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Procedia Computer Science 00 (2020) 000–000
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Procedia Computer Science 179 (2021) 95–102

5th International Conference on Computer Science and Computational Intelligence 2020

Healthy Elder: Brain Stimulation Game for the Elderly to Reduce

the Risk of Dementia
Yogi Udjajaa,*, Reinert Yosua Rumagita, Wikaria Gazalia, Jonathan Denia
a
Computer Science Department, School of Computer Science, Bina Nusantara University, Jakarta, Indonesia 11480

Abstract

In general, everyone will experience a period of growth, starting from infants to children to adults. There will come a time when
a person's growth stops and decreases. When cognitive capabilities are not used often, it will decline, and this phenomenon is
known as cognitive impairment. The most common form of cognitive impairment is dementia. Dementia is a degenerative
disease that cannot be cured with the usual treatment techniques for physical degenerative diseases, such as surgery or physical
contact. It is because this disease attacks the human nerve. One method that can be done is to prevent or reduce the risk of
dementia by stimulating the brain. To implement this method, the researchers made a game that can stimulate the brain. The
researcher used the Game Development Life Cycle (GDLC) method in the process of making the game. The test was conducted
at Berea Nursing Home and Pusaka 41 Nursing Home. The result shows that out of 30 people who were tested, 19 people showed
improvement in terms of their cognitive capabilities in seven days.
©
© 2021
2020 The
The Authors.
Authors. Published
Published by
by Elsevier
ELSEVIER B.V.B.V.
This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0)
This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0)
Peer-review under responsibility of the scientific committee of the 5th International Conference on Computer Science and
Peer-review under
Computational responsibility
Intelligence 2020of the scientific committee of the 5th International Conference on Computer Science and
Computational Intelligence 2020
Keywords: Type your keywords here, separated by semicolons ;

1. Introduction

The number of elderly people in Indonesia has grown quickly and exponentially. This statement is supported by
the data from the census of the population. In 2010, the census recorded 18.1 million elderly people, and in 2016,

* Corresponding author. Tel.: +628982683399.

E-mail address: udjaja.yogi@gmail.com, yogi.udjaja@binus.ac.id

1877-0509 © 2020 The Authors. Published by ELSEVIER B.V.

This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0)
Peer-review under responsibility of the scientific committee of the 5th International Conference on Computer Science and
Computational Intelligence 2020

1877-0509 © 2021 The Authors. Published by Elsevier B.V.

This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0)
Peer-review under responsibility of the scientific committee of the 5th International Conference on Computer Science and
Computational Intelligence 2020
10.1016/j.procs.2021.12.013
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2 Yogi Udjaja at al. / Procedia Computer Science 00 (2020) 000–000

the number increased to 21 million (8.04 percent of the total population of Indonesia, which was 261.1 million
people). It is estimated that the number would continue to increase to 26 million in 20181. The higher life
expectancy of the citizens increases the number of elderly people in the following years. This causes the risk of
degenerative diseases among elderly people. Degenerative diseases refer to the deterioration of cognitive and
physical capabilities, such as the decline in sight, hearing, and the most difficult to cure of all, memory (dementia).
Dementia ranked fourth in terms of fatal diseases after heart disease, stroke, and cancer2.
This research focuses on dementia because it is more complex to cure compared to other degenerative diseases.
In the case of degenerative diseases that affect one’s physical capabilities, surgery can be conducted to cure the
diseases. However, in the case of degenerative diseases affecting the cognitive capabilities—such as dementia, the
process of healing cannot be conducted through surgery or other physical procedures. It is because dementia
compromises the nervous system, and it is characterized by some symptoms, such as memory loss, difficulty with
speech, focusing, and planning, and disorientation of time and space. Besides cognitive impairment, dementia also
affects the patient’s neuropsychiatry and causes social deficit, which in turn, causes depression, withdrawal,
hallucination, delusion, agitation, and insomnia3.
Dementia occurs progressively, which means that early preventive measures can be implemented when the
symptoms occur. If it is not treated early, dementia will spread and cause more serious diseases. Out of all patients
who suffer from dementia, 50 to 60 percent of them suffer from Alzheimer’s disease. Another type of dementia that
is frequently found is vascular dementia. Moreover, dementia can be caused by other diseases such as Parkinson’s
disease4.
The data from the Ministry of Health of the Republic of Indonesia (2016) showed that 46 million people in the
world suffer from Alzheimer’s disease, and 22 million of them lives in Asia. Furthermore, according to the theories
on diseases, dementia affects 10 percent of people above 65 years old and 47 percent of people above 85 years old5.
Before it happens, preventive measures should be implemented early in order to decrease the risk of dementia.
The data from Alzheimer’s Organization of Indonesia (2019) revealed several ways to decrease the risk of
dementia (see Figure 1.1)6. Figure 1.1 shows that the risk of dementia can be minimized by maintaining a healthy
heart, exercising productively, consuming fruit or vegetables, socializing, and stimulating the brain. This research
focuses on early treatment by stimulating the brain. One of the methods that are commonly applied is the brain gym.
Brain gym is a set of simple movement-based activities that aim to balance the function of the left and right brain. It
can stimulate the brain so that it does not lose its intellectual capacity, and it can restore the condition of forgetful
people since it re-activates the centers of the nervous system5.

