Univ Access Inf Soc
DOI 10.1007/s10209-013-0294-3
LONG PAPER
Bridging the gap between illiterate older adults and cognitive
stimulation technologies through pervasive computing
Victoria Meza-Kubo • Alberto L. Morán •
Marcela D. Rodrı́guez
 Springer-Verlag Berlin Heidelberg 2013
Abstract The global ageing of the population has made
the increase in age-related diseases more obvious, some of
which are accompanied by a patient’s cognitive decline
(CD). That is a hard problem for Mexico, as a large number
of older adults belong to marginalized sectors. These older
adults are characterized by their illiteracy and limited
financial resources, which make them more vulnerable to
conditions such as the Alzheimer’s disease. According to
the literature, a person who participates often in cognitive
stimulation (CS) activities reduces the risk of suffering a
CD-related condition. This has provided the motivation to
carry out case studies to understand older adults’ interac-
tions in CS sessions, and their relation with technologies
and with members of their social family networks (SFN).
To address these technological, social and illiteracy gaps, a
pervasive CS collaborative system has been designed and
evaluated which eases interaction through natural inter-
faces and enables SFN members to interact with older
adults during their CS activities regardless of their physical
location. The evaluation results provide evidence that
participants perceived the system as useful, easy to use and
providing a pleasurable user experience. Furthermore,
these results show the feasibility of augmenting traditional
board games (e.g. chess, checkers) to create pervasive CS
V. Meza-Kubo (&)
A. L. Morán
Facultad de Ciencias, Universidad Autónoma de Baja California,
Km 103 Carr. Tijuana-Ensenada, CP 22860 Ensenada, México
e-mail: mmeza@uabc.edu.mx
A. L. Morán
e-mail: alberto.moran@uabc.edu.mx
M. D. Rodrı́guez
Facultad de Ingenierı́a, Universidad Autónoma
de Baja California, Km 103 Carr. Tijuana-Ensenada,
CP 22860 Ensenada, México
collaborative applications and the importance and benefits
of integrating SFN members as informal caregivers.
Keywords Cognitive stimulation
Illiterate older adults

Social family networks
Pervasive collaborative systems

Tangible interfaces
1 Introduction
Mexico, like other developing countries, is experiencing an
ageing population process that according to estimations
will accelerate in the following years [1]. With this, the
incidence of age-related conditions will also increase.
Cognitive decline (CD) with or without dementia is one of
these conditions, which directly affect the quality of life of
older adults (persons older than 60 years).
In addition to ageing, a low educational level and the
lack of social contact contribute to accelerate CD [2]. In
this situation, Mexico faces a great challenge, as there are
high levels of illiteracy among older adults. It is estimated
that one out of three older adults cannot read nor write [1].
Furthermore, an increasing number of older adults are
living alone, which may be due to the fact that their
children have moved to their own homes or they are
widowed [1].
This way, it is important to develop strategies to modify
in a favourable manner the conditions of the elderly in
order to prevent the apparition or delay the onset of CD.
Nowadays, there is no cure for some of these conditions,
for example, the Alzheimer’s disease, thus a multi-
dimensional therapeutic approach that includes both phar-
macological and non-pharmacological interventions is
proposed. One of these non-pharmacological interventions
is cognitive stimulation (CS). According to the literature, a
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person who participates often in CS activities reduces the
risk of suffering a CD-related disease, or improves his/her
cognitive functioning and behaviour [3–5].
However, access to this kind of intervention is not
available to the poorer and more vulnerable social groups,
such as illiterate older adults, as many of them usually do
not have coverage, or are not entitled to any health service
[6]. Thus, given the lack of specialists and programmes to
attend the CD problem, it is necessary to think of and plan
alternative ways to provide support for them. It is argued in
this paper that pervasive systems could enable the creation
of accessible computer-based CS materials and activities
for the elderly. Furthermore, making these systems avail-
able through current government specialized centres would
not only enable addressing some of the aforementioned
limitations regarding availability of the service, but also
regarding the lack of personnel by facilitating the partici-
pation of older adults’ relatives to monitor and provide help
in CS activities.
The remaining sections of the paper are organized as
follows. Sections 2 and 3, respectively, describe related
work and the methodology followed to conduct this
research. Section 4 describes an ensemble of case studies
that enabled the development of an initial understanding
regarding older adults’ interactions in CS activities and
some features of their social family network (SFN). Sec-
tion 5 presents the main design and implementation aspects
of the prototype pervasive CS collaborative system devel-
oped. Section 6 describes and discusses the process fol-
lowed to evaluate the proposed system, as well as the
obtained results. Section 7 discusses the importance and
benefits of using interfaces that are more suitable for illit-
erate older adults and for involving the members of their
SFN into their CS activities using a system such as the
proposed one. Section 8 concludes the paper and proposes
some lines of future work.
2 Related work
Several research works have proposed technological solu-
tions to cope with CD. These proposals are based on
studies that identify CS therapy as a strategy for main-
taining the mental functions of older adults and their
quality of life. Some works propose the use of formal
exercises, such as those used in traditional (non-techno-
logically supported) therapies. Smartbrain and GRADIOR
[7, 8] are examples of these multimedia applications that
implement personalized exercises for the cognitive training
of the older adults’ preserved abilities using standard
computers and touch screens. Tárraga [7] proposed that
there were no differences in a cognitive intervention pro-
gramme for older adults when activities were applied with
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the help of technology, and even found some advantages
over using the original implementations (e.g. automatic
activity performance log).
