Using Games as an Effective Intervention for Supporting Families Living with Dementia

This paper explores the role of games in supporting dementia family caregivers during the pre-and early stages of the disease. It provides a comprehensive review of existing studies that focus on support mechanisms for both dementia patients and their caregivers, with a specific emphasis on games designed for this purpose. This paper outlines a research study conducted in two experiments. The first experiment involved conducting separate focus groups to explore how technology can assist older adults during the COVID-19 pandemic and its aftermath. Group A consisted of 9 participants from the UK, while Group B comprised 8 participants from Taiwan. The aim was to gather insights and perspectives from different cultural contexts. The second experiment of the study involved testing games with dementia family caregivers to assess their effectiveness and identify areas for refinement and improvement. A total of 20 participants took part in this experiment. By conducting focus groups and game testing with participants from different regions, this research aimed to gather diverse perspectives and insights, enhancing the validity and applicability of the findings. The findings of this project extend beyond the scope of dementia care and have implications for addressing various long-term health conditions. Games platforms have the potential to serve as effective tools for supporting communities that provide care for individuals with dementia. They offer opportunities for promoting self-understanding, accessing relevant resources, and facilitating informed decision-making within the context of health journeys.


Introduction
In the modern era, games have transcended their traditional role as mere sources of entertainment and have found diverse applications across various fields.They can be categorized into Social Games, Games for Health, and Serious Games (Educational Games) based on their intended purposes.Our objective is to develop a game prototype that caters to the specific needs of the market.
The focus of this research is to explore how games can provide support for dementia carers, specifically targeting early-stage dementia and family carers.The diagnosis of dementia poses significant challenges for the entire family, and reaching, educating, and promoting positive behavioural goals among patient carers can be facilitated through a combination of social marketing and gaming techniques [1].Existing research in this area primarily revolves around the dementia condition itself, with limited support available for caregivers [2].
This research marks a new frontier in the gaming industry by combining practical and theoretical research, N. Y. Liu 2 which can serve as a knowledge base for a specific, innovative project that has the potential to stimulate strategic research worldwide.Games are not just for entertainment, but they can also be utilized as problemsolving tools and for acquiring new knowledge.Designing an appropriate game is the first step towards providing the technological tool required by dementia carers to increase their knowledge of health issues.The methodological advantage of this project lies in the fact that games provide a means for self-understanding and self-learning.The theoretical advantage is that advances in game technology can contribute to social and health support by catering to individual needs.The primary benefit of this project is the enhancement of the quality of life for individuals and communities, including improved health and wellbeing.

Literature Review
Literature review focused on three principal domains: Firstly, reviewing exciting services support for people with dementia and their family caregivers.Secondly, exploring the game for dementia and family caregivers.Finally, will conclude with a comprehensive summary and problem statement.

Support People with Dementia and Family Caregivers
The aging of the world's population is accelerating.The rate of dementia in countries around the world is constantly increasing, which has become a significant issue discussed worldwide.Suppose a family member is diagnosed with dementia.In that case, it will be a big challenge for dementia itself and the family numbers, including ignorance of the disease, unfamiliarity with the medical system, negative emotions, social pressure, and economic pressure.