Figure 1.1 How to Reduce the Risk of Dementia 6

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Yogi Udjaja at al. / Procedia Computer Science 00 (2020) 000–000 3

Stimulation to the brain can be conducted through many fun ways; one of them is by playing games7. Games can
be a method of therapy for dementia in fun activities. Moreover, doing physical activities can affect cognitive
functions8.
Based on those arguments, the researchers created a brain-stimulating game that can enhance the cognitive
functions and prevent dementia. This game was created and adjusted to the level of experience of the elderly people.

2. Related Research

2.1. Dementia

Dementia or senility is a disease that often affects elderly people, and due to chronic brain disorder, they often
experience moments of forgetfulness. Dementia is a scientific terminology for senility, which is a more common
term for most people. The word ‘dementia’ comes from the word emence, and it was first used by Pinel (1745 –
1826)9. In general, dementia develops slowly. The patients will experience symptoms of mild depression and
confusion, which will turn severe, and it will be followed by the loss of general intellectual capabilities9.
The cognitive decline will emerge in the form of forgetfulness, which is the mildest form of cognitive
impairment. This impairment was discovered in approximately 39 percent of elderly people whose ages are between
50 to 59 years old, and the percentage would increase to 85 percent for 80-year-old people10. In general, this
impairment includes the decline in the naming abilities and the speed of information retrieval from memory.
Besides the decline in memory, the patients of dementia will experience a decline in fluid intelligence9. The
impairment signals the decline in the function of the right brain, and this will manifest through the difficulties in
nonverbal communication, problem-solving, face identifying, focusing and concentrating. The aging process can
also decrease the ability that involves perceptual speed, such as identifying an object or remembering a digit symbol.
This ability is relatively important since it affects one’s cognitive capabilities.
Cognitive impairment also affects the patterns of interaction with the environment and social activities10. The
patients tend to withdraw from the society. This decline is also accompanied by the decline of activities of daily
living (ADL) which occurs in stages. Several activities that will deteriorate are conducting financial management,
managing correspondence, travelling or commuting by public transport, doing hobbies, cooking, organizing food
and medicine, using telephones, and so on. Slowly the patients will not be able to do many daily activities, such as
getting dressed, combing their hair, taking showers, eating and other basic activities.
Dementia can be classified into three main categories, which are11:
• Alzheimer’s Disease
Alzheimer’s disease is the most common form of dementia. Alzheimer’s disease was discovered in 50 to 60
percent of the patients of dementia, and it is estimated to affect 35.6 million people worldwide. There are
two types of Alzheimer’s disease, which are presenile dementia (Alzheimer’s disease type 2) which affects
adults below 65 years old, and senile dementia (Alzheimer’s disease type 1) which affects elderly people
above 65 years old. This disease is caused by the decreasing number of brain cells; thus, people with this
disease possess less level of neurotransmitter than normal. Neurotransmitter functions as the controller of
the brain functions. Alzheimer’s disease is hereditary and commonly passed on through the family. Even
though it is genetic, not all family members will get the disease. Women have a higher risk to suffer from
this disease than men because due to their hormones, women are faster to go into menopause compared to
men with their andropause. Andropause is a specific condition characterized by the decrease of testosterone
on elderly men whereas menopause is a phase in which both the ovaries of women stop producing estrogen,
which causes the cessation of menstruation. Andropause occurs on men whose ages are around 55 to 60
years old while menopause occurs on women whose ages are approximately 50 years old12.
• Vascular Dementia
Vascular dementia is the second most common form of dementia after Alzheimer’s disease, and it is caused
by the weak blood circulation to the brain (cardiovascular disease). Men have a higher risk to suffer from
vascular dementia compared to women, particularly at younger age. This is because of some risk factors
such as cardiovascular disease, which is a disease commonly found in men. The cardiovascular disease
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itself is a term for various conditions in which the blood vessels are either constricted or blocked, which
may result in heart attack, chest pain (angina), or stroke.
• Dementia due to other diseases
Some diseases may cause dementia to patients. One of them is Parkinson’s disease. This disease is unique
and may cause muscle stiffness, speech problems, and tremors.