The aforementioned works provide evidence about the
benefits of using systems to complement the recommended
traditional therapies for coping with the CD of older adults.
These technologies require that older adults have experi-
ence on the use of computer-based technologies. However,
older adults tend to show poor performance in controlling
their movements, and greater difficulty in using complex
interaction devices [9, 10], which could worsen due to their
illiteracy.
For these reasons, several works have focused on pro-
viding applications that are more accessible to the elderly.
These proposals include the design of WIMP-based user
interfaces that are adequate for the elderly. For instance,
Fisk et al. [11] proposed a set of design guidelines to cope
with older adults’ physical and cognitive decline; and
Kurniawan et al. [12] proposed a set of design guidelines
for the design of web pages that are adequate to older
adults given their visual impairment. In addition, other
works have proposed the use of alternative and more
‘‘natural’’ interaction mechanisms, such as virtual reality,
touch, tangible or mixed interfaces. For instance, tangible
user interfaces have been proposed in order to facilitate
older adults’ interaction with the digital world. A tangible
user interface ‘‘gives physical form to digital information,
employing physical artifacts both as representations and
controls for computational media’’ [13]. Examples of this
include the work of Davidoff on Mailbook [14], which uses
a tangible book metaphor and interface to facilitate email
communication for the elderly; and the work of Hodges
et al. [15], which uses an augmented coffee set to assess the
cognitive status of an older adult through an activity of
daily living (i.e. coffee preparation).
A factor that contributes to accelerate CD in older adults
is the lack of contact with members of their social family
network (SFN—family and friends). Some works propose
the use of pervasive computing as a means to provide
connection between family members. For instance, Morris
[16] proposes social-network visualizations, that are con-
tinuously updated with sensor and self-reported data, to
foster awareness and empowerment of social health; Vetere
et al. [17] proposed the support of multi-generational bonds
(e.g. the virtual box system that supports reciprocal inter-
action among grandparents and their grandchildren by
integrating the fundamental themes of play, setting, reci-
procity and expression.
Other works aimed at improving older adults’ cognitive
state, and have proposed the design of additional CS
activities. For example, the use of digital games was pro-
posed as a promise to improve the quality of life of older
adults, with the potential to improve their physical and
Univ Access Inf Soc
mental health, and their social networking, and in general,
offering a fun way to spend time. Examples of these works
include: (1) ElderGames [18], a platform that allows users
to improve their cognitive skills and individual well-being
by playing on a mixed-reality platform, (2) SOCIABLE
[19], a platform that implements a set of cognitive training
games (using the Microsoft Surface computer) that cover
the needs of elderly people with mild cognitive impairment
and of people suffering from mild Alzheimer’s disease. Its
aim is to facilitate the social interaction of older adults, and
the management of electronic health records to health
professionals.
The approach proposed in this paper, similar to that of
Gamberini and Alcaniz [18] and Pantelopoulos et al. [19],
is to introduce suitable interaction mechanisms, so that
illiterate older adults could actually perform their CS
activities and benefit from computer-based CS technolo-
gies in a natural and simple way. The proposed method-
ology involves the integration of tangible interfaces, and
pervasive and collaborative systems, in order to do so. The
present work proposes that an approach enabling the
elderly to receive therapy using the concept of play, and at
the same time to interact with their relatives, will have
positive effects in their CD, but will also enable them to
maintain and extend their SFN. Thus, it is important to first
better understand how older adults perform their CS
activities and how older adults’ SFN relationships evolve
across time and space in order to propose a system design
that enables us to create appropriate user interfaces for
illiterate older adults and the diversity of members in their
SFN.
3 Methodology
In order to design technologies to support CS activities,
during the last 3 years, several studies were performed
that enabled to understand how pervasive computing
technology could support these interactions and how they
can be supported. These studies were performed in three
phases:
Phase 1: Initial understanding: In this phase, three
studies were performed in order to gain an initial under-
standing regarding older adults’ SFN and their participation in
CS activities. The first study aimed at identifying the actors,
roles and their interactions within a CS session [20]. The
second study aimed at further understanding the factors and
problems faced by older adults when working with CS
materials during a CS session [21]. The third study aimed at
identifying factors that affect the relationships of older adults
with their family [22], in order to characterize the older adult’s
SFN and to identify how it evolves across time and space. The
main results of these studies established a baseline of initial
findings to support further efforts.
Phase 2: Design and implementation: By using scenario-
based design, the way to design accessible technology for
illiterate older adults was envisioned to perform their CS
activities as well as the way SFN members could be
introduced into these activities. The creation of scenarios
of use allowed to envision and frame the understanding
obtained in phase 1, and to identify a set of design insights,
which later informed the design and implementation of a
prototype of a pervasive collaborative system to support
older adult’s CS activities.
Phase 3: Evaluation: In order to evaluate the interaction
of illiterate older adults with the proposed system, and to
determine the importance and benefits of integrating the
members of the older adult’s SFN into their CS activities
(as informal caregivers), in this phase the system was
evaluated with a group of older adults and their relatives,
who expressed their opinions regarding the perceived
usefulness and ease of use of the proposed system.
