long-term care and with population who already has functional decline in many areas. In many previous interventions games have been guided for LTC residents mainly by research staff but this study is carried out in the everyday life of a LTC facility, and the staff implements the digital gaming intervention. Previous digital gaming research has also focused on physical performance, and there is still only little research that considers the social and psychological aspects of gaming [13, 17].

The aim of this study was to test the implementation of digital gaming intervention on a small scale before the full-scale effectiveness study to detect its possible problems. The objective was to obtain information on the feasibility of the intervention and the factors influencing the successful implementation of it, obtain preliminary information on the benefits of the intervention on long-term care residents’ functioning and activity, and test the performance of functional capacity measurements for LTC-residents. We also wanted to test the use of activity monitors with this population which will be used in the future effectiveness study to gain information about changes in physical activity.

Research questions were:

This was a qualitative feasibility study. One long-term care facility located in Northern Finland participated in this study. The LTC facility and participants were selected by purposeful sampling. Both residents of the facility and the staff were invited to participate in the study. Facility residents were invited to participate in the intervention and staff were invited to participate in the post-intervention interview. Participants of the intervention were selected between February and March 2023 according to the inclusion and exclusion criteria by the personnel of the facility who knew the residents well. Inclusion criteria to participate in this study were: 1) able to walk (independently) at least 10 m with or without walking aid 2) sufficient cognitive ability to understand the purpose of the study and instructions for the gaming 3) does not have any disease that would prevent light exercise 4) does not have any acute severe disease 5) living permanently in the facility. Exclusion criteria were: 1) not able to walk independently or with walking aid 2) severe memory disorder or other severe or acute illness 3) too poor vision to play games 4) is receiving some other treatment which may affect the change in functioning or activity. The researcher introduced the study to suitable residents, distributed the research information forms and inquired about their interest in participating in the study. The intern working in the facility contacted the relatives of the residents and delivered the consent forms to sign. Facility staff and interns who participated in the intervention's implementation were invited to participate in the post-intervention interviews.

Eligible residents participated in an eight-week digital gaming intervention with a Finnish innovation, a Yetitablet (picture 1). Yetitablet is a large tablet computer with 55–65″ screen utilizing Android operating system. Yetitablet has a touch screen and a mobile stand on wheels, which allows the screen to be raised and lowered, as well as tilted as needed, all the way to a desk position. Large screen size enables group activities and social interaction. Yetitablet includes YetiCare software which gives Yetitablet an accessible user interface and has many stimulating applications for entertainment, rehabilitation, and physical exercise [18] (Fig. 1).

The development of the intervention started by conducting a systematic literature review on the previously implemented digital game interventions and their effectiveness on the functioning and activity of older people in a long-term care setting [13]. The dosage and duration of the intervention were determined based on this review.First, a one-hour training session was held for the facility staff. A member of the YetiCare company introduced the Yetitablet and advised how to use it remotely via Teams. After the introduction the principal investigator presented the intervention and guided staff in testing the Yetitablet and its games. During the intervention, study participants could choose the games and the amount of gaming because it better reflects the real-life situation and gives a true picture of the effects in a long-term care environment on this population. However, facility personnel were instructed to organize three gaming sessions per week, lasting for about half an hour to one hour. The personnel were instructed to consider the players’ physical and cognitive functioning and coping when directing the games and to adjust the game session according to the participants’ resources. Games were encouraged to be played with about four participants or more. As the intervention progressed, instructions were given to consider the progression of participants so that a more challenging level was selected for the games, and playing would take place as much as possible in a standing position. All persons working in the unit could carry out the intervention. A logbook was given for the facility and gaming session instructors were asked to mark down every playing sessions’ date, duration, participants, and games played during the session. The logbook also contained instructions for the intervention, for example what games could be played, how to make progress to the program, playing in a standing position and in groups. The Yetitablet and logbook were placed in a large multiuse room next to the dayroom.

YetiCare applications (later: games) were classified into the following categories in the Yetitablet: coordination, motor skills, smart games, and entertainment. YetiCoordination included games like darts, bowling and YetiCups (picture 2). These games are played by throwing soft balls at the screen. Also, YetiReaction, YetiCups and YetiBubbles were included in the coordination category, but those games are played by touching the screen. These games require reaction ability, body and movement control and balance if games are played in a standing position. Motor skills category included games like YetiForms, YetiGather and YetiMaze. In these games a player must use fine motors skills in the upper limbs to reach the goal of the game such as moving an object from the starting point to the finish line through a labyrinth. YetiBrain Games included games like a memory game, guess the word –game and a word grid. These games require short term memory, attention, and perceptiveness. Entertainment category included games like table hockey or football, tic-tac-toe, and trivia. Although these games are classified as entertainment, playing them requires for example concentration, quick reactions, body control and weight shifting if played standing up. The staff were instructed to use the YetiCare gamified applications, but they were also allowed to use other content downloaded to the tablet such as Google Maps, newspapers, card games, sudoku and sensory applications. The staff and/or residents could choose the games played during the gaming sessions (Fig. 2).