2.2. Therapy to Decrease the Risk of Dementia

Dementia is a disease that often affects elderly people, and it causes a decline of cognitive capabilities,
capabilities to acquire knowledge from experiences13. Therefore, one’s cognitive capabilities are influenced by his
or her brain to think and process certain information.
As mentioned in the background, dementia is a type of disease that can progress further. The symptoms of
dementia can be recognized so that early treatment can be conducted. One common symptom experienced by the
patients of dementia is the decline in memory, starting from mundane and simple issues, such as forgetting the
positions of the surrounding objects.
The form of therapy that has been tested to prevent dementia is the brain gym. Brain gym is a set of physical
activities or movements that can help relieve stress, clear the mind, and improve memory14. Brain gym is also
considered as a safe method of treatment since it is non-pharmacologist and does not involve any medication.
Brain gym can facilitate learning activities and provide adjustment to daily tension, challenges, and demands.
Moreover, brain gym can strengthen the blood and oxygen circulation to the brain and stimulate the two brain
hemispheres so that they can work in balance. Brain gym is also proven to trigger the brain so that the intellectual
capability and awareness do not diminish, and it is believed that brain gym can restore the mind of forgetful people
since it re-activates the centers of the nervous system on the brain stems15.
However, in this technological era, people prefer using gadgets or other electronic devices that can be used
anytime and anywhere. The technological development makes digital media spread further and readily accessible to
society, including elderly people. Gadgets and social media have been a part of elderly people’s daily activities.
Therefore, the development on technology-based methods of therapy is needed in order to keep up with the routines
of elderly people.
One of the suitable technology is the smartphone because the smartphone is the most familiar form of technology
for elderly people. The proposed method of therapy is through games since games are considered relatively effective
and flexible in stimulating the brain and preventing dementia for elderly people17.

2.3. Games as Brain Stimulation

The brain is a complicated and vital organ for human lives since it is the center of all human behaviors and
activities. Similar to other parts of the body, the brain functions can be enhanced if trained or may decline if idle.
However, different from other parts of the body, besides sufficient physical training and nutritional intake, the brain
needs stimulation to enhance its functions and awareness.
Out of several methods to stimulate the brain, one of the relatively effective methods is by playing games.
Playing games can improve the cognitive capabilities of the brain. It can also bring positive impacts to one’s health
because it can improve visual ability and decision-making process. In fact, people who play games can make
decisions 85-percent faster compared to those who do not play games18.
On one hand, games are addictive and may unavoidably function as a form of entertainment if the players
understand the process of playing the games. On the other hand, if the games contain elements of education, the
players can train and stimulate their brain, or even master and enhance their cognitive capabilities19.
The positive impact of playing games on brain health is to balance the left and the right brain. Games can prompt
the players to do a series of physical activities with the principle of crossing movements. These movements utilize
extremities on both sides of the body so that both brain hemispheres can be used at the same time. For example,
coordination between the eyes and hands is need when playing strategy and puzzle games. These movements are
proven to be able to balance the functions of both brain hemispheres20.
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2.4. Mini-Mental State Examination as Diagnosis Tool for Dementia