4 Phase 1: Initial understanding
4.1 Case study 1: Identifying the actors, roles
and their interactions within a CS session
To identify those involved in the CS activity, their roles
and ways of interaction, an observational study of a CS
session was conducted at a local older adult’s residence
[20]. Participants were 10 patients and 3 caregivers; 7 of
which had less than 6 years of study, and all were illiterate
regarding computer use. Different actor–actor and actor–
materials interactions were identified, which had different
purposes. The observed interactions were:
• Patient–caregiver interaction, this occurs between the
older adult and the caregiver, with the older adult
initiating it to request help or to request to end an
activity (e.g. ‘‘Which [one] is the four? [Addressing to
caregiver]’’);
• Caregiver–patient interaction, the older adult and the
caregiver are also involved, but the interaction is
initiated by the latter, in order to provide directions to
older adults or to encourage them to perform the CS
activity (e.g. ‘‘caregiver: Let’s see, these … you have to
put them in here and you have to look to which it
resembles most’’);
• Caregiver–patient–patient interaction, occurs when a
caregiver allows or promotes the integration of a
second older adult to the activity of a first one, with the
aim of providing feedback to the first older adult and
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promoting help among them (e.g. ‘‘Patient1 has been
observing the activity of patient2 (whom is making a
mistake), and patient1 knows the answer, and decides
to participate. Patient1: This is number seven [pointing
at the right piece] Caregiver: That is right, that is
number seven’’);
• Caregiver–caregiver interaction, this kind of interac-
tion occurs when a caregiver interacts with another
during the CS session in order to give directions to
other caregivers, to seek help from or to delegate tasks
to other caregivers, or to request information regarding
an older adult (e.g. ‘‘caregiver1 is working with
Patient1 and Patient10, when Caregiver2 brings
Patient2 to the yard. Caregiver1: Bring her to this side,
bring Patient2 here’’);
• Caregiver–materials interaction, this type of interac-
tions occur between the caregiver and the materials,
and are related to the preparation or configuration of the
cognitive stimulation activity with the aim of choosing
materials for older adults, to deliver materials to older
adults or to remove materials from the table (e.g.
‘‘Caregiver1 walks to the table of materials. Caregiver1
takes a set of foam rubber puzzles and observes them
one by one, until he chooses one of them. Once the
materials are chosen, he takes them to the worktable
and puts them in front of Patient1’’);
• Patient–materials interaction, in this type of interac-
tion, older adults interact with the involved supporting
materials in order to perform their CS activities.
4.2 Case study 2: Understanding older adult–materials
interactions during a CS activity
To explore alternative interaction mechanisms that may
be integrated in a system that aims to support older adults
to perform their CS activities, a study was carried out to
compare two types of interaction in a CS activity: direct
manipulation of physical objects and indirect manipula-
tion of digital objects [21]. Participants in the study were
a group of 27 older adults, aged between 60 and 88 years
old, from a local government elderly support programme;
23 of them had at least 5 years of elementary school. The
activity consisted of solving a Tangram, a 7-piece Chi-
nese puzzle, with which different figures or patterns can
be formed. In the first modality, the Tangram was
assembled by direct manipulation of the wooden pieces,
while, in the second modality, it was assembled by
indirect manipulation of the logical pieces using the
computer’s mouse.
The main results of this study indicate that manipulating
the pieces was much easier for older adults using the
physical Tangram game than using the digital one (rate of
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14:1 s). It was observed that older adults’ moving and
rotating operations on logical pieces became highly
complex with the computer’s mouse. Surprisingly, even
though participants had better performance using the
physical Tangram, most of them expressed a preference
towards the use of the digital Tangram (e.g. ‘‘I prefer to
use the computer in the future, to learn how to use it, that
looks ease, but [manipulating] the mouse is compli-
cated’’). A possible explanation, based on information
from the on-exit interview, is that they expressed interest
in learning to use the computer because they consider it as
a powerful tool [for communication and social interac-
tion], which could be used to interact with the members of
their SFN. This way, the effort required to learn to use the
computer would pay off, however, they should have to
solve their difficulties to use the mouse or keyboard
devices. These results suggest the need to explore alter-
native interaction mechanisms for CS applications for
older adults. Thus, the use of tangible interfaces is pro-
posed, to combine the use of physical objects (ease of
interaction) with the use of the computer (additional
motivation to participate in the activity).
4.3 Case study 3: Identifying factors that affect
the relationships of older adults with their family
To understand the evolution of the relationships among
older adults and their children, and how current com-
munication technologies are used to preserve these rela-
tionships, a study was performed through semi-structured
interviews conducted with six older adults between 65
and 75 years old and their children [22]. The main find-
ings are: (1) The focus of their relationships change over
the years, (2) older parents become the focal point for
family gatherings and news distribution, (3) female
children tend to have a closer relationship with their old
parents, (4) children encourage their parents to carry out
different activities to cope with their loneliness, (5)
children do not consider the current CD of their parents
as a problem and (6) the adoption of new communication
technologies (such as the use of portable phones and SMS
technologies) has positively affected the parent–child
relationships.
These findings enabled the identification of certain roles
technology should play in order to facilitate the involve-
ment of the members of older adults’ intergenerational
SFN in their CS activities. Technology should facilitate not
only the active participation of those who already maintain
a strong relation or interact frequently with older adults
(such as the daughters), but also those that may face
restrictions to interact with them (e.g. due to distance or
lack of time to frequently visit the older adult).
