=Paper=
{{Paper
|id=Vol-3715/paper7
|storemode=property
|title=Mosaic of Memory: a serious game to improve spatial and autobiographical memory in Alzheimer’s patients
|pdfUrl=https://ceur-ws.org/Vol-3715/paper7.pdf
|volume=Vol-3715
|authors=Ilaria Amaro,Attilio Della Greca,Cesare Tucci,Genoveffa Tortora
|dblpUrl=https://dblp.org/rec/conf/ini-dh/AmaroGTT24
}}
==Mosaic of Memory: a serious game to improve spatial and autobiographical memory in Alzheimer’s patients==
https://ceur-ws.org/Vol-3715/paper7.pdf
Mosaic of Memory: a serious game to improve spatial
and autobiographical memory in Alzheimer’s
patients⋆
Ilaria Amaro1,∗,† , Attilio Della Greca1,† , Cesare Tucci1,† and Genoveffa Tortora1,†
1
Computer Science Department, University of Salerno, Fisciano, Italy
Abstract
Alzheimer’s disease (AD) involves significant cognitive impairments that impact patients’ quality of life.
This paper proposes a novel computerized cognitive training (CCT) approach through both a web and
mobile application called ”Mosaic of Memories (MoM)” that aims to slow the deterioration of spatial and
autobiographical memory in AD patients. MoM uses a serious game framework similar to the traditional
card memory game, promoting spatial memory by requiring users to match pairs of cards on a virtual
grid. Importantly, MoM integrates personalized and multisensory content, presenting images, names,
and audio of meaningful individuals to stimulate autobiographical memory. The application also adapts
difficulty levels based on user performance and incorporates a facial microexpression monitoring system
to assess frustration levels during the game. MoM thus emerges as a dynamic cognitive training tool
designed to stimulate spatial and autobiographical memory in AD patients, adapting to the user’s profile
and characteristics.
Keywords
Memory, serious game, Alzheimer’s disease (AD), Artificial Intelligence (AI), Computerized Cognitive
Training (CCT), spatial memory, autobiographical memory.
1. Introduction
Alzheimer’s disease (AD) is the most common form of dementia and is a major cause of disability
with a significant impact on the health of individuals and society.
Although the clinical presentation may vary in mild or early cases, AD tends to mainly affect
the cognitive domains of episodic memory (EM), semantic memory (SM), and spatial abilities
(SA)[1].
In addition to memory and visuospatial deficits, patients with AD manifest a variety of symptoms
related to the cognitive and affective spheres (such as difficulty solving problems and feelings
of sadness and lack of motivation) that significantly affect the patient’s daily life [2] [3] [4].
Within the complex symptomatological picture presented by AD patients, memory deficits
INI-DH 2024: Workshop on Innovative Interfaces in Digital Healthcare, in conjunction with International Conference on
Advanced Visual Interfaces 2024 (AVI 2024), June 3–7, 2024, Arenzano, Genoa, Italy (2024)
∗
Corresponding author.
†
These authors contributed equally.
Envelope-Open iamro@unisa.it (I. Amaro); adellagreca@unisa.it (A. Della Greca); ctucci@unisa.it (C. Tucci); tortora@unisa.it
(G. Tortora)
Orcid 0009-0003-0592-2389 (I. Amaro); 0000-0002-4900-8666 (A. Della Greca); 0000-0001-5181-7115 (C. Tucci);
0000-0003-4765-8371 (G. Tortora)
© 2024 Copyright for this paper by its authors. Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0).
CEUR
ceur-ws.org
Workshop ISSN 1613-0073
Proceedings
indeed represent one of the most debilitating aspects. In the following paper, we will focus
on (i) spatial memory deficits and (ii) autobiographical memory deficits to propose a web and
mobile application that serves as a compensatory exercise to slow down the deterioration of
these two types of memory.
• (i) Spatial memory
Spatial memory is a brain function responsible for recognizing, encoding, storing, and
retrieving spatial information about the organization of objects or specific pathways [5].
Several studies [6] [7] have established the link between the hippocampus and memory
for object location in space. However, hippocampal dysfunction, which is evident in
patients with Alzheimer’s disease and Mild Cognitive Impairment (MCI) [8] [9], leads to
impairment in the ability to remember the spatial arrangement of objects.
In addition, the hippocampus is also involved in processing viewpoint-independent
spatial representations when comparing visual scenes [10][11] [12]. This element
explains its role in understanding the spatial arrangement of a scene independently of
the observer’s perspective.