Dementia Care
There are many options for people with dementia for different stages and needs according to each family situation is unique.There are four primary types of care for people with dementia, which will be discussed in detail below: In-Home Care: In-home care comprises a wide range of services provided in the home setting, which enables individuals with dementia to continue living in their own home [3].In-home services can be categorized into four types, namely: 1).Companion services: These services include general supervision, recreational activities, or companionship visits.2).Personal care services: This category involves assistance with personal care, such as bathing, dressing, toileting, eating, exercising, and other related activities.3).Homemaker services: These services focus on housekeeping, shopping, meal preparation, and other similar tasks.4).Skilled care: Skilled care is provided by licensed health professionals and is typically geared towards wound care, injections, physical therapy, and other medical needs.
Adult Day Centre: Adult day centres primarily offer individuals the opportunity to engage in social activities and participate in various programs within a safe environment [4].The benefits of adult day centres extend beyond providing support for individuals with dementia, as they also offer respite for caregivers, enabling them to take much-needed breaks and balance their caregiving duties with other responsibilities.
Long-term Care: Long-term care offers a variety of services to assist the elderly with their medical and nonmedical needs [5].In the United Kingdom, long-term care can be provided in their own homes, care homes, day-care centres, organizations, or charities.Care homes and daycare centres can be operated either by the local government or the private sector.Bupa is one of the private healthcare specialists in the UK, offering services such as private medical insurance, health clinics, and care homes.On the other hand, non-profit organizations and charities primarily support the local citizens, particularly in terms of social services.These social services provide assistance for individuals with dementia and their friends, family, and caregivers, aiming to enhance their sense of well-being through social activities and daily living support [6].
Hospice Care: Hospice care is designed for individuals in the final stages of dementia and their families [7].The services provided include 1) medical care to alleviate symptoms and pain, 2) counselling for emotional and spiritual support, 3) respite care to provide relief to caregivers, and 4) support for families in various ways.
Council's Public Health Unit [10].VOP has developed a 10-year plan to make Manchester "A Great Place to Grow Older".
The research group at the University of Southampton, focusing on dementia, maintains strong collaborations with the NHS, social care services, and the older adult communities.Additionally, there is significant support from local government and non-profit organizations, particularly within the private sector.For instance, the Alzheimer's Society's "Singing for the Brain" program in Southampton and the Dovetail Centre's Memory Support Group [11] are notable examples.
To enhance the city in the future, five key challenges need to be addressed: (i) Increasing awareness and understanding of dementia.(ii) Promoting a consistent and supportive response from general practitioners, healthcare professionals, and social care providers.(iii) Improving customer service, especially in larger corporate companies where technology and speed are prioritized.(iv) Encouraging a slower pace of life and better utilization of quiet and green spaces.(v) Creating a welcoming environment for people with dementia to access and enjoy all the facilities that the city has to offer.

Family Caregivers of People with Dementia
Caring for people with dementia is one of the most challenging roles, and support for family caregivers is often lacking [12].Although the need for support for family caregivers has been recognized for some time, it is still often lacking.With an aging population, the demand for health and social care services is increasing, and people are increasingly turning to the internet for information and support.Four themes of interrelated needs emerged from family caregivers of people with dementia, as discussed in a study by Bressan, Visintini and Palese in 2020 [13].
(i) Being supported: The majority of family caregivers need support in various ways.This support can come from other family members, community events, adult day centres, and more.(ii) Receiving accessible and personalized information: Family caregivers require accurate and timely information.Different stages of dementia necessitate different forms of support.For instance, during the early stages of dementia, caregivers may need basic information on finding support.(iii) Being trained and educated to care for their loved ones with dementia: Knowledge is essential for family caregivers, as it helps them enhance their understanding, coping abilities, and caregiving skills.(iv) Finding a balance: Family caregivers require support to maintain a balance between their caregiving responsibilities and personal lives.

Game Design
Game design session discussed two main research theories such as MDA framework (Mechanics, Dynamics, and Aesthetics) and Serious game.MDA is an important framework in game design which includes the fundamental components.Serious games discussed the valuable insights.

MDA Framework
Games are entertainment tools collaboration of designers and teams of developers, and enjoyed by players.The MDA Framework, introduced by Hunicke, Leblanc, and Zubek in 2004 [14], offers an approach to game design.Mechanics encompasses the specific components of the game, including data representation and algorithms.It is concerned with the technical aspects that constitute the game's internal workings.In addition, mechanics also refer to "the different actions, behaviors, and control mechanisms available to the player in a game context" [14][15].According to Marczewski (as cited in Kim, 2015), game mechanics are "a distinct set of rules that dictate the outcome of instructions within the system with an input, a process, and an output."Together with the game's content, such as levels and assets, the game mechanics support the overall gameplay dynamics [14].
Dynamics encompasses the real-time behavior of game mechanics, as they interact with player inputs and the outputs of other mechanics over time.It is concerned with how the game unfolds and reacts to the player's actions.An example highlighted by Kim (2015) is the dynamics of time pressure and opponent play, which contribute to the creation and support of the aesthetic of challenge.
Aesthetics concerns the positive emotional responses that players experience when interacting with the game system.It encompasses the feelings, moods, and overall experience that the game intends to evoke during gameplay.According to Kim (2015) [15], aesthetics encompasses the "diverse goals of games and the elements of enjoyment."To further explore the concept of what makes a game enjoyable and the various forms of enjoyment it encompasses, Hunicke et al. (2004) [14] have identified several categories of aesthetics that relate to the objectives or purposes of the game.Categories of Aesthetics [14] includes: Sensation (Game as sensepleasure), Fantasy (Game as make-believe), Narrative (Game as drama), Challenge (Game as obstacle course), Fellowship (Game as social framework), Discovery (Game as uncharted territory), Expression (Game as selfdiscovery), Submission (Game as pastime).