Univ Access Inf Soc
5 Phase 2: Design and implementation of a pervasive
CS collaborative system
Taking into consideration the results of the previous stud-
ies, an ensemble of design insights was identified that a
system seeking to facilitate older adult’s CS activities
through technology and to integrate SFN members into
those activities should consider. A brief discussion of these
insights follows.
5.1 Design insights
5.1.1 Communication
Older adults and their relatives should be able to commu-
nicate among each other in a synchronous manner. Com-
munication mechanisms should allow for coordination and
socialization while performing a CS activity. Furthermore,
designers should consider that most of older adult users
would have high illiteracy levels, so that the selected
communication mechanisms should not require them to
read or write.
5.1.2 Awareness
Older adults and their relatives should be able to become
aware of the opportunities for interaction before starting a
CS session, and be aware of what is actually happening
during the execution of the CS activities. Designers should
promote the use of simple notifications mechanisms so that
older adults could easily interpret them (e.g. graphical or
sound notifications).
5.1.3 Collaboration
Older adults and their relatives should be able to collabo-
rate and perform their CS activities regardless of their
being co-located or distributed. Relatives should be able to
take on the caregiver role during the CS session, and per-
form any action required, including providing help or
feedback, and giving instructions or encouragements,
among others. As for communication, collaboration
mechanisms should not require older adults’ abilities such
as reading or writing.
5.1.4 Interaction with materials
Older adults and their relatives should be able to execute
every required action on the materials, or environment, in
order to participate or to provide support for the actual CS
activity. This implies that older adults and relatives should
be provided with the adequate means to manipulate CS
materials, considering factors such as their age, preferences
and motor and literacy skills, since inadequate interaction
means could derive frustration or anxiety, and thus hinder
the active participation of the older adult.
5.2 Scenario
Based on the insights identified in the previous section, the
following scenario envisions the use of specific technolo-
gies to facilitate to illiterate older adults the execution of
their CS activity and to address the seamless integration of
members of the older adult’s SFN into this activity.
This scenario depicts the functionality of a system,
which is used by older adults from a governmental Senior
Citizen’s Center and their remote relatives. The system
considers specific features to address issues regarding the
interaction of older adults with materials and with other
participants. For instance, it considers: (1) the use of a
Tangram game to cognitively stimulate the older adults, as
they prefer to participate in a board game rather than on a
formal exercise; (2) the use of a tangible user interface
(TUI) for the Tangram game to allow for the direct
manipulation of the puzzle pieces, as it is easier for older
adults to play the game by actually interacting with (i.e.
moving) the wooden pieces rather than interacting with the
digital pieces using a mouse; (3) the use of an audio
channel to allow for verbal interaction between the older
adult and his remote relative, as it is easier for an illiterate
older adult to ‘‘talk’’ to his relative rather than having to
‘‘write and read’’ messages to interact with him and (4) the
use of a digital version of the Tangram game in a desktop
system, as a common interaction modality for the younger
relative (e.g. children or grandchildren), among others.
‘‘At the Senior Citizen’s Center, Carlos moves to the
entertainment room, and goes to one of the multi-
touch tables (Fig. 1a). The system detects his pres-
ence and displays a welcome message on the table.
Then, the system asks him to choose one of the
scheduled exercises proposed by the specialist. He
chooses the Tangram game (according to him pref-
erences) and takes the required materials. As Carlos
starts the activity and interacts with the tangible
pieces of the Tangram, this is reported to those
members of his SFN who have subscribed to this
service to be notified via their Smartphones. His son
Cruz has indicated, to all members, that he may
attend to his father’s CS activity at that moment
(Fig. 1b). After solving two puzzles, Carlos starts to
have problems, as the third one is slightly more
complicated than the two previous. Thus, Cruz, who
has been receiving reports about the progress of the
activity on his Smartphone, goes to his computer
and starts the Digital Tangram remote interface
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Fig. 1 a The older adult interacting with the TUI, directly manip-
ulating the physical Tangram pieces over the GUI projected on the
tabletop multi-touch surface. b The relative interacting with the
(GUI ? mouse ? keyboard), which presents the
current status of the activity and enables him to
participate in the CS activity (Fig. 1c). In the Col-
laboration Client, he can see his father’s movements
and provide feedback during the assembly of the
puzzle through the audio channel that has been ini-
tiated between the two applications. In this way,
Carlos is able to complete the whole set of exercises
of the CS activity and achieves 20 min of interaction
(feedback, support, socialization) with his son. A
record of the activity has been saved in order for the
specialist to track Carlos’ performance evolution’’.
From the previous scenario, it was noticed that Carlos
did not experience any problem to perform the CS activity
by using the tangible and touch interfaces. However, he
had problems due to the difficulty of the task. In order to
assist Carlos with this problem, his son Cruz was notified
and allowed to participate in his father’s CS activities. On
the one hand, Cruz acted as a caregiver providing
instructions, feedback and motivation to Carlos. On the
other hand, Cruz participation was essential to achieving
Carlos completion of the activity, as he represented an
additional motivator.
5.3 System prototype
Based on the insights presented above and on the envi-
sioned scenario, a prototype of a pervasive collaborative
system that provides support for CS sessions was devel-
oped, which is accessible to illiterate older adults and that
allows for the integration of remote SFN members.
Figure 2 shows the two main interfaces of this system: The
older adult client and the SFN member collaboration client
interfaces.
