key: cord-0684232-8hgecroc
authors: Cuevas-Lara, César; Izquierdo, Mikel; Zambom-Ferraresi, Fabiola; Sáez de Asteasu, Mikel L.; Marín-Epelde, Itxaso; Chenhuichen, Chenhui; Zambom-Ferraresi, Fabricio; Ramírez-Vélez, Robinson; García-Hermoso, Antonio; Casas-Herrero, Álvaro; Capón-Sáez, Amaya; Lozano-Vicario, Lucia; Criado-Martín, Irene; Sánchez-Latorre, Marina; Antoñanzas-Valencia, Cristina; Martínez-Velilla, Nicolás
title: A Feasibility Study for Implementation “Health Arcade”: A Study Protocol for Prototype of Multidomain Intervention Based on Gamification Technologies in Acutely Hospitalized Older Patients
date: 2020-11-01
journal: Int J Environ Res Public Health
DOI: 10.3390/ijerph17218058
sha: fd72fa389c2167f09d740fffb4927581f4774c10
doc_id: 684232
cord_uid: 8hgecroc

The aim of this article is to present the research protocol for a study that will evaluate the feasibility of implementation of Health Arcade prototype multidomain intervention based on physical and cognitive training using gamification technologies at improving care for older people hospitalized with an acute illness. A total of 40 older people will be recruited in a tertiary public hospital at Pamplona, Spain. The intervention duration will be four to nine consecutive days. Additionally, the patients will receive encouragement for maintaining active during hospital stay and for reducing sedentary time. Primary implementation-related outcomes will be the adherence to treatment (i.e., number of games and days completed during the intervention period), reaction or response time, and number of success and failures in each game per day. Secondary implementation-related outcomes will be self-perceived grade of difficulty, satisfaction, enjoyment per game and session, and self-perceived difficulties in handling the prototype hardware. Other health-related outcomes will also be assessed such as functional capacity in activities of daily living, mood status, quality of life, handgrip strength, physical activity levels, and mobility. The current study will provide additional evidence to support the implementation of multidomain interventions designed to target older persons with an acute illness based on friendly technology. The proposed intervention will increase accessibility of in-clinical geriatrics services, improve function, promote recovery of the health, and reduce economic costs.

The risk of loss of independence and the likelihood of developing new disabilities that increases with the ageing process is one of the major issues in developed countries. Such loss of functional independence, coupled with a gradual impairment of cognitive and physical abilities, is associated with a greater chance of institutionalization and mortality [1, 2] . In this context, the World Health Organization (WHO) published the first "World Report on Ageing and Health" [3] in 2015. This framework emphasizes that care for older people must shift their main focus from disease to intrinsic capacity (i.e., physical function). This becomes particularly important when dealing with old people at risk of disability, also known as frail, to act on them early on.

One of the major events leading to disability in elderly adults is usually acute medical illness with its subsequent hospitalization. Hospitalization-acquired disability incidence usually varies between 5% and 60% [4, 5] . Recent evidence has shed light on hospitalization-related iatrogenic disability in elderly people, which is frequently characterized by lengthy periods of bedrest. Previous studies have observed that the time that older adults spend outside of said bed, pacing or walking along available spaces in the hospitals ranges from 7 to 43 min per day, reaching 83 min per day when also counting the time they spend on their feet [6, 7] . This phenomenon has been named "pyjama paralysis" [8] . The decrease in mobility during hospital-stays in conjunction with the reduction of functional and physiological reserves in elderly hospitalized patients may result in many adverse events. These adverse events include loss of autonomy regarding activities of daily living (ADLs), a higher incidence of falls, cognitive impairment, sarcopenia, reduced caloric intake and social isolation [9] . Thus, the hospitalization should turn out to be the turning point and the appropriate place for establishing interventions to prevent hospitalization-acquired disability [10] .

In this scenario, serious games could present an innovative intervention. Serious games are defined as games in which the final goal is to promote a change in the user, not the training in and of itself. This change could range between the acquiring of new knowledge to changes in attitudes or even changes in cognitive, physical, and/or social abilities [11] . The design of these games is based exclusively on virtual and technological environments, comprising an important component of virtual reality simulation. Furthermore, recent evidence has proposed the term "gamification," which is used to mention the gaming elements in non-gaming contexts with the aim of reaching a behaviour change in the user [11] [12] [13] [14] . These interventions have been proven to be effective in different settings, such as children, teenagers, or young adults, mainly in education, commerce, and communication. [15] [16] [17] [18] [19] [20] . However, current evidence suggests it is still necessary to redesign and adapt these technologies to the characteristics and preferences of old patients in order to achieve maximum engagement [21] .

The Health Arcade project has designed to promote a change in geriatric patients' routines during hospital stay by creating a favourable setting that will attract and motivate them for performing physical and cognitive activities to prevent iatrogenic nosocomial disability [22] . The main aim of this project is to validate the impact of a pilot-system of multidomain intervention (i.e., physical and cognitive training) using gamification technologies to improve patients' functional abilities (Figure 1 ), while also encouraging personal motivation and internal locus of control, which have been shown to be predictive variables in health promotion [16, 23, 24] . 

The Health Arcade utilized an uncontrolled, pre-post-test trial to determine the implementation of the prototype multidomain intervention based on physical and cognitive training using gamification technologies. This design was suitable for establishing the feasibility, appeal, and potential implementation of an innovative intervention prior to launching into a more costly and intensive randomized controlled trial design. The study will be implemented in the acute care for elderly (ACE) unit of the department of geriatrics in a tertiary public hospital (Hospital Complex of Navarre [CHN] , Pamplona, Spain). This department is constituted by 35 beds allocated to the unit and a staff of 12 geriatricians. Admissions in the ACE unit proceed mainly from the accident and emergency department.

