Reflective and Reflexive Stress Responses of Older Adults to Three Gaming Experiences In Relation to Their Cognitive Abilities: Mixed Methods Crossover Study

BACKGROUND: The gamification of digital health provisions for older adults (eg, for rehabilitation) is a growing trend; however, many older adults are not familiar with digital games. This lack of experience could cause stress and thus impede participants’ motivations to adopt these technologies. OBJECTIVE: This crossover longitudinal multifactorial study aimed to examine the interactions between game difficulty, appraisal, cognitive ability, and physiological and cognitive responses that indicate game stress using the Affective Game Planning for Health Applications framework. METHODS: A total of 18 volunteers (mean age 71 years, SD 4.5; 12 women) completed a three-session study to evaluate different genres of games in increasing order of difficulty (S(1)-BrainGame, S(2)-CarRace, and S(3)-Exergame). Each session included an identical sequence of activities (t(1)-Baseline, t(2)-Picture encode, t(3)-Play, t(4)-Stroop test, t(5)-Play, and t(6)-Picture recall), a repeated sampling of salivary cortisol, and time-tagged ambulatory data from a wrist-worn device. Generalized estimating equations were used to investigate the effect of session×activity or session×activity×cognitive ability on physiology and cognitive performance. Scores derived from the Montreal Cognitive Assessment (MoCA) test were used to define cognitive ability (MoCA-high: MoCA>27, n=11/18). Kruskal-Wallis tests were used to test session or session×group effects on the scores of the postgame appraisal questionnaire. RESULTS: Session×activity effects were significant on all ambulatory measures (χ(2)(10)>20; P<.001) other than cortisol (P=.37). Compared with S(1) and S(2), S(3) was associated with approximately 10 bpm higher heart rate (P<.001) and approximately 5 muS higher electrodermal activity (P<.001), which were both independent of the movement caused by the exergame. Compared with S(1), we measured a moderate but statistically significant drop in the rate of hits in immediate recall and rate of delayed recall in S(3). The low-MoCA group did not differ from the high-MoCA group in general characteristics (age, general self-efficacy, and perceived stress) but was more likely to agree with statements such as digital games are too hard to learn. In addition, the low-MoCA group was more likely to dislike the gaming experience and find it useless, uninteresting, and visually more intense (χ(2)(1)>4; P<.04). Group differences in ambulatory signals did not reach statistical significance; however, the rate of cortisol decline with respect to the baseline was significantly larger in the low-MoCA group. CONCLUSIONS: Our results show that the experience of playing digital games was not stressful for our participants. Comparatively, the neurophysiological effects of exergame were more pronounced in the low-MoCA group, suggesting greater potential of this genre of games for cognitive and physical stimulation by gamified interventions; however, the need for enjoyment of this type of challenging game must be addressed.