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Univ Access Inf Soc
notification system through his Smartphone. c The relative interacting
with the traditional (GUI ? mouse) interface to participate in the CS
activity
5.3.1 Older adult client interface
This interface allows illiterate older adults to perform their
CS activities in a more natural way as they are more used
to directly manipulate physical objects instead of indirectly
manipulate digital objects using the mouse. The proposed
simplified interface uses audio or pictures instead of text
for instructions or messages. The main elements of the
interface include (see Fig. 2a): the shared digital board or
work area that is projected on the tabletop, the tangible
objects and their digital representation, an exercise selec-
tion and solution menu, the SFN member picture and status
and a tele-pointer for the remote relative user.
5.3.2 SFN members’ collaboration client interface
This interface basically replicates the older adult client
interface and gathers gesture and audio information to be
sent to the older adult’s client side. The main difference is
the absence of the TUI physical objects. It includes (see
Fig. 2b), the shared digital board or work area, the digital
representation of the objects and the exercise selection and
solution menu.
The current prototype system integrates functional ver-
sions of these three clients. Figure 3 shows its main com-
ponents. The older adult client interface introduces the use
of tangible objects and a multi-touch tabletop surface
computer as alternative means of interaction for the older
adult. The tangible interface uses a Reactivision server for
the recognition of the Tangram pieces, and the TUIO
protocol for communication with the actual computer
application [23]. The SFN member collaboration client
interface presents a traditional GUI-based interface that is
used with a mouse and keyboard. The SFN member com-
munication client interface presents the functionality of a
Univ Access Inf Soc

Fig. 2 System prototype:

a TUI-based older adult client
interface on a tabletop multi-
touch surface. b GUI-based
SFN member collaboration
client interface on a laptop
computer

Fig. 3 Main components

of the pervasive CS
collaborative system

basic notification system in a Smartphone. It presents the
messages it receives from the older adult client interface.
Event communication between the older adult client and
the SFN member clients is implemented using a client–
server architecture (C#, socket based, custom XML pro-
tocol), which basically replicates a subset of events from
the local client to the remote client using an Internet con-
nection. Audio communication between the older adult
client and the SFN member collaboration client was
implemented using an off-the-shelf audio application.
6 Phase 3: Evaluation of the proposed system
obtain their opinion regarding the perceived usefulness and
ease of use of the proposed system.
6.1 Participants
Participants were six healthy older adults, and six of their
relatives (one per older adult), including 5 adult children,
ages between 33 and 55 years and 1 grandchildren,
21 years old. All of the older adults’ relatives had experi-
ence on using computers. Older adults with cognitive
decline did not participate in this part of the study, as they
were unable to respond to the questionnaires by
themselves.

The aim of this evaluation was to determine the importance 6.2 Setting
and benefits of integrating the members of the older adult’s
SFN as informal caregivers, and as additional motivators, The evaluation was conducted at a controlled setting that
during the execution of the older adult’s CS activities, and was adequate for the older adult and her relative, either at

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the university premises (5) or the older adult’s home (1).
The latter setting was considered due to mobility restric-
tions of one of the participants at the time of the evaluation.
In order to try to minimize the differences between the two
environments, similar arrangements were established using
the same video projector and tabletop surface and laptop
computers. Video projection and questionnaire fill-in pla-
ces were established at both places. In addition, separate
places for the execution of CS exercises were also estab-
lished in order to simulate the relative’s remote assistance
situation. At the university premises, we used contiguous
rooms, while at the older adult’s home participants were
located in opposite ends of a living room with a temporal
division between them, so that they had no line of sight
between them, and were able to maintain voice commu-
nication through the audio channel.
6.3 Procedure
The evaluation consisted of three stages:
Stage 1. Video projection: Older adults and their relatives
observed a video clip showing a scenario of use of the
proposed system, similar to the one presented in Sect. 5.2.
At the end of the video projection, facilitators responded to
all the participants’ questions that might have arisen.
Stage 2. Cognitive stimulation activity: Older adults and
their relatives participated in a CS activity exercise. The
aim of this exercise was to let them know and use the
proposed system. A pair of facilitators explained the pur-
pose of the exercise, one providing support to the older
adult and the other to the relative. Each participant used
their respective interfaces, the tangible interface (physical
objects on the tabletop multi-touch surface computer)
for the older adult and the traditional interface
(GUI ? mouse ? keyboard) in the laptop computer for the
relative.
Participants performed two different activities: (1) a
cognitive activity, which consisted on carrying out the
assembly of four figures using the Tangram puzzle (max-
imum 10 min). In this case, the older adult performed the
activity while his/her relative observed and provided help
and motivation and (2) an entertainment activity, which
consisted on playing during 10 min with one of the pro-
vided games (Tic-Tac-Toe, Checkers and Connect-4).
Older adults choose the game they preferred and then they
and their relative played against each other.
Stage 3. On-exit questionnaire: Finally, an on-exit
(TAM-based) questionnaire was applied. Participants were
asked about their general perception of ease of use and
usefulness by using standard questionnaires [24]. The
perceived usefulness, ease of use, intention of use and
expected use sections, are important factors influencing
user acceptance of information technologies. Questionnaire
items were included that enabled the examination of other
factors that may play a critical role in shaping perceived
ease of use in the early stages of user experience with a
system [25, 26]. Questions were added regarding the per-
ceived anxiety and perceived enjoyment while using the
system. Most questionnaire items were measured on a
7-point Likert scale, ranging from 1 (‘‘completely dis-
agree’’) to 7 (‘‘completely agree’’). Additional open ques-
tions were included in order to obtain details regarding the
CS activities that they perform and the communication
technologies that they use. Facilitators helped older adults
to complete the questionnaire by reading the questions and
writing their answers.
