Game-Based Assessment of Cognitive Status in Clinical and Non-Clinical Samples by Tiffany Tong A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy Department of Mechanical and Industrial Engineering University of Toronto © Copyright by Tiffany Tong 2018 Game-Based Assessment of Cognitive Status in Clinical and Non- Clinical Samples Tiffany Tong Doctor of Philosophy Department of Mechanical and Industrial Engineering University of Toronto 2018 Abstract In this dissertation I validated a serious game for cognitive assessment that was originally developed in my Masters thesis (Tong, 2014). I used a whack-a-mole game that requires response inhibition, by adding a distractor character that should not be hit. I evaluated the game as a potential screening tool for the clinically relevant condition of delirium, and I examined how game performance was correlated with the Mini-Mental State Examination (MMSE), a standard assessment of cognitive ability in the elderly. Patients 65 years and older presenting at the Sunnybrook emergency department participated in three clinical studies and response time (RT) on the game was found to be significantly correlated with MMSE scores, and sufficiently predictive of whether the person had delirium as determined by the Confusion Assessment Method. Comparing game performance at 8-hour intervals, I found that game RT showed good test-retest reliability in the second clinical study. In the third clinical study, I found that false alarm rate provided a useful supplement to median correct RT in predicting clinical measures. Following the clinical studies, I evaluated the game with healthy adults in a pilot study to determine how the duration of character appearance affected whether the task was speeded or ii not. I found that a character appearance duration of around 800 msec marked the transition from a speeded to an unspeeded task. I then carried out a final experiment with healthy adults where the two appearance durations used were 800 msec (borderline speeded) and 1200 msec (unspeeded). The experiment assessed game performance for eight combinations of character appearance duration and two other dichotomous factors, and assessed performance on four tasks that measure different aspects of inhibition ability (Stroop task, Flanker task, anti-saccade task, Go/No-Go discrimination task). False alarms increased significantly in the condition where targets were least frequent and distractors were visually similar to the target. Game performance was strongly correlated with performance on the Go/No-Go discrimination task but not with the other three inhibition tasks used. The results of this thesis point the way towards the development of serious games that can supplement current clinical assessments. iii Acknowledgments Dr. Mark Chignell, words cannot begin to describe my gratitude to you for taking a chance on me. Without your wisdom, guidance, and mentorship, this thesis would not have been possible. I am grateful to the members of my thesis committee, Dr. Birsen Donmez and Dr. Kelly Lyons, and my external examiner, Dr. Bruce Morton, who provided guidance and feedback on my thesis. I would also like to thank my clinical advisor, Dr. Jacques Lee, for providing mentorship and the opportunity to carry out research in a clinical setting. I also extend my appreciation to Dr. Jacques Lee’s research team at Sunnybrook Research Institute. To the members of the Interactive Media Lab: thank you for the great memories and friendship. To my family and friends: thank you for your endless patience, encouragement, and support of my academic pursuit. The serious game evaluated in this dissertation was jointly created between the Interactive Media Lab at the University of Toronto, under the direction of Dr. Mark Chignell, and our collaborator, Dr. Jacques Lee and his research team at Sunnybrook Research Institute. The game was originally developed and evaluated for its usability in my Masters thesis (Tong, 2014). This game underwent continual iterative design that was driven by invaluable feedback on the feasibility and usability of the game in a clinical context from Dr. Lee's research team. iv Table of Contents Acknowledgments .......................................................................................................................... iv Table of Contents .............................................................................................................................v List of Tables ................................................................................................................................ xii List of Figures ............................................................................................................................ xviii List of Appendices ....................................................................................................................... xxi List of Abbreviations .................................................................................................................. xxii List of Units ............................................................................................................................... xxiv Chapter 1 ..........................................................................................................................................1 1 Introduction .................................................................................................................................1 1.1 Problem Statement ...............................................................................................................1 1.2 Research Questions and Overview of Studies .....................................................................1 1.3 Road Map .............................................................................................................................3 Chapter 2 ..........................................................................................................................................5 2 Background .................................................................................................................................5 2.1 Cognitive Assessments ........................................................................................................5 2.1.1 MMSE ......................................................................................................................5 2.1.2 MoCA ......................................................................................................................7 2.1.3 CAM ........................................................................................................................7 2.1.4 Discussion (Advantages and Disadvantages) ..........................................................8 2.2 Cognitive Psychology Tasks and Executive Functioning ....................................................9 2.2.1 Inhibition Ability and Tasks ....................................................................................9 2.2.2 Inhibition across the Lifespan ................................................................................15 2.2.3 Discussion (Advantages and Disadvantages) ........................................................16 2.3 Computer Cognitive Screening ..........................................................................................17 v 2.3.1 Overview ................................................................................................................17 2.4 Discussion (Advantages and Disadvantages) ....................................................................18 2.5 Serious Games for Cognitive Screening ............................................................................18 2.5.1 Introduction ............................................................................................................18 2.5.2 Serious Games for Cognitive Screening ................................................................19 2.5.3 Discussion (Advantages and Disadvantages) ........................................................24 2.6 Summary ............................................................................................................................25 Chapter 3 ........................................................................................................................................27 3 Methodology .............................................................................................................................27 3.1 Description of the game .....................................................................................................27 3.2 Design and Development Process ......................................................................................27 3.2.1 Design ....................................................................................................................27 3.2.2 Development ..........................................................................................................28 3.3 Measurements ....................................................................................................................28 3.4 User Requirements .............................................................................................................28 3.5 Game Architecture and Design ..........................................................................................29 3.5.1 Level Design ..........................................................................................................30