• (ii) Autobiographical memory
Autobiographical memory constitutes a complex cognitive system that facilitates the
retrieval of prior information, events, and personal experiences [13]. This system con-
ceptually, chronologically, and thematically organizes autobiographical memories by
operating on multiple levels of abstraction ranging from vivid sensory, perceptual, emo-
tional, and conceptual details of specific moments to more general summaries of life
periods [14] [15] [16].
Such organization allows personal memories to be recalled and combined in various
ways and for multiple purposes [17]. This type of memory is crucial for maintaining
personal identity over time and consists of two main elements: personal episodic memory
and personal semantic memory [18] [19] [20]. Personal episodic memory concerns the
recollection of specific events in one’s life with contextual details such as place, time, and
people involved. In contrast, personal semantic memory includes personal information
not directly related to events.
Alzheimer’s disease profoundly impairs both components of autobiographical memory
[21] [20]. This leads to significant difficulties in recalling specific life events and general
personal information. The resulting disorientation and loss of identity [22] deeply affect
patients’ sense of self and personal continuity.
Currently, pharmacological treatments used to counteract early cognitive impairment
in patients with AD are limited [23]. Given these limitations, there has been a surge of
interest in compensatory cognitive interventions, such as Cognitive Training (CT), over
recent decades. CT, which involves guided practice of tasks reflecting specific cognitive
functions [24], holds promise in slowing cognitive decline associated with aging and
disease. Its benefits can be observed even in the long term [25]. However, it is crucial
that the training targets the main domains impacted by Alzheimer’s disease, including
episodic memory, semantic memory, and visuospatial skills [26].
Computerized cognitive training (CCT) offers numerous advantages regarding accessi-
bility and personalization. Indeed, it has been shown that CCT can improve episodic
memory function and visuospatial skills in individuals with mild cognitive impairment
[23]. However, training protocols must be optimized to maximize the transfer of benefits
to daily activities [27].
In light of the evidence in the literature, in the following paper, we propose a CCT that consists
of a web and mobile application based on a serious game called ”Mosaic of Memories (MoM).”
The goal is to train spatial and autobiographical memory in patients with Alzheimer’s disease
to slow the progressive degeneration of these two types of memory. Inspired by the traditional
card memory game, the game requires patients to match pairs of cards placed on a virtual grid.
To achieve a correct pairing, the patient must strive to remember the position of the cards on
the grid, thereby exercising spatial memory. One of the main features of MoM is the use of
personalized content in the form of cards, which contain images of people significant to the
user matched with their respective names. This unique approach fosters emotional engagement
during gameplay and effectively serves as an effective tool for exercising the patient’s semantic
autobiographical memory.
MoM stands out for its adaptability, offering training for both spatial and autobiographical
memory. The application is designed to be highly customizable and user-centered, adjusting
the game’s difficulty level in real time based on the patient’s performance. This is measured
by the time taken to complete the game and the number of mistakes made, ensuring a tailored
experience for each user.
MoM is designed with user comfort in mind. It features a support function that the user can
activate after making three consecutive mistakes during the game session. This feature provides
a visual hint through a pair of illuminated matching cards. This feature ensures patients can
continue the game without frustration, even if they make mistakes. MoM is not just a game,
it’s a CCT tool. After each correct pairing (two matching cards), the user is shown a window
containing information about the card (face and name).
This association stimulates semantic autobiographical memory due to the connection between
image and name. MoM understands the importance of personal connections. That’s why, at any
time during the game, the user has the option of accessing the ’cherished individuals’ function.
This function allows the patient to view the card of all cherished individuals, containing their
image, their name, and a short descriptive audio recorded directly from the cherished individuals.
In this way, the user receives multi-sensory stimulation, integrating visual and auditory stimuli
to make autobiographical memory stimulation more effective.
An additional innovative aspect of MoM is integrating a facial microexpression monitoring
system that detects frustration, which can negatively affect the gaming experience. This data
is recorded along with the gaming data in the ”admin” panel of the user’s profile and made
available to the therapist and the patient’s family to enable continuous monitoring of their
emotional state and gaming performance trends over time. Each user account will have two
profiles: one accessible to the patient to play and one accessible only to family members and
therapists.
2. Related Works
The demographic crisis in Western countries has led to an increase in the elderly population and
an increase in people with Alzheimer’s disease, which is the most prevalent form of dementia
[28]. People with dementia may experience difficulties such as memory loss, confusion, and
behavioral disturbances that typically impair their ability to perform daily activities [29].