6.4 Results
This section presents the results of the TAM-based ques-
tionnaire as answered by participants during the on-exit
survey. Results relating to an actual perception of use (ease
of use, usefulness, enjoyment and anxiety) are presented in
Table 1, while those related to projected use (intention of
use and expected use) are presented in Table 2. These
results are further discussed based on evidence observed
during the actual execution of the study.

Table 1 Results regarding ease

Both activities—mean (SD) Cognitive activity Entertainment activity
of use, usefulness, enjoyment
and anxiety as perceived by Older adults Relatives Older adults Relatives Older adults Relatives
older adults and their relatives,
for both and each kind of Ease of use 6.28 (.36) 6.76 (.11) N/A N/A
performed activities (cognitive 6.52 (.35)
or entertainment)
Usefulness 6.40 (.28) 6.26 (.18) 6.54 (.29) 6.28 (.18) 6.25 (.21) 6.23 (.19)
6.32 (.23)
Enjoyment 6.47 (.37) 6.33 (.14) 6.14 (.14) 6.23 (.08) 6.80 (.08) 6.42 (.14)
6.40 (.28)
All values are means, followed Anxiety 2.36 (1.2) 1.80 (.50) 2.61 (1.49) 1.80 (.50) 2.11 (1.10) 1.80 (.50)
by standard deviations in 2.17 (1.02)
parentheses

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Univ Access Inf Soc
Table 2 Results regarding intention of use and expected use by both
participants
Older adults Relatives
Intention of use 6.28 (0) 5.78 (.10)
6.03 (.29)
Expected use (days/week) 5.23 (.32) 4.28 (.89)
4.76 (.79)
6.4.1 Participants’ actual perception of use
6.4.1.1 Ease of use Evaluation results provide evidence
that all participants perceived the system as ease to use
(6.52, SD = .35, agree/completely agree). Particularly,
relatives perceived the system slightly easier to use (6.76,
SD = .11) than older adults (6.28, SD = .36). A possible
explanation for this could be that most relatives are current
computer users either at work or at school, and thus the
technology used was familiar to them. On the contrary,
older adults were not familiar to the tangible user interface
(TUI) provided, and although it used physical objects, they
were required to actually understand that these objects
acted as the interface to the system. In this sense, an older
adult said that [she] ‘‘… was used to play the Tic-Tac-Toe
by drawing the crosses and the circles’’ given that in the
tangible version of the game they used wooded cross and
circle pieces which had to be physically placed over the
projected board, instead of using a gesture to draw the cross
or circle as in the original (paper- and pencil-based) game.
The fact that both users considered that the system
(including its interfaces) was easy to use, allowed us to
conclude that each interface was adequate for its target
user. As regards to the proposed metaphor (game concept),
it can be considered adequate as it was understood and
managed by both users for the execution of the activities.
Finally, regarding the provided audio channel, it allowed
for adequate and transparent communication and collabo-
ration between both participants.
6.4.1.2 Usefulness Evaluation results also provide evi-
dence that all participants perceived the system as useful
(6.32, SD = .23, agree/completely agree). Participants
agreed that activities were useful for both functions, cog-
nitive and entertainment. However, there is a slight dif-
ference in the perceived usefulness for the cognitive
function between older adults (6.54 [SD = .29]) and their
relatives (6.28 [SD = .18]).
Possible explanations for this could be that (1) the
Tangram activity is perceived as more useful to cognitively
stimulate the older adult (e.g. ‘‘[it] requires you to think
more’’, ‘‘it requires mental ability and ‘awakens’ your
cognitive abilities’’), and to allow the participation of
relatives as an aid in the execution of the CS activities and
(2) the entertaining activity is perceived as more useful for
socialization and having fun (e.g. ‘‘[Game] is a common
game, already known to both of us, and thus familiar’’,
‘‘The [Game] fosters the older adult and grandchildren’s
interaction’’).
6.4.1.3 Enjoyment Overall, perceived enjoyment for the
system was high (6.40, SD = .28, agree/completely agree)
both for older adults (6.47, SD = .37) and their relatives
(6.33, SD = .14). The results show that the entertainment
activity was graded slightly higher (older adults 6.80,
SD = .08 and relatives 6.42, SD = .14) than the cognitive
activity (older adults 6.14, SD = .14 and relatives 6.23,
SD = .08). A possible explanation for this could be that (1)
the entertainment activity was familiar to them (‘‘this is the
game I know…’’, ‘‘I know how to play this one’’), while
the cognitive activity was unfamiliar (‘‘this is my first time
playing the Tangram’’), (2) the entertainment activity was
more engaging to both of them as it represented a com-
petition or challenge between the older adult and his/her
relative (‘‘I got you’’, ‘‘I will let you win next time’’), while
the cognitive activity represented a challenge mainly to the
older adult, whom has even expressed that this activity
made her feel under evaluation. Finally, these character-
istics of the entertainment activity allowed for a more
social interaction, even with participants’ laughter and
jokes, which did not happen during the cognitive activity.