Serious Game
Professor James Paul Gee introduced a set of principles aimed at designing educational games that are effective in their purpose.These principles can be classified into three main categories: empowered learners, problem solving, and understanding [16].These game design principles have been widely employed in various research studies to enhance the effectiveness and impact of educational games [17].
The first category, empowered learners, focuses on motivating learners to engage with the game.This can be achieved through principles such as co-designing, customization, forming identity, and manipulation.By allowing players to make decisions, customize their experience, and take on new identities within the game, they gain a sense of control and empowerment.The ability to manipulate objects in the game world further immerses players and enhances their involvement.
The second category, problem solving, is discussed in terms of seven principles.The first principle emphasizes the importance of presenting well-ordered problems that guide players in the early stages of the game, enabling them to develop strategies that will help them tackle challenges later on.The concept of "Pleasantly Frustrating" is also introduced, highlighting that optimal learning occurs when there is a balance between challenge and enjoyment, often referred to as the state of "flow" [18].
The third category, understanding, is addressed through two principles: system thinking and meaning as action image.System thinking involves helping players understand how each element of the game fits into the broader context or genre.This promotes a deeper understanding of the game mechanics and their interconnectedness.Meaning as action image, on the other hand, leverages players' prior experiences with other games to convey meaningful messages and themes.
Overall, Gee's principles provide a framework for designing learning games that empower learners, foster problem-solving skills, and promote deep understanding.By incorporating these principles, game designers can create educational experiences that are engaging, challenging, and meaningful for players, preparing them for the future.

Games for dementia and Family Caregivers
People with dementia are living longer and may require proper support for their physical and psychological needs.As the population ages, it is important to consider how to care for these individuals in the future [19].
Technology is emerging to provide existing care that can maintain their health [20].However, the challenge for technology in supporting the elderly is to consider affordable and appropriate technologies to assist future dementia care, which outlines some of the technologies currently available and describes the many challenges to the integration of such technologies [19].
It is important for people living with dementia to remain active and continue their daily routines.Several types of games have been suggested for people with dementia, including Jigsaw Puzzles, which can increase cognitive scores in seniors with dementia [21].Dominoes, which provides therapeutic mental stimulation [22] , and Bingo, which is a meaningful activity for older adults and can help with their cognitive level [23].
While there are exciting games for dementia, they are limited to family caregivers, particularly those related to dementia.A few examples of games related to carers include: (a) [That Dragon, Cancer], an immersive, narrative video game telling the story of Joel Green's fight against cancer, based on the Green's experience of raising their son Joel, (b) [Life in a Spin], which offers practical support and advice for young adult carers, allowing players to learn how to balance caring with their daily life, and (c) [The Dysphagia Game], developed with the NHS, which provides knowledge of dysphagia mainly for professional caregivers.

Summary and Problem Statement
Dementia affects millions of people worldwide.It is characterized by cognitive decline, including memory loss, difficulty communicating, and changes in behaviour and personality.The primary support for individuals with dementia is facilitating their integration into society.However, the COVID-19 pandemic has presented unprecedented challenges and risks for people living with dementia [24].The restrictive measures and social isolation enforced during the pandemic have led to an increased likelihood of neuropsychiatric disturbances among individuals with dementia [25].Despite the declaration by the WHO chief in 2023 that the COVID-19 pandemic is no longer a global health emergency, its effects continue to impact older adults, including those with dementia [26].
Dementia not only affects individuals with the condition but also has a profound impact on their entire family, particularly the primary caregiver [27].Assuming the caregiving role can be challenging and demanding, often leading to caregiver burnout.
Providing accurate and timely information is crucial, especially during the pre-and early stages of dementia, to support family caregivers.During this period, caregivers may experience frustration, a lack of information, and uncertainty about how to effectively fulfil their caregiving responsibilities [28].Offering the right resources and guidance becomes essential in helping them navigate this journey as caregivers.
Thus, this study designs a game namely [Make a Cup of Tea] targeting family caregivers of individuals with dementia in the pre-and early stages.The purpose of the game is to help people understand dementia as a crucial and significant first step.The research experiment consists of two phases.Firstly, a focus group will be conducted to understand the needs of older adults and how COVID-19 has affected their social lives.Secondly, prototypes of the game (Make a Cup of Tea) will be tested with family caregivers to refine the game before its release in the market.This research is a multidisciplinary study that incorporates collaboration with various disciplines and engages with society.