In an attempt to improve the quality of life of AD patients, numerous interventions based on
nonpharmacological therapies have been proposed in recent decades [30][31]. Specifically, reha-
bilitation has become a recommended practice to improve patients’ autonomy and interaction,
delay cognitive and functional decline, and promote well-being [32].
The rehabilitation approach traditionally includes mobility and balance rehabilitation inter-
ventions, strategies to prevent falls, intensive physical exercises, cognitive stimulation, and
psychological and occupational therapies [33]. However, the increasing prevalence of dementia
has highlighted the need for more effective treatments, thus leading to a growing interest in
new rehabilitation methodologies, such as serious games [34] [35].
In recent years, the video game industry has constituted the fastest-growing commercial sector
among all entertainment media worldwide, and the evolution of these technologies has paved
the way for the emergence and development of serious games. These digital games, unlike tradi-
tional games, have multiple purposes beyond entertainment, such as educational purposes [36],
enhancement of users’ abilities [37], and, in recent years, even training of cognitive functions for
the elderly population [38]. The research community is not just interested but deeply invested
in exploring solutions for game-based cognitive assistance [39] [40]. This strong interest under-
scores the relevance and urgency of this topic in our field. One example is the work of Nacke
and colleagues [38], who examined the impact of digital games on handheld consoles, such as
the Nintendo DS, on the elderly population. The research revealed that although elderly gamers
were more proficient and accurate in solving game tasks using the traditional pen-and-paper
method than the Nintendo DS system, the digital game experience for the elderly elicited a
more incredible feeling of fun and engagement. This phenomenon can be explained through
the concept of flow, representing a mental state of complete concentration and satisfaction in
the play activity [41].
According to flow theory, to achieve optimal engagement, a game must have four essential
elements: clear objectives, constant feedback, the ability to focus on activities, and the ability
to complete activities. In addition, studies suggest that older people prefer games that elicit
positive emotions and feelings of tension rather than excitement and extreme challenges [42].
Therefore, digital games need to adjust their difficulty and offer positive rewards to ensure a
rewarding gaming experience for elderly players, thereby also improving their learning process
[43].
Understanding the responses of the elderly during digital gaming activities has enabled the use
of video games as less expensive and more accessible assistive tools. This is made possible by
the fact that the mechanisms of serious games rely on specific cognitive, social, and behavioral
skills that can be improved by increasing the time of play and the difficulty of challenges [44]
[45]. These skills include motor skills, perception-attention, working memory management,
content memory, reasoning, planning, problem-solving, and social interaction skills [46].
Several papers in the literature have examined the use of serious games for subjects with
cognitive deficits related to MCI, considered a possible precursor to Alzheimer’s, and patients
with AD.
One example is the 2020 work of Thapa and colleagues[47], in which the authors proposed
a virtual reality (VR)-based cognitive training program for subjects with MCI. This program
involved participants performing interactive activities via VR devices, such as a visor and
two wireless controllers. The activities included games to exercise attention, memory, and
processing speed. For example, participants could prepare juices following virtual recipes, shoot
birds in a virtual beach environment, remember sequences of fireworks numbers, and organize
objects in a virtual house. Each training session lasted 100 minutes thrice a week for eight
weeks. Each session also included eye stretching exercises and massages to promote relaxation
and reduce visual fatigue.
The results of the study showed that the group subjected to the virtual reality-based cognitive
training intervention experienced a significant improvement in executive function and resting
brain function compared with the control group subjected to a health care educational program.
Another example is the 2022 study by Liu and colleagues [48], in which patients with MCI
underwent a Tai Chi training program based on serious games. The program included exercises
that included typical Tai Chi movements, such as body weight shifting, limb movements, and
coordination between movements and breathing. While performing the exercises, participants
received real-time feedback on the screen, indicating their movements’ accuracy. The work
results showed significant improvement in global cognitive function, executive function, atten-
tion, and walking in MCI patients.
Several works in the literature have shown that serious games can be used not only as rehabili-
tation tools but also as diagnostic tools for patients with AD. One example is Sea Hero Quest
[49], a game based on spatial navigation that challenges players to explore aquatic mazes to
achieve specific goals. The game can be used as an early diagnostic tool, as it assesses users’
navigation ability, a deficient skill in patients with AD [49]. It has been found that people with
the apoE4 gene, which is considered a risk factor for the development of dementia in later life,
show lower performance in spatial navigation tasks [50]. Therefore, using less efficient routes
to achieve Sea Hero Quest goals may indicate cognitive difficulties.