6.4.1.4 Anxiety The data gathered through the TAM-
based questionnaire provide evidence that the perceived
anxiety regarding system use was low for participants
(2.17, SD = 1.02); this means that they disagree/slightly
disagree when answering questions such as ‘‘I felt nervous
using the [cognitive]/[entertainment] system’’. Particu-
larly, the perception of anxiety was slightly higher for
older adults (2.36, SD = 1.2) than for their relatives
(1.80, SD = .50). Additionally, the results showed that
older adults felt slightly more anxious during the cogni-
tive activity (2.61, SD = 1.49) than during the enter-
tainment activity (2.11, SD = 1.10). A possible
explanation for this is twofold: (1) most older adults
perceived the cognitive activity as a challenge just for
them, and even perceived it as a test or evaluation; while
for the relatives this activity represented an opportunity to
try to help their older adult’s relative on a particular task
and (2) the cognitive activity (Tangram game) was
unfamiliar to all older adults, while the entertainment
activity was familiar for all, but one (‘‘I had already
played tic-tac-toe and checkers before, but the Tangram
game was unknown to me’’). Finally, the reported high
ease of use enabled participants to focus on the activity
rather than on the means to perform it (e.g. user interfaces
123

and communication channel), allowing them to achieve a
high level of enjoyment also reported.
6.4.2 Participants’ projected use
6.4.2.1 Intention of use The results from the evaluation
provide evidence of high intention of use (6.03, SD = .29)
by participants. Older adults stated to have a higher
intention to use the system (6.28, SD = .0) than their rel-
atives (5.78, SD = .10). A first possible explanation refers
to the difference in time availability for this type of
activities. On the one hand, older adults stated to have
plenty of time available to perform this kind of activities.
On the other hand, SFN members declared their intention
to use the system but were conscious about their time
limitations, as most of their time is dedicated to their main
activities—work or school—(‘‘I’m sure is a good option to
stay in touch with my parents, and it would help us to be
aware of them whenever our activities and commitments
allow us’’). A further explanation refers to an additional
motivation that older adults found to use the system,
regarding its use as a means of interaction and communi-
cation with distant SFN members. Relatives, on the other
hand, did not found this additional motivation. In addition,
it should be noted that the older adult has a one-to-many
relation to his relatives, while their relatives have a one-to-
one relation with their parent/grandparent (e.g. one mother/
father—many children and grandchildren).
6.4.2.2 Expected use Participants were also asked to
state the expected use they would give to the system if they
have it available. The mean expected use in days per week
is slightly higher for older adults (5.23, SD = .32) than for
their relatives (4.28, SD = .89). As discussed for the
intention of use, a possible explanation for this could also
be related to the difference in time availability to perform
the activity (‘‘I am not sure I would use it, because I have
little spare time at home or work’’).
6.4.3 Open questions
Finally, regarding the open questions to obtain information
about their communication practices and CS activities, 5
out of 6 participants (83 %) reported that the telephone is
their main communication technology—the remaining
participant does not have a cellular or landline telephone.
Only 2 out of 6 participants (33.3 %) reported having used
email for communication with their siblings and friends,
and this motivated by the high costs of international calls.
Regarding CS activities, none of the participants
receives CS from a specialist, but all of them consider that
they perform several activities that promote their mental
health, for example, reading, exercising and playing board
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Univ Access Inf Soc
games. Regarding board games use, 4 out of 6 participants
(66.6 %) expressed that they usually play board games
with their grandchildren when they come to their home, as
a way to entertainment them and have fun together.
7 Discussion
The case studies and the evaluation conducted provide
evidence of the benefits perceived by potential users of the
proposed system, which was designed to: (1) be easier to
use for illiterate older adults through the use of accessible
multi-modal interfaces (tangible and touch) and to (2)
enable the participation of the members of their SFN in the
CS activities by means of the game concept.
It can be argued that the development of natural and
pervasive systems for CS activities facilitated the interac-
tion between users and technologies, including illiterate
older adults. Moreover, the addition of collaborative fea-
tures to the system allows for the participation of members
of their SFN. The natural and easy access to a communi-
cation and shared collaboration channel, and the addition
of suitable mechanisms to be aware about participant’s
events during the CS activity, allowed older adults and
their relatives to collaborate (e.g. the cognitive activity),
compete (e.g. the entertainment activity) and socialize (e.g.
aspects of social communication related to the actual
gaming experience, or about the social or family context of
the SFN that involves them), in a fun and entertaining
environment, regardless of older adults’ illiteracy levels.
Furthermore, it can be argued that providing collabora-
tive activities that encourage SFN members to spend time
together by playing games and using pervasive interaction
devices appropriate to their age and computer skills is of
great importance. For this reason, the concept of play is
considered as an appropriate approach to enable older
adults to receive therapy, and at the same time, to interact
with their relatives. This will have positive effects not only
by preventing the apparition or acting on the older adults’
CD evolution, but also by facilitating the involvement of
the younger members of the SFN.
It was also observed that a CS activity based on a
competition game was perceived as more attractive to older
adults since it provides the opportunity to interact with
their children or grandchildren. But it is important to
mention that the proposed activities and games must be
known to older adults, or very simple to learn, to avoid
frustration or deception.
