Video Games and Cognitive Impairment

Use of Video Games to Manage Cognitive Impairment in Older Adults

Capstone Essay by Delores Currie

Population and Problem Identification

            While there are some changes that occur during the normal aging process, such as slower processing of information, altered cognition should never be viewed as a normal sign of aging. Abnormal cognition ranges from mild cognitive impairment to significant loss of the ability to carry out normal activities of daily living (ADLs). Unfortunately, many of these clients end up in a long-term care environment, where social and mental stimulation could be further decreased Additionally, the loss of cognitive function can be detrimental to the psychosocial aspect of the patient, further diminishing their quality of life (Best et al., 2022).

            Treatment for cognitive impairment is underwhelming, as even though there are many pharmacological interventions approved, patients often slowly decline both mentally and physically despite treatment. These medications are intended to slow cognitive decline, but require careful assessment by the practitioner, as they can increase the risk of drug interactions and unwanted side effects for older adults. (Best et al., 2022).

            The inclusion of nonpharmacological interventions such as photo albums, presence of family members who can provide comfort, consistency in daily activities, and reminiscing are beneficial to the older adult. As cognition declines even further, patients may benefit from memory training, structured environments and increased encouragement. Music, dance, and art therapy have been employed to improve physical and mental health in older adults (Dell'Osso et al., 2024).

            Previously, most research focused on simple puzzle games with varying degrees of cognitive improvement. The same concept has recently been applied to the use of video games. Older adults trained with video games have seen “significant improvement in cognitive functions, depressive symptoms, sleep quality, and anxiety” (Dell’Osso et al., 2024). Additionally, Clemenson et al., demonstrated an improvement in hippocampal memory that persisted for up to four weeks after the study was completed (2020).

Unfortunately, research outcomes vary depending on which video games were used. For example, participants who played a simplified 2-dimensional game, such as Angry Birds scored much lower on the Mini Mental State Exam (MMSE) and the Alzheimer’s Disease Assessment Scale (ADAS-Cog) than those who played interactive complex video games, such as Super Mario 3D (Clemenson et al., 2020).

            Nurse leaders have a responsibility to improve the care of the clients they treat. Those suffering from cognitive impairment, whether mild or severe, would benefit from a comprehensive and robust treatment plan that includes both pharmacological and nonpharmacological treatment methods. Therefore, the aim of this Capstone is to discuss the question: does the use of video games compared to normal pharmacologic treatment alone lead to improved cognitive function for older adults with cognitive impairment?

Pathophysiology

            Cognitive function includes attention, awareness of self and surroundings, and memory. Abnormal cognition can occur for a variety of reasons beyond the scope of this paper, which focuses on dementia-related cognitive impairment. There are several types of dementia, but the most common are Alzheimer’s disease and Vascular Dementia (sometimes referred to as multi-infarct) dementia. Lewy body dementia is a less common, but still important type of dementia that practitioners should know (Best et al, 2022).

            Alzheimer’s Dementia occurs due to several changes in the brain. Mainly, a decreased production of Acetylcholine in the cerebral amygdala, cortex, and hippocampus. There is also thought to be an increase in glutamate levels, which indirectly results in neuronal death by causing an influx of calcium into the cell. Finally, chemical changes in Tau protein structure in the microtubules of the neuron lead to neurofibrillary tangles and beta amyloid plaque buildup with eventual destruction of nerve terminals. Finally, there is evidence to suggest genetics plays a role in increasing the risk of developing Alzheimer’s disease, although the specific genes responsible have not been completely identified (Best at al., 2022).

            Vascular, or multi-infarct, dementia occurs after one or more cerebrovascular accidents (CVA), where one or more vessels throughout the brain tissue become obstructed, depriving the tissue distal to the obstruction of oxygen and nutrients. If the CVA is not reversed, this can lead to neuronal death with severe deficits. Depending on the size and location of the tissue destruction, changes to cognition can occur suddenly or progress slowly (Best et al, 2022).  

            Lewy body dementia results from excessive deposition of a protein, alpha-synuclein, in the neuron, impairing communication. This protein is responsible for facilitating transmission of neurotransmitters across the synaptic cleft. Lewy body dementia leads to alterations in neurotransmitters, particularly acetylcholine and dopamine (Best et al., 2022). 

Physical Assessment

            Regardless of the underlying cause of dementia, the physical assessment findings for each type of dementia often overlap, with a few exceptions. Vascular dementia tends to cause musculoskeletal abnormalities, such as altered gait, muscle weakness, and abnormal reflexes more often than cognitive disturbances. Lewy Body dementia causes abnormalities in memory and learning ability due to alterations in acetylcholine, and changes in mood and motivation due to abnormal dopamine levels (Best et al, 2022). All physical causes of cognitive alterations should be ruled out before a client is diagnosed with dementia or cognitive impairment. Dementia is classified in three overlapping stages that correspond with symptom severity: mild, moderate, and severe. Recent memory impairment is usually the first symptom (Best et al, 2022).

            Mild symptoms are not always obvious and include impairment in recent memory, judgment and decision-making abilities. These symptoms typically appear within the first four years. The person remains independent at this stage, often attributing their lapses in memory to old age or regular forgetfulness. Clinicians should include information from family members and caretakers, as they might notice symptoms before the client (Best et al, 2022).

            The moderate stage lasts for two to three years, and is characterized by a progressive decline in cognition, independence and decision making. These clients are disoriented to time, place, and situation and are often found wandering and getting lost easily. They struggle to carry out activities of daily living, such as cooking, eating, dressing, or toileting. Behavioral and personality changes may become apparent. It is at this stage that many clients are referred to long-term care (Best et al., 2022).