Mini-Mental State Examination (MMSE) is a simple testing method to diagnose the categories of dementia by
evaluating the respondents’ cognitive capabilities21. This MMSE method is a simple method that can be conducted
in 5 to 10 minutes. Clinically, MMSE can also provide comprehensive and accurate results because besides
discovering cognitive capabilities, the mental status of elderly people can also be detected.
The testing method can be conducted by providing some questions. The questions enabled the researchers to
evaluate the 5 cognitive aspects of the respondents, which are orientation, registration, attention and calculation,
recall, and language22. The orientation test aims to discover the respondents’ awareness and thinking concerning the
time and place. This test is designed since the patients of dementia in general experience disorientation or confusion.
The registration test aims to test the respondents’ long-term and short-term memory and the respondents’
responsiveness in recognizing an object. The attention and calculation test aims to test the respondents’ focus
through calculation tests and concentration tests. The recall test aims to test the respondents’ short-term memory by
recalling something that has just been heard before. Lastly, the language test aims to test the respondents’ abilities to
name, pronounce, listen and write.
Every question has its own scores, and the total score for MMSE is 30. There are 4 categories of Alzheimer’s
disease, which are normal, mild, moderate, and severe (see table 1). The patients with normal cognitive category can
still conduct daily activities whereas the patients with severe cognitive category always need someone else’s
assistance in conducting daily activities (see table 2).

Table 1. Questions on MMSE Test 22

No. Questions Aspect Score
1 Year Orientation 1
2 Month Orientation 1
3 Date Orientation 1
4 Day Orientation 1
5 Season Orientation 1
6 Country Orientation 1
7 Province Orientation 1
8 City Orientation 1
9 Hospital Orientation 1
10 Current position (in the room/on the floor) Orientation 1
11 Naming three objects Registration 1
12 Naming three objects Registration 1
13 Naming three objects Registration 1
14 Subtraction of 7 out of 100 Attention and Calculation 1
15 Subtraction of 7 out of 100 Attention and Calculation 1
16 Subtraction of 7 out of 100 Attention and Calculation 1
17 Subtraction of 7 out of 100 Attention and Calculation 1
18 Subtraction of 7 out of 100 Attention and Calculation 1
19 Repetition of the previous 3 objects Recall 1
20 Repetition of the previous 3 objects Recall 1
21 Repetition of the previous 3 objects Recall 1
22 Guessing the pictures of objects Language 2
23 Repetition of “if not and or but” Language 1
Giving oral command: Get the papers with your right hand,
24 Language 3
fold both of those papers and put them on the floor
25 Giving written command: “Hold your left ear” Language 1
26 Composing a sentence Language 1
27 Imitating pictures Language 1
Total of Scores 30
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Table 2. Alzheimer’s Disease Assessment Scale 22

MMSE Score Category of Alzheimer’s Disease Level of Autonomy
0–9 Severe Total dependence on other people’s assistance
10 – 17 Moderate In need of supervision
18 – 26 Mild Independent of other people’s assistance
27 – 30 Normal Unproblematic