Games Design for Family Caregivers of People with Dementia
[Make a Cup of Tea] is designed for family caregivers who are dealing with patients in the pre-and early stages of dementia.The game consists of five mini-games that need to be completed in order to make a cup of tea.These mini-games are designed to convey the five key messages about dementia as propagated by the organization Dementia Friends 1 [29].The five key messages are as follows: (i) Dementia is caused by diseases of the brain.(ii) Dementia is not limited to memory loss; it can also affect thinking, communication, and daily tasks.(iii) It is possible to live well with dementia.(iv) Dementia is not a natural part of aging.(v) There is more to a person than their dementia.

Game Content
In these five stages, players will need to acquire five key tools for making a cup of tea, such as a cup, water, tea bag, sugar, and milk.Each step will have its own game message (according to the Dementia Friends' five key message), and also give suggestion and suggestions for people caring for dementia patients.Each stage is described in detail below: Step One • Tool: Cup • Message: There is more to a person than their dementia.• Game Type: Customize the Cup Avatar -The different designs featured on the cups exemplify the fact that individuals have distinct personalities. 1. Select the colour of the cup.2. Choose an emotional expression for the cup.3. Personalize the cup by selecting an image that reflects your interests.• Suggestion: Let the people with dementia retain their identity/personality.
Step Two • Tool: Water • Message: Dementia is not a natural part of aging.
• Game Type: Speed Game -The normal aging process is shown through slower movements.As the player catches drops in the game, the age of the character increases, resulting in a slower movement.The score is determined by the number of drops caught.Once the player reaches a score of 100, the input keys start swapping around intermittently.For example, pressing the left key may occasionally make the character move right, and vice versa.During this Step Four • Tool: Sugar • Message: Dementia is not limited to memory loss; it can also affect thinking, communication, and daily tasks.• Game Type: Message Game -People with dementia find it difficult to comprehend communication.The sense of taste of individuals with dementia often undergoes changes, with a preference for sweet flavours being common.In this game, the player's objective is to locate a specific item displayed at the bottom of the screen within a scattered collection of objects on the screen.The score is based on the number of items successfully found within the given time limit.• Suggestion: People with dementia may find it difficult to communicate or convey their thinking.They need others to be more patient with them, and to understand their needs.
Step Five • Tool: Milk • Message: It is possible to live well with dementia.
• Game Type: Historical Game -Game Story: People like to talk about the past.In this game, the player is presented with multiple-choice questions about historical events.Upon answering questions correctly, the player is awarded milk, which is then

Game Purpose
The purpose of the game is to explore how games can support dementia caregivers and has three main objectives: Health, Education, and Social.The game aims to provide a platform for the transfer of knowledge about dementia and offer suggestions for family caregivers to improve their health behaviour, such as managing their negative emotions.This falls under the Health objective.
The Education objective involves increasing the player's knowledge about dementia through the game's story and information while also providing suggestions on how to care for people with dementia.
The game also has a Social component, which is achieved through raising awareness of dementia and allowing players to discuss these issues.The study fully supports the need for dementia caregivers to connect with both an online social network and the local community to help engage people and discuss their problems while also supporting each other.
[Make a Cup of Tea] was designed as a mock-up game to test with dementia family caregivers, representing the game concept.There are various details that require improvement.In this research stage, the game serves as the main platform but can be further integrated with social platforms, both online and local communities, to provide comprehensive support for dementia family caregivers.

Research Methodology
This study includes Experiment I: Focus Group with older adults to understand their needs, particularly when they are faced with the COVID-19 pandemic and how it affects their social life.Experiment II: Game Testing is conducted with family caregivers to assess the reliability of the prototype game [Make a Cup of Tea] for potential users.The objective of these experiments was to refine the game prototypes and improve their usability for family caregivers of individuals with dementia in the preand early stages.

Experiment I: Focus Groups
Purpose: This investigation aimed to understand the impact of COVID-19 on older adults, allowing them to provide direct and in-depth discussions about their feelings and situations.The focus groups were conducted in two groups: A -people in the United Kingdom, and Bpeople in Taiwan.Procedure: The studies were conducted through online meetings for the focus groups.Each group had a 1-hour discussion that allowed everyone to share their ideas.The questions were open-ended.At the end of the discussion, participants were invited to add additional topics related to their lives.