Although several studies have been conducted in the literature on the use of serious games for
people with AD, to date, there are still multiple vital limitations, as proposed interventions often
need to take into account the specific sensory and interaction needs of individuals with AD. For
example, many developed applications do not support cognitive error recognition during play
and cannot dynamically adapt to the user’s cognitive ability and profile [42] [51].
Similarly, the proposed interaction modes need to take full advantage of current technologies’
naturalness and multimodal capabilities. In addition, the aesthetic design, including the use of
colors, edges, and perspectives, is not optimized for people with cognitive impairments. More-
over, serious games aimed at Alzheimer’s patients should consider all four cognitive spheres:
memory, planning ability, initiative, and perseverance [52].
3. Methodology
The serious game ”MoM” is designed to provide a therapeutic experience for Alzheimer’s
patients, using memory game as the basis. This game aims to stimulate autobiographical and
spatial memory deficits in AD patients. The methodology of the game is illustrated in figure 1
and the guidelines used for the design are described below:
Figure 1: Illustration depicting the methodology of the MoM game, divided into two parts. On one
side, the Alzheimer’s patient interacts with the game interface, while on the other side, their cherished
individuals the administrative interface.
3.1. Guidelines for MoM design
In section 2 of our paper, we discussed the limitations found in the literature regarding the
design and development of applications targeting AD patients. In light of these shortcomings,
during the design of MoM, we aimed to tailor the design and operation of the application to the
characteristics of AD patients to improve the gaming experience and its effectiveness.
• Autobiographical memory
One of the main goals of MoM is to slow the decline of autobiographical memory. Studies
in the literature have shown that multimodal sensory stimuli positively influence the
retrieval of personal memories and, in particular, that visual and auditory information play
a central role in retrieving autobiographical memory [53]. For this reason, the application
adopts a multimodal approach that uses multisensory stimulation, combining visual and
auditory information to enhance information processing and memory retrieval. In fact,
during the game session, the user receives visual stimuli (given by cards) and auditory
stimuli (given by recordings of patients’ cherished individuals).
• Colors of the user interface
The initial selection of colors for the cards in the game grid and the background was made
after a thorough review of the literature, which highlighted the interaction between color
and memory processes. Indeed, color can influence both encoding and retrieval of stimuli,
and specifically, older adults benefit from using color to improve memory performance
[54]. In the MoM design, we opted for green for the background of the cards and the
names of the cherished individuals displayed after each correct pairing. Studies support
this choice, indicating a better ability to remember green-colored stimuli, especially in
older adults, than other colors, such as red or blue [54].
• Dynamism of the game system
Two of the limitations found in the literature on ”serious games” concern the lack of
dynamic adaptation to the user’s cognitive profile and the lack of support in case of errors
[42] [51]. Our MoM game model offers different difficulty levels (easy, medium, expert)
to overcome these limitations. The difficulty of the game can automatically adapt to the
user’s performance by selecting the auto mode, or be manually selected by the patient’s
cherished individual in the admin area. In addition, in both the auto and manual modes,
visual feedback indicates the correct answer after three consecutive errors made by the
user, allowing the user to continue the game while avoiding frustration.
3.2. Player Interface
Figure 2: The initial game screen presents game metrics: time elapsed, move count, and correct
pairings (points). Below are buttons for initiating a new game, accessing help, and view with cherished
individuals.
The patient will have access to an initial interface in the easy mode with 12 boxes arranged
in a 4x3 grid. Each box contains the face of a relative or cherished individual of the patient. The
player can interact not only with the game tiles but also with three main buttons: ”New Game”,
”Help” and ”Cherished individuals” as shown in figure 2.
Figure 3: List of cherished individuals, showcasing their names and the audio recording.
• New Game button: Starts a new game by randomly rearranging the cards and resetting
the score of player. As shown in figure 2
• Help button: It becomes clickable after the player has made three mistakes and, once
clicked, suggests a correct move, temporarily revealing two equal cards after which it
becomes unusable again. As shown in figure 4
• Cherished individuals button: Allows the player to display the card of all cherished
individuals, showing the name of the loved one their photo and a short audio of the loved
one’s voice. As shown in figure 3
3.3. Game Steps
1. The player starts by clicking on the ’New Game’ button.
2. The player turns over two cards at a time, trying to find matching pairs of cherished
individuals faces.