3. Research Method

The researchers utilized the game development life cycle23,24 as the method of creating the game. Then to adjust
to the elderly people’s model experiences, the researcher adopted the concepts of game experience from ref. 25,26,27.
The combination of concepts can be considered as a foundation to create better experiences for elderly people. The
standard for the game content refers to table 1. The survey and testing were conducted at Pusaka 41 Nursing Home
and Berea Nursing Home.
According to the results of the survey, the physical condition of elderly people is different from the physical
condition of younger people. According to the Constitution of the Republic of Indonesia Number 13 of 1998, elderly
people are people who have reached the age of 60 years old or older27-. There are several physical aspects that need
to be considered, which are limbs, sense of sight, and sense of hearing. Based on the survey, there are several game
specifications that need to be considered:
a. The colors of the background and objects in the game
Neutral colors or a simple combination of colors must be used for the colors of background and objects in the
game. It is suggested to use black, white, or pastel colors.
b. Size of the texts and objects in the game
The texts and the objects in the game must be properly sized so that they are clear and visible for elderly
people. Games that are developed on smartphone platforms would have smaller screen resolution. Therefore,
the composition and the size of the texts and objects must be adjusted.
c. No fast or agile movements required
The elderly people’s process of thinking and moving is not as fast as the younger people. Therefore, the game
mechanism does not require the users to move fast, but it still stimulates the brain of elderly people.
d. No short time limit
The shorter time limit makes the game more difficult to play, and it could pressure the users. As a result, this
game is expected to be able to entertain the elderly people and make them more relaxed.
e. Audio
Audio or background music and sound effects in the game must be calming for the users so that it will be
able to provide better user experiences.

4. Result and Analysis

The testing was conducted on 30 elderly people, 18 people from Pusaka 41 Nursing Home and 12 people from
Berea Nursing Home. Their average age is 56 to 77 years old. The testing was conducted in 7 days, and the playing
time was maximum 1 hour a day. The testing was conducted by administering pre-test and post-test. A pre-test is the
process of testing which is conducted before the experiment whereas a post-test is the process of testing which is
conducted after the experiment. The experiment, in this case, means playing the game for 7 days. The result can be
seen in table 3. When totaled, the players experienced 63-percent of improvement, and the improvement started
from 3 to 23 percent. On the other hand, 2 elderly people actually experienced a decline, and after being
interviewed, it was found that the 2 people did not routinely play the game.
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Table 3. Result of Pre-Test and Post-Test

Player Age Pre-test Post-test Category Deviation Percentage
1 56 21 25 Mild 4 13%
2 58 20 25 Mild 5 17%
3 58 26 26 Mild 0 0%
4 61 28 28 Normal 0 0%
5 63 30 30 Normal 0 0%
6 64 29 29 Normal 0 0%
7 65 24 25 Mild 1 3%
8 65 27 28 Normal 1 3%
9 65 24 24 Mild 0 0%
10 66 26 27 Mild - Normal 1 3%
11 68 27 28 Normal 1 3%
12 68 30 30 Normal 0 0%
13 68 24 27 Mild - Normal 3 10%
14 68 30 30 Normal 0 0%
15 68 25 26 Mild 1 3%
16 69 24 26 Mild 2 7%
17 69 25 27 Mild - Normal 2 7%
18 70 14 21 Moderate - Mild 7 23%
19 70 20 22 Mild 2 7%
20 71 23 26 Mild 3 10%
21 71 19 23 Mild 4 13%
22 72 27 27 Normal 0 0%
23 72 27 27 Normal 0 0%
24 73 25 24 Mild -1 -3%
25 73 24 27 Mild - Normal 3 10%
26 74 26 25 Mild -1 -3%
27 74 20 21 Mild 1 3%
28 75 23 26 Mild 3 10%
29 76 25 27 Mild - Normal 2 7%
30 77 27 29 Normal 2 7%

5. Discussion and Conclusions

In this case, the game can be considered as a tool to prevent or reduce the risk of dementia. In the course of 7
days, there are some cases in which the elderly people whose Alzheimer’s disease belong to the moderate category
actually got better, and their category of Alzheimer’s disease became mild. Several cases actually showed that the
elderly people with mild category of Alzheimer’s disease improved to normal category. Furthermore, cognitive
enhancement also occurred, and the average was 3 to 23 percent. If brain gym is not implemented, the cognitive
capabilities will someday deteriorate. This game is merely an alternative. There are many other options that can be
used in accordance with the wishes of each person.

Acknowledgement

The researchers would like to convey their gratitude to Pusaka 41 Nursing Home, Berea Nursing Home, and the
respondents who have helped and contributed a lot for this research.
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