Dissecting Digital Card Games to Yield Digital Biomarkers for the Assessment of Mild Cognitive Impairment: Methodological Approach and Exploratory Study

Karsten Gielis, Marie-Elena Vanden Abeele, Robin De Croon, Paul Dierick, Filipa Ferreira-Brito, Lies Van Assche, Katrien Verbert, Jos Tournoy, Vero Vanden Abeele, Karsten Gielis, Marie-Elena Vanden Abeele, Robin De Croon, Paul Dierick, Filipa Ferreira-Brito, Lies Van Assche, Katrien Verbert, Jos Tournoy, Vero Vanden Abeele

Abstract

Background: Mild cognitive impairment (MCI), the intermediate cognitive status between normal cognitive decline and pathological decline, is an important clinical construct for signaling possible prodromes of dementia. However, this condition is underdiagnosed. To assist monitoring and screening, digital biomarkers derived from commercial off-the-shelf video games may be of interest. These games maintain player engagement over a longer period of time and support longitudinal measurements of cognitive performance.

Objective: This paper aims to explore how the player actions of Klondike Solitaire relate to cognitive functions and to what extent the digital biomarkers derived from these player actions are indicative of MCI.

Methods: First, 11 experts in the domain of cognitive impairments were asked to correlate 21 player actions to 11 cognitive functions. Expert agreement was verified through intraclass correlation, based on a 2-way, fully crossed design with type consistency. On the basis of these player actions, 23 potential digital biomarkers of performance for Klondike Solitaire were defined. Next, 23 healthy participants and 23 participants living with MCI were asked to play 3 rounds of Klondike Solitaire, which took 17 minutes on average to complete. A generalized linear mixed model analysis was conducted to explore the differences in digital biomarkers between the healthy participants and those living with MCI, while controlling for age, tablet experience, and Klondike Solitaire experience.

Results: All intraclass correlations for player actions and cognitive functions scored higher than 0.75, indicating good to excellent reliability. Furthermore, all player actions had, according to the experts, at least one cognitive function that was on average moderately to strongly correlated to a cognitive function. Of the 23 potential digital biomarkers, 12 (52%) were revealed by the generalized linear mixed model analysis to have sizeable effects and significance levels. The analysis indicates sensitivity of the derived digital biomarkers to MCI.

Conclusions: Commercial off-the-shelf games such as digital card games show potential as a complementary tool for screening and monitoring cognition.

Trial registration: ClinicalTrials.gov NCT02971124; https://ichgcp.net/clinical-trials-registry/NCT02971124.

Keywords: Klondike Solitaire; card games; cognition; dementia; expert study; generalized linear mixed effects analysis; mild cognitive impairment; mobile phone; monitoring; older adults; screening.

Conflict of interest statement

Conflicts of Interest: None declared.

©Karsten Gielis, Marie-Elena Vanden Abeele, Robin De Croon, Paul Dierick, Filipa Ferreira-Brito, Lies Van Assche, Katrien Verbert, Jos Tournoy, Vero Vanden Abeele. Originally published in JMIR Serious Games (https://games.jmir.org), 04.11.2021.

Figures

Figure 1
Figure 1
Klondike Solitaire. The seven build stacks can be seen at the bottom, the suit stacks are at the top left. The pile of undealt cards can be seen in the top right.
Figure 2
Figure 2
The 5 phases through which the cognitive functions were defined. CDR: Clinical Dementia Rating, MoCA: Montreal Cognitive Assessment, MMSE: Mini-Mental State Examination.
Figure 3
Figure 3
Performance on time-based digital biomarkers for both groups. MCI: mild cognitive impairment.
Figure 4
Figure 4
Performance on performance-based digital biomarkers for both groups. MCI: mild cognitive impairment.
Figure 5
Figure 5
Performance on error-based digital biomarkers for both groups. MCI: mild cognitive impairment.
Figure 6
Figure 6
Performance on execution-based digital biomarkers for both groups. MCI: mild cognitive impairment.
Figure 7
Figure 7
Performance on result-based digital biomarkers for both groups. MCI: mild cognitive impairment.
Figure 8
Figure 8
Performance on auxiliary-based digital biomarkers for both groups. MCI: mild cognitive impairment.

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