            As the disease progresses towards the severe stage, clients may have trouble communicating, with some even becoming aphasic. They may dress inappropriately and lose interest in grooming. Eventually, clients may become bedridden, nonverbal, and even lose the ability to recognize loved ones (Best et al.,, 2022). Common among all types of dementia is sundowning, the escalation of confusion and erratic behaviors that occurs later in the evening. This may lead to aggression as clients experience increased anxiety and may even develop delusions or hallucinations (Best et al., 2022). 

Cognitive assessment should focus on attention, intelligence, language, memory, reasoning, processing speed, and problem solving. There are several assessment tools to help practitioners identify and monitor the progression of cognitive impairment. A commonly used tool is called the Mini-Cog, where a patient is asked to repeat three words, draw a clock, and repeat the previous words again. This is a quick preliminary test used to identify the presence of cognitive dysfunction, but it is limited in that its mostly focused on memory (Best et al., 2022).

The Mini-Mental State Examination (MMSE) is the most commonly used, as it evaluates several aspects of cognition such as orientation, attention, recall, comprehension, reading, and writing. A score of 18-23 indicates mild cognitive impairment, and a score of 0-17 indicates severe cognitive impairment. (Best et al., 2022).

Practitioners needs to identify and document the client’s baseline mental status, because any acute change in orientation, cognition, attention, or behavior could indicate progression of the disease, or a medical condition such as urinary tract infection. There are several screening tools, such as the Delirium Elderly at Risk (DEAR) scale, which are used to identify delirium superimposed on dementia (Best et al., 2022).

            Finally, all practitioners should include a thorough physical assessment. These clients may neglect their physical health as the condition progresses, potentially leading to starvation and dehydration. They may not be able to communicate their needs or even be aware of their deficits (Best et al., 2022).

Pharmacology

            Unfortunately, there is no cure for dementia; pharmacological treatments are aimed at slowing the progression and managing symptoms. Acetylcholinesterase inhibitors such as Donepezil, Galantamine, and Rivastigmine aim to improve memory by making more acetylcholine available at the synaptic cleft. N-Methyl-D-Aspartate (NMDA) receptor antagonists like Memantine can be used to prevent calcium build up in neurons, which improves information storing in the brain (Best et al., 2022).

            Other medications that are commonly prescribed in the treatment of dementia are focused on preventing and treating delirium superimposed on dementia. These include antipsychotics like Haloperidol and benzodiazepines like Lorazepam (Best at al., 2022).

            Practitioners must weigh the risks and benefits when prescribing medications for patients with dementia. This is especially important, as this population tends to be older, with decreased kidney and renal function, leading to altered processing and excretion of drugs. They are already at risk of polypharmacy due to their age-related comorbidities and they are at risk of medication misuse due to their cognitive impairments (Best at al., 2022).

            Finally, recent studies have shown no significant difference in patient outcomes between Alzheimer’s medications and placebo (Deng and Li, 2024).

Leadership Role and Solution

            Due to the risks associated with the pharmacological treatment of dementia, nonpharmacological management is growing in popularity. There are three main goals for the treatment of dementia in older adults: (1) preserving cognitive function, (2) preserve the ability to perform ADLs, and (3) preserving the patient’s quality of life (Best et al., 2022).

            Evidence demonstrates that the use of video games is helpful in achieving all three goals, especially for those residing in long-term care. Studies have consistently demonstrated that older adults who engage in video game use have improved cognitive functions, which will directly improve ADLs and quality of life. These studies often make note of improvements in depression, sleep quality, anxiety, social functioning, and physical activity. (Clemenson et al., 2021; Dell’Osso et al., 2024; Kikkohovi et al., 2023; Yiming et al., 2024).

Key Stakeholders

            While gaming consoles are not without costs, many find video gaming to be a cost-effective alternative (Kukkohovi et al., 2023). Many people are instrumental in the implementation and continued use of video games for improving cognition in the older adult. This includes the patients and their families, insurance and gaming-console companies involved in cost-setting, and physicians and nurse leaders who choose to implement video gaming into their treatment plans.

Summary

            Despite best efforts, treatment for cognitive impairment remains limited and at worst, ineffective. Pharmacological methods increase the risk of injury for older adults and do not significantly improve their quality of life. Nonpharmacological interventions like video gaming are a safe alternative for older adults, and include benefits such as improved cognitive and social functioning, and improvements in mental health. Nurse leaders should implement the use of video games in their treatment plans for older adults with (or at risk of) cognitive impairment. This will come with challenges such as cost of the equipment and training older adults on the use of the technology, but the evidence demonstrates clear benefits.

References:

Best, J. T., Buttriss, G., & Hines, A. (2022). Pathophysiology, Physical Assessment, &

Pharmacology: Advanced Integrative Clinical Concepts. F.A. Davis.

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Dell'Osso, L., Nardi, B., Massoni, L., Battaglini, S., De Felice, C., Bonelli, C., Pini, S., Cremone,

I. M., & Carpita, B. (2024). Video Gaming in Older People: What Are the Implications

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Jia, Y., Shi, M., Yang, P. et al. Associations of computer gaming with incident dementia,

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Kukkohovi, S., Siira, H., Arolaakso, S., Miettunen, J., & Elo, S. (2023). The effectiveness of

digital gaming on the functioning and activity of older people living in long-term care

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