Data collection and analysis:
The data was collected from older adults.The software NVivo 11 for Mac was used to assist in the analysis.

Experiment II: Testing Prototypes Game
This experiment aims to test the game with twenty participants, who are family caregivers of people with dementia, using qualitative research methods.The minimum sample size calculated was fifteen participants, as shown in Figure 1 using G*Power.Given the study's focus on a broader, observable effect, a large effect size of 0.8 was chosen, along with an alpha value of 0.05 and a power value of 0.8, in line with general practice [30].While the convention for alpha is 0.05, in exploratory fields, 0.1 is sometimes used, which would require a sample size of 16.Purpose: The purpose of this study was to assess the reliability of the game for dementia family caregivers using qualitative methodology.

Method:
The participants were British dementia family caregivers.The survey questions were developed based on the instrument used in the previous experiment with experienced gaming professionals.

Procedure:
The participants were asked to play the game or watch a video for five minutes, and then complete the respective questionnaire (Appendix A).
Data Collection and Analysis: Over thirty dementia family caregivers participated in the study, and qualitative data was collected from them.The data collected was used to determine the reliability of the game, particularly for those involved in pre-or early-stage dementia.

Experiment I: Focus Group
The focus groups consisted of two small groups: Group A with 9 participants from the United Kingdom and Group B with 8 participants from Taiwan.The participants were asked open-ended questions to express their thoughts and feelings.

Group A
In the focus group A research, there were 6 females and 3 males, totalling 9 participants.Among them, 3 participants were over 90 years old, 2 participants were 65 years old, 1 participant was 66 years old, 2 participants were 72 years old, and 1 participant was 77 years old, as shown in Table 1.
Table 1.Participants in the UK The focus group discussion was centred around three themes such as emotional, social and technology.The emotional theme had two codes, while the social theme had four codes, as shown in Table 2.

Emotional Theme
The emotional theme within the two code such as "miss" and "worried".These are negative emotion which will discuss below.For the code "miss" the participants are miss their family numbers.However, they do phone or video call.
• GB01: I miss seeing my family.Although they phone me.It is not quite the same, as a being with them.• GB07: I miss my grandchildren.
• There are two participants who mention "worried".
They worried about themselves, family numbers and whole situation in the world such as economy.• GB 05: The economy is collapsing and the great harm that this is going to do to the population, that's what worries me more than anything else • GB 08: I am worried about my family this village where many people died and about the situation in the entire world.

Social Theme
In the social theme with four code difficult to shop, indoor, traveling and holiday.
The participant GB02 mention that it is difficult to go for shopping.
• GB 02: It's difficult to shop now, it takes a lot longer.There are two participants GB06 and GB09 mentioned that, the most time they are "indoors".
• GB 06: Being unable to move around in the way that I would have down in the past, like having to be indoors all the time which means staying in the house the whole day long.• GB09: Easter is three days of celebrations with family and friends but this year.It was solitary time spent indoors with TV for company.
EAI Endorsed Transactions on Pervasive Health and Technology 2023 | Volume 9 There are two codes are similar meaning such as "travelling" and "holiday".
• GB07: I'm fed up of not traveling.Tough times, hopefully once the vaccine starts offering protection the world will go back to normality.• GB02: The thought of a holiday.Impossible at this time.other than that, we carry on.

Technology Theme
During the pandemic, older adults have learned to utilize technology to connect with their friends and families.Three participants specifically mentioned their increased knowledge and usage of technology.
• Participant GB4 stated, "Yes, a lot more.I learned to use Zoom and Teams." • Participant GB6 shared, "I used to email my grandchild, and now I have learned to use Zoom for church meetings." • Participant GB7 expressed, "I craved seeing people, not technology...I learned Zoom but hate it...I learned from my children to use Marco Polo, which is a video messaging mobile app." • Participant GB7 mentioned that while she previously used emails, she has now also learned to use online video call platforms such as Zoom.