Qualitative data was collected during this study to obtain information on the intervention's benefits to the residents and its feasibility. Data was collected from the facility staff through a semi-structured thematic interview [19]. Two interns working at the facility at the time of the intervention and one permanent facility staff member participated. The interviewees were a nurse, an occupational therapist student and a geronomy student. Interviews were carried out after an eight-week intervention period in June 2023 via Teams and recorded with the permission of the participants. Two participants were interviewed together and one alone for scheduling reasons. The group interview lasted 59 min and the interview with one participant lasted 28 min. The interviews proceeded according to pre-planned themes which were attitudes towards the intervention and new technology, benefits of intervention for residents, the strain caused by the intervention on staff and residents, implementation of the intervention and usability of the Yetitablet. In addition, the personnel were asked for their thoughts and suggestions for changes related to the intervention protocol. The interview questions were based on earlier research about technology acceptance [20] and ICF framework [21]. The material was transcribed and the total number of transcribed material was 16 pages with the text type Times New Roman, with font 12 with a line spacing of 1.5.

Functioning measurements were done to the residents participating in the intervention before and after the eight-week intervention to test the suitability of the measurements for the target group. Testing data was not analyzed in this study due to the small sample size. Measures done were Short Physical Performance Battery (SPPB) which measures the mobility of older people, and it combines the results of balance tests, gait speed and chair stand [22], Timed Up and Go test (TUG) which measures mobility and balance [23], Geriatric depression scale (GDS-15) which is developed for identifying depressive symptoms in the older people [24] and The Revised Index for Social Engagement (RISE) which measure social engagement among long-term-care facility residents [25].

Qualitative data was analyzed by inductive content analysis [26]. The analysis began by reading through the transcribed material several times. Next, expressions (sentence or set of thoughts) that corresponded to the research questions were extracted from the data (n = 106) and grouped according to the research question. Original expressions were then reduced to a more condensed form and expressions with identical content were combined into a subcategory, which were named with descriptive names (n = 36). Finally, subcategories with the same content were grouped to form main categories (n = 15).

Out of 18 residents in the facility eight were eligible to participate in the study based on the inclusion criteria and one refused to participate due to old age. Four residents who participated in the intervention were men and three were women. The mean age of participants was 86 years (range 8198 years). Participants had multiple physical, sensory, and cognitive impairments. All participants had a diagnosed memory disorder, one had poor vision and two had osteoarthritis. Male participants did not have walking aids, but all participating women used a walker. A summary of baseline characteristics of the residents participating in the intervention is presented in Table 1.

Functioning measures could have been performed on the research participants. One participant refused to do the Timed Up and Go (TUG) and Short Physical Performance Battery (SPPB) measures in pretest and posttest and one refused to do Geriatric depression Scale (GDS-15) in the posttest. All seven participants finished the eight-week intervention program without any injuries. Gaming sessions lasted from five (5) minutes to two hours with an average of 30 min and participants played games from zero to four times per week based on the logbook.

The intervention brought joy and variety to the residents, as the games delighted and increased residents’ alertness and it was seen as a meaningful and varied activity. Residents had fun while playing games and one resident laughed and giggled while playing. “…this is funny, she giggled, and she had so much fun.” Interviewee 1. One resident who never participated in activities found himself meaningful activity through gaming (Table 2).

Success of intervention implementation was classified into three main categories: active participation of the residents in the gaming sessions, low involvement of staff in the implementation of the intervention and variable success of implementing the intervention protocol in the everyday life of LTC facility. The interviewees felt that the staff showed little interest in Yetitablet and few of them used Yetitablet. Instructing residents how to play the games was mainly the responsibility of interns, and therefore few of the permanent staff used the Yetitablet.

The residents participated actively in the gaming sessions. They participated in the game when requested, gaming physical and mental load was suitable for residents, and they were able to concentrate on playing well. Some of the residents were always happy to play, but some had to be motivated sometimes. Watching others play encouraged participation, and some found it difficult to stop playing once they started playing.

Factors affecting the implementation formed nine main categories: positive attitude and motivation of staff important in implementation, staff attitude towards technology can challenge implementation, staff competence in using Yetitablet, practical training, clear instructions and an example of use support the implementation, proper placement of the device is essential to use, residents’ attitude towards participating in activities, poor cognition as a challenge, identifying individually suitable games for residents and successful use of the touchscreen.

The staff's competence in using Yetitablet influenced its use. Easy use of Yetitablet supported its use and staff members who did not participate in the Yetitablet training were able to use it. The device was also handy to use so using it was not time consuming. On the other hand, there were some challenges in using Yetitablet. Sometimes the power button was hard to find and navigating the tablet, for example, from the game back to the home screen was challenging for some of the staff.