3. If the player makes a correct match, the cards remain face up, the player earns a point
and a pop-up is displayed showing the picture and name of the corresponding cherished
individual. As shown in figure 5
4. If the player makes a mistake, the cards are covered again and the score is not affected.
5. If three consecutive mistakes are made, the ”Help” button becomes available and, if clicked,
suggests a correct match. After pressing the button, it again becomes disabled until the
player makes three consecutive mistakes again, as shown in figure 4.
6. The game continues until all pairs have been found.
7. Game statistics are recorded to monitor progress over time.
Figure 4: Utilization of help feature, can be activated only after 3 errors.
Figure 5: The window that appears when making a correct pairing shows the photograph and the name
of a loved one.
3.4. Admin interface
The administrative interface is explicitly dedicated to a cherished individual or therapist of the
AD patient and provides complete control over game settings and functionality (figure 7). The
game experience can be customized to fit the patient’s needs in this mode. Available features
include:
• the ability to add or remove cards with pictures, names, and audio of relatives or loved
ones;
• adjusting the difficulty level of the game by adapting the cognitive challenge to the
patient’s abilities and progress. As seen in figure 7, the administrator can choose three
different difficulty levels that can be selected manually (easy, medium, expert) or the
automatic mode can be selected, which provides the automatic adaptation of the game to
the user’s abilities;
• change the colors of the cards and background to accommodate patient-specific
preferences or needs (e.g., color blindness).
In addition, as shown in figure 6, the system carefully records and stores data from each game
session, which consists of the following: (a) games played, (b) games completed, (c) average
frustration rate, (d) aids used, (e) averages of game times, and (f) number of games played by
difficulty. These features allow caregivers to monitor the patient’s progress over time.
Figure 6: Dashboard of the admin application including: (a) games played, (b) games completed, (c)
average frustration rate, (d) help utilized, (e) average playtimes, and (f) games played per difficulty level.
3.4.1. Handling user frustration
If users experience high frustration levels during game sessions, this can negatively affect the
gaming experience, leading to anger and stress [55].
For this reason, MoM, a system designed to enhance the gaming experience, provides prompts
when the player makes three consecutive errors during the game session. This feature is aimed
Figure 7: Customizable settings tailored to meet the patient’s needs, such as difficulty levels, card and
background colors, and inclusion of cherished individuals in the interface.
at reducing and mitigating the feeling of frustration, thereby improving the overall gaming
experience. The literature shows that user frustration during learning tasks positively correlates
with a specific mean intensity of facial micro-expressions, namely Action Unit (AU) 4 [56],
which corresponds to the Brow Lowerer micro-expression. Therefore, we used the AU R-CNN
model presented in [57], which aims to detect facial micro-expressions using a multi-label
classification approach to address the complexities of facial expression analysis. Unlike standard
R-CNNs, which may have difficulty capturing subtle changes in appearance in highly structured
images such as human faces, AU R-CNN exploits prior expert knowledge encoded by the Facial
Action Coding System (FACS) [58].
4. Conclusions
In conclusion, our proposed serious game represents a computerized cognitive training (CCT)
designed for people with Alzheimer’s disease (AD) to slow cognitive impairment of spatial
and autobiographical memory. Taking advantage of the dynamic and interactive nature of the
game, MoM is proposed as a tool to support the cognitive rehabilitation of patients with AD
while promoting emotional well-being through personalized content. The adaptability of the
game and its user-centered design allows for the creation of tailored experiences that adapt to
individual needs and progress. However, to refine and optimize the system, future developments
will involve a testing phase with actual patients and gathering feedback from mental health
professionals. In addition, to validate the therapeutic efficacy of the serious game, it will be
necessary to compare patients’ performance at the game over time and the results of specific
neuropsychological tests to assess autobiographical and spatial memory. This approach will
provide a better understanding of the impact of the game on cognitive functions of patients and
provide concrete evidence of its therapeutic efficacy.
5. Acknowledgments
This study was carried out within the FAIR - Future Artificial Intelligence Research and received
funding from the European Union Next-GenerationEU (PIANO NAZIONALE DI RIPRESA
E RESILIENZA (PNRR) – MISSIONE 4 COMPONENTE 2, INVESTIMENTO 1.3 – D.D. 1555
11/10/2022, PE00000013).
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