Group B
The focus group in Taiwan also discussed two themes: emotional, social and technology.Within the emotional theme, there were six codes identified, and within the social theme, there were two codes.These are presented in Table 4.
• TW04: "I feel that, though the new report, there will be anxiety in my heart."• TW06: "...some elderly people may feel anxious.It is uneasy to stay at home and can't go out, causing great psychological damage." Only one participant felt sad.• TW05: "When I saw on TV that someone got it, and when I saw someone passed away, I felt very sad." Participant TW06 mentioned feeling Depressed and Down.
• TW06: "Feel depression at home all the time."• TW06: "It is broadcast 24 hours a day in Taiwan and often makes people feel down." Five participants expressed fear. • TW01: "I am afraid to go out."• TW02: "I am afraid of death.I am afraid that my friends would get sick, and I was also afraid that my family would get sick."• TW03: "I am old, but our government handled it very well, so although I was afraid, it would return to normal …" • TW08: "I am afraid that the child will get ." EAI Endorsed Transactions on Pervasive Health and Technology 2023 | Volume 9 • TW06: "...waiting indefinitely for the epidemic to ease, causing a lot of fear in people's hearts."

Social Theme
There are only two codes mentioned in the social theme: Careful and Cancelled.
Participant TW01 mentioned being "careful".• TW01: "I'm very careful when I go out.I have to wear a mask and I have to wash my hands." Participant TW06 mentioned that their activities have been cancelled.• TW06: "Our activities have been cancelled."

Technology Theme
There were three participants who mentioned an increase in their use of technology compared to before.The responses are provided below: • TW01: "I have been using video calls more frequently to connect with my family."• TW07: "I rely on video calls a lot now."• TW08: "Although we were already familiar with technology, we have been using it more often now, especially for video calls with our families." However, participant TW05 highlighted that using technology platforms, particularly an iPad, was a new experience for them.On the other hand, TW04 mentioned purchasing an Apple Watch to monitor their health, specifically their blood oxygen levels.• TW05: "I have started using an iPad frequently, which is a new device for me."• TW04: "I bought an Apple Watch to track my health information, particularly my blood oxygen levels."

Experiment II: Testing Mock-Up Game with Dementia Family Carers
During this stage, the mock-up game was tested with dementia family carers using the metric instrument.This session focuses on the results obtained from comparing the means of individual framework elements and grouped combinations.The study included twenty participants, comprising of four males and sixteen females, as indicated in Table 5.The majority of the participants, specifically six individuals, fell within the 65-75 age range, as shown in Table 6.The most family caregivers are female, and 34% of them are aged 65 or over.

Normality
The data in Appendix B underwent normality tests using the Kolmogorov-Smirnov and Shapiro-Wilk tests.The tests indicated insignificant results (p < 0.05), suggesting that the data distributions were normal.Hence, it is appropriate to use a t-test [31].

Independent-Samples T-test
Responses were collected from a total of twenty participants who served as dementia family carers.In the analysis, the participants' responses to the Make a cup of tea game were compared to a null value, which was determined by the sum of "Neither" responses (which equaled 3 for each question).The mean results obtained from the participants were higher than the null value, indicating that the majority of participants either agreed or strongly agreed with the statements.However, there were certain questions, namely H_Education_SM and E_Social_SM (as presented in Appendix C), where lower results were observed.These questions pertained to the impact of the game's background music/sound on understanding health issues and its role in improving knowledge of health issues.The findings suggest that the background music/sound had a limited effect on the overall gaming experience, as it was considered more of a supplementary element rather than a core component.Nonetheless, this issue will be addressed for future enhancements.
The [Make a cup of tea] game primarily focuses on the visual design, as mentioned in the game content.The unsuccessful results obtained from the independent sample t-tests were primarily associated with the background music of the game.Based on these results, it can be concluded that the sound and music in the game do not significantly impact the overall gaming experience.However, the game's ability to support dementia family carers, particularly at pre-and early-stages, was measured through various tests, including normality tests and means Lilliefors Significance Correction

Grouping Non-Parametric Means Test
The Mann-Whitney test was performed on the grouped factors, and the results showed higher mean ranks compared to the null value (where every question was answered with "No Opinion" = 3), as presented in Table 8.This indicates that the participants generally agreed or strongly agreed with the statements.Each of the factors exhibited significant results (p < 0.05), as shown in Table 9.