This way, the evidence obtained in the evaluation, as
reported in Sect. 6, concerning the high perceived levels of
ease of use, usefulness and enjoyment, along with the low
levels of anxiety, suggests that systems like the one pro-
posed represent a good opportunity to assist in the CS of
Univ Access Inf Soc
older adults. Furthermore, according to the evaluation
results, the features of the proposed system also: (1) pro-
mote socialization by allowing the participation of relatives
and (2) help to cope with the older adults’ lack of experi-
ence using computer-based applications and their illiteracy
by means of the use of more natural interfaces to conduct
the activity (tangible and touch) and to communicate dur-
ing the activity (audio channel).
The findings of this study replicate, and are supported
by, the results of several related works. For instance, Tár-
raga et al. [7] considered that both formal and entertain-
ment activities should be used to promote the CS of older
adults, as these allow to take the older adults’ preferences
into consideration; Davidoff et al. [14] and Hodges et al.
[15] considered that it was important to facilitate adequate
interaction mechanisms to older adults through alternative
interaction modalities (e.g. tangible interfaces), so that they
focused on the activity and not on the interaction mecha-
nisms used to perform the activity and finally, Gamberini
and Alcaniz [18] and Pantelopoulos et al. [19] considered
that common and well-known entertainment activities
should be used, as these were more enjoyable to partici-
pants (older adults and their relatives), and allowed to
engage them in the CS activity.
Finally, it is important to highlight what are considered to
be the two main limitations of the present work. An important
limitation regarding the study refers to the size of the sample
used in the evaluation. The small number of participants (12
participants, 6 older adult-relative pairs), although allowed to
establish promising preliminary evidence towards the
observed tendencies in the users’ perception towards the
proposed system, does not offer results with statistical sig-
nificance. It is hoped that these results would serve as a cat-
alyst to encourage others to further investigate on this research
line, as they have indeed motivated this work.
Another important limitation, regarding the conceptual
proposal, emerges due to the key assumption that, in order
to participate in the older adults CS session, the relative has
to be available and, most importantly, has to have easy
access to a computer with the SFN member client installed.
One way to overcome this limitation is to provide the older
adult’s relative access to the application in an ‘‘anywhere–
anytime’’ manner. One way to perform this is to provide
collaboration features, such as those proposed for the
(PC-based) SFN member collaboration client, in the
(Smartphone-based) communication client. The authors are
interested in following this as a direction of future work.
8 Conclusions and future work
The increase in life expectancy of human beings has not
only made apparent the increased incidences of age-related
conditions such as the Alzheimer’s disease, but also has
posed a challenge in terms of whether and how technology
could support their treatment. Among others, cognitive
stimulation has been proposed as a non-pharmacological
intervention to cope with the cognitive decline associated
to some of these diseases. However, it is also necessary to
address important limitations for its implementation, such
as the lack of specialized personnel to conduct therapy, or
the difficulty of access by some marginalized groups, such
as those with low education or income. This work has
proposed an approach regarding how pervasive CS col-
laborative systems could provide members of such groups
with a natural and easy means of interaction with tech-
nology (in order to deal with accessibility problems).
Moreover, this approach can promote the integration of
members of the older adults’ SFN to provide support
during the CS activities, allowing them to act as informal
caregivers, and as additional motivators and attention
keepers (in order to deal with the lack of specialized per-
sonnel to assist them).
Notably, both types of participants considered the sys-
tem useful and ease to use. It is important to mention that
even though older adults and their relatives felt little anx-
iety while using the system, this factor did not impact their
perceived ease of use and usefulness about it. A possible
explanation, as expressed by participants, was that their
anxiety resulted from playing a game that they did not
knew, and not necessarily from using the system (i.e. the
proposed interfaces). As a conclusion, it must be high-
lighted that these results provide evidence towards (1) the
use of multi-modal interfaces to adapt computer applica-
tions to the capabilities, educational level, needs and
preferences of the older adults and their SFN members and
(2) the use of technology to integrate their SFN members to
participate in CS activities, providing the means for rela-
tives to act as informal caregivers and as additional moti-
vators for the older adult. Thus, by providing natural
interaction interfaces, users, particularly illiterate older
adults, reduce their anxiety levels and consequently make
themselves more willing to use the system, regardless of
their previous literacy level or experience on the use of
computers.
Finally, concerning future work, three possible lines of
further investigation are identified: (1) conducting an
in situ evaluation of actual use, with a statistically signif-
icant sample size, to obtain further evidence about the
impact on the participation in CS activities of older adults,
their caregivers and the members of their SFN. Such evi-
dence could include, for example, information about the
caregivers’ and relatives’ perception about the proposed
tool, how do they compare it to other traditional and
technological CS methods and tools, which are the long-
term effects of using the proposed system, whether the
123

proposed activities will keep older adults interested in
performing their therapies, and which would be the costs,
among others; (2) developing a new version of the SFN
member collaboration client, which provides a means to
allow the older adult’s relatives to participate actively
‘‘anywhere and anytime’’ from their Smartphones and (3)
Proposing an ensemble of design guidelines that aid
developers to improve the usefulness, ease of use and user
experience of their pervasive CS systems, and which
integrate the lessons learnt from the conducted case studies
and evaluations.
Acknowledgments The authors would like to thank the personnel
and patients of Residencia Lourdes and of the municipal Tercera Edad
group for their support and participation in this study. This work was
partially funded by UABC under grant 0207 of the XIII Convocatoria
Interna de Proyectos de Investigación and grant 0212 Proyectos de
Servicio Social 2012.
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