Discussion
According to Experiment A, the COVID-19 pandemic has had a lasting impact on older adults, as revealed by the research experiments.In Taiwan, older adults experienced more negative emotions such as nervousness, anxiety, and depression, leading them to be more cautious during the pandemic.Conversely, in the UK, older adults faced more family-related issues such as missing their families, as well as dealing with the cancellation of holidays and travel plans.
The study found that older adults in the UK adapted by learning to use new technologies, while older adults in Taiwan, who were already familiar with these technologies, used them more frequently during the pandemic.Additionally, older adults in Taiwan acquired new devices for various purposes, including health tracking and video calling with family members.The results of the study illustrate the cultural differences between Taiwan and the UK.
In Experiment II, the [Make a Cup of Tea] mock-up game was tested with dementia family caregivers to evaluate its components of Health, Education, and Social.The results were positive and indicate that the game has the potential to support dementia family caregivers, particularly in pre-and early stages.However, the Social component was challenging to quantify due to its complexity and diverse aspects.
While [Make a Cup of Tea] is not yet ready for the market, Experiment II is a crucial step towards further research and game development.

The Refined and Expanded Game Prototypes
The game is specifically designed for individuals in the pre/early stages of dementia and their families.Its purpose is to increase awareness and understanding of the symptoms experienced during the early stages of dementia, as well as provide suggestions on how to care for individuals with the condition.
Renamed: The game formerly known as [Make a Cup of Tea] has been renamed as [Tea Time!]In British, Irish, and certain Commonwealth countries, the term "tea" is sometimes used to refer to the main evening meal, instead of using the terms "dinner" or "supper."However, this article focuses on the various types of secondary and lighter meals known as "tea."Consequently, the [Tea Time!] games are designed with three different themes, each representing the symptoms of dementia that individuals might experience.During the game, players can travel around the world, exploring their favourite flavours, while also gaining insight into the challenges faced by individuals with dementia and how to support them.

Refined Game:
The five key messages regarding dementia, advocated by the organization Dementia Friends, remain unchanged.However, improvements have been made to the game type, story, and suggestions in order to enhance the user experience.The following modifications have been implemented in each step, except for step two which remains unchanged: Step One (cup) • Game Type: The game type has been changed to an Emotion Game -this game tracks and records emotions.Emotions play a significant role in the lives of older adults and people with dementia often experience changes in their emotional responses.
EAI Endorsed Transactions on Pervasive Health and Technology 2023 | Volume 9 Step Three (tea) • Game Type: Memory Game -Match pairs of different tea bags.• Suggestion: In different types of dementia there is damage to different parts of the brain.However, in all cases, people with it are encouraged to get involved with social activities to maintain their health.
Step Four (sugar) • Game Type: Attention Game: Find the correct item.
• Suggestion: People with dementia may find it challenging to communicate or express their thoughts.Caregivers need to be patient and understanding in order to comprehend their needs.
Step Five (milk) • Game Type: Problem Solving Game -Jigsaw puzzle.
• Suggestion: People with dementia still can be themselves and live independently.
Expended Theme: The game consists of three different cultural themes: Cuppa, Fondue, and Sushi (Table 7).The primary theme, Cuppa, has been refined based on the previous mock-up game called [Make a Cup of Tea].It focuses on conveying five important messages about dementia and provides suggestions for families of individuals with dementia.
Making a cup of tea is a common daily task in English culture and is generally considered an intuitive action for most people.However, memory loss and cognitive difficulties are well-known signs of dementia, which can make even simple tasks like making tea challenging.Researchers have discovered that minor mistakes while performing routine activities can be early indicators of the condition.The other themes explore specific symptoms of dementia and provide recommendations on how to support individuals with dementia for their family members.

Future Work
This research is focused on the game itself for family carers of pre-and early-stages of dementia.There are various ways to proceed based on the research results.
Three of the main recommended directions for future works are discussed below: Game Testing: Games has been developed; the next stage will used the new AR games to test large number of people.In order to find out the games are reliable in the market.
Expandig Games: The research can continues expending different theme with different culture such as Taiwanese beef noodles etc.It will make games more interested and more information.Additionally, as the current design is for carers of pre-and early-stages of dementia, the next step can be expanding to carers of patients of middle or late stage of dementia.
Applied to different health issues: The research could also be applied to different health issues, especially mental health.There are many health issues which are similar to dementia.For example, Post-traumatic stress disorder (PTSD) and Schizophrenia.PTSD is type of anxiety disorder is very similar to dementia; PTSD patients can lose their memory, for example.There may be treatments for this type of mental health to help patients get back to normal life [32].:The seriousness of schizophrenia this type of mental health issue depends on how well patients can cope with it.Family and friends play an important role including listening and helping out with their daily life.

Final Remark
This research project is a collaboration between digital design, computer science, and healthcare studies, aiming to enhance the living standards of dementia patient carers through educational games.The primary focus is to educate and enlighten carers, ultimately improving their understanding and support for dementia patients.The paper explores the challenges faced by older adults during the COVID-19 pandemic and post-pandemic periods, highlighting how technology can enhance their lives and facilitate connections with family and friends.
Based on the research findings, the game [Make a Cup of Tea] was developed as a mock-up to demonstrate an ideal support system for family carers of dementia patients.The game yielded positive results, providing valuable insights for future expansion and development.Furthermore, [Make a Cup of Tea] has been refined as an augmented reality (AR) game, offering users a more immersive environment.
The impact of this research is expected to be significant in improving the quality of life, particularly for family carers of individuals in the pre-and early-stages of dementia.Playing the game will positively affect the player's well-being and overall quality of life.G11: I think playing the game in combination with social media platforms can help support people with their health issues.G12: * I don't think using the online community will be able to help support people with their health issues.G13: The game allowed me to link with communities to discuss the health issues.
G14: *The game does not allow me to link with community members to discuss the health issues.
G15: Using an avatar whilst playing the game helps to bring me closer to the community.G16: I feel that using my avatar within the community helps me to change my health behaviors.G17: I think the game world encourages players to seek out real-world communities to find support for their health issues.G18: In the game, I was able to speak to other people about health issues.
G19: I felt the game story made me interested in finding out more about health issues.

:
The participants were individuals aged over 65 years old.The focus groups involved general open-ended questions focused on two main topics: How do you feel about COVID-19?How has COVID-19 impacted your life?Did you use more technology during COVID-19?Did you learn to use new technology during the COVID-19 pandemic?

Figure 3 .
Figure 3.A screenshot of Tea Time!
Suggestion: Normal age-related changes in cognition can happen, but confusion and memory loss are NOT part of the healthy aging process.To looking after dementia needs more patience.Game Type: Brain Training Game -People with dementia may experience difficulty in remembering things.Adopting a healthy lifestyle and consuming non-alcoholic beverages can reduce the risk of developing dementia.The player needs to find the matching tea bag hidden under the cards, similar to the game of Pairs.Consumption of alcoholic drinks, which are detrimental, triggers the appearance of additional cards, while good cards cause the number of cards to decrease.
1 https://www.dementiafriends.org.ukperiod, a confused icon is displayed to indicate the key swap.• • Suggestion: One common cause of dementia is Alzheimer's disease.Individuals who adopt a healthy lifestyle, especially from mid-life onwards, are less likely to develop Alzheimer's disease.This means engaging in healthy habits such as regular physical exercise, maintaining a healthy weight, not smoking, consuming a balanced diet, and moderate alcohol consumption.

Table 2 .
An initial list of aspects identified from focus group (A)

Table 3 .
Participants in Taiwan

Table 4 .
An initial list of aspects identified from focus group (B)

Table 5 .
Respondent's gender of participants

Table 7 .
These tests were conducted to assess the effectiveness of the [Make a cup of tea] game in supporting dementia family carers.Normality tests were conducted using the Kolmogorov-Smirnov and Shapiro-Wilk tests for the group factors.The results indicated significance for Health and Social factors (p < 0.05), as shown in As a result, nonparametric tests were employed to analyse the data, as these tests do not assume a normal distribution of the data.
EAI Endorsed Transactions on Pervasive Health and Technology 2023 | Volume 9tests.

Table 8 .
Grouping the Mann-Whitney Mean Rank

Table 9 .
Grouping the Mann-Whitney Significance Statistics

Table 7 .
Game Details EAI Endorsed Transactions on Pervasive Health and Technology Evaluate how social media supports the Health component G20: * Whilst playing the game, I did not focus on the game story.
G41: * I don't think the gameplay engaged me enough for me to gain new knowledge.G42: I found the avatar can motivate other players to discuss the health issues.G43: I found the game world graphics helped me to gain new knowledge about real-life health issues.EAI Endorsed Transactions on Pervasive Health and Technology * Reverse-worded questions EAI Endorsed Transactions on Pervasive Health and Technology 2023 | Volume 9 Appendix C. Independent-Samples T-test EAI Endorsed Transactions on Pervasive Health and Technology 2023 | Volume 9