Older adults aged 75 or over admitted to the Department of Geriatrics of the CHN between September 2020 and January 2021. Inclusion and exclusion criteria are described in Table 1 . Table 1 . Eligibility criteria.

Exclusion Barthel Index score ≥60 points.

Expected length of stay <6 days. Without major cognitive disorder or with mild cognitive impairment (Mini Mental State Examination ≥19; Global Deterioration Scale score = 1-3).

Uncontrolled arrhythmias, acute pulmonary embolism and myocardial infarction, or extremity bone fracture in the past 3 months. Able to ambulate (with/without assistance).

Terminal illness. The participant must be able to communicate and collaborate with the researchers.

Participants will be identified during the geriatric assessment process at admission in the ACE unit. The geriatricians will conduct a screening interview to determine whether potentially eligible patients meet the inclusion criteria. Demographic characteristic (e.g., age, residence, and level of education, etc.) will be also included.

The study followed the principles of the Declaration of Helsinki [25] and was approved by Hospital Complex of Navarre Clinical Research Ethics Committee on 6th November 2019 ID-PI_2019/96). All patients or their legal representatives provided written informed consent.

The intervention will consist in a supervised training including cognitive and physical stimulation using the games of the Health Arcade prototype (developed by OUIPLAY sl., Dundee, UK). This pilot-system is made up of a selection of technologies, such as movement detection through Near-Field Communication Sensors, wireless communication systems, feedback systems (i.e., LEDs 

The Health Arcade utilized an uncontrolled, pre-post-test trial to determine the implementation of the prototype multidomain intervention based on physical and cognitive training using gamification technologies. This design was suitable for establishing the feasibility, appeal, and potential implementation of an innovative intervention prior to launching into a more costly and intensive randomized controlled trial design. The study will be implemented in the acute care for elderly (ACE) unit of the department of geriatrics in a tertiary public hospital (Hospital Complex of Navarre [CHN] , Pamplona, Spain). This department is constituted by 35 beds allocated to the unit and a staff of 12 geriatricians. Admissions in the ACE unit proceed mainly from the accident and emergency department.

Older adults aged 75 or over admitted to the Department of Geriatrics of the CHN between September 2020 and January 2021. Inclusion and exclusion criteria are described in Table 1 . Table 1 . Eligibility criteria.

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The highest number

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Int. J. Environ. Res. Public Health 2020, 17, x 6 of 13

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The architect

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The architect

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The architect

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6

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Supermarket shelves

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The architect

Select the option that corresponds to the figure shown in the picture.

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Select the option that corresponds to the fruits of the picture that appears on the screen.

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Select the option that corresponds to the word that does not correspond to that category of words.

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Press the button with the number that appears on the screen.

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Press the button with the number that appears on the screen.

Select the correct option in less than 15 s.

Supermarket shelves

Select the option that corresponds to the position of the food of the picture that appears on the screen.

Select the correct option in less than 20 s.

The architect

Select the option that corresponds to the figure shown in the picture.

Select the correct option in less than 15 s. 

Press the button with the number that appears on the screen.

Select the correct option in less than 15 s.

Supermarket shelves

Select the option that corresponds to the position of the food of the picture that appears on the screen.

Select the correct option in less than 20 s.

The architect

Select the option that corresponds to the figure shown in the picture.

Select the correct option in less than 15 s. 

Press the button with the number that appears on the screen.

Select the correct option in less than 15 s.

Supermarket shelves

Select the option that corresponds to the position of the food of the picture that appears on the screen.

Select the correct option in less than 20 s.

The architect

Select the option that corresponds to the figure shown in the picture.

Select the correct option in less than 15 s.

Select the option that corresponds to the number of a certain symbol indicated in each sequence.

Select the correct option in less than 20 s.

Select the option that corresponds to the fruits of the picture that appears on the screen.

Select the correct option in less than 20 s.

Categories Select the option that corresponds to the word that does not correspond to that category of words.

Select the correct option in less than 20 s.

Press the button with the number that appears on the screen.

Select the correct option in less than 15 s.

Clock needles Select the option that corresponds to the time shown in the clock. Select the correct option in less than 15 s.

Word soup

Select the option that corresponds to the word hidden in word soup.

Select the correct option in less than 20 s.

Memorize the picture Remember and select the option that corresponds to the image shown in the previous image.

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Calendar Select the option that corresponds to the date shown on the calendar. The highest number

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Situations Select the option that corresponds to the action or activity shown in the image.

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Supermarket shelves

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The architect

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Categories Select the option that corresponds to the word that does not correspond to that category of words.

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Clock needles Select the option that corresponds to the time shown in the clock. Press the button with the number that appears on the screen.

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Calendar Select the option that corresponds to the date shown on the calendar. The highest number

Select the option that corresponds to the highest number displayed on the screen.

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Situations Select the option that corresponds to the action or activity shown in the image.

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Supermarket shelves

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The architect

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Select the option that corresponds to the fruits of the picture that appears on the screen.

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Categories Select the option that corresponds to the word that does not correspond to that category of words.

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Calendar Select the option that corresponds to the date shown on the calendar. The highest number

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Situations Select the option that corresponds to the action or activity shown in the image.

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Press the button with the number that appears on the screen.

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Supermarket shelves

Select the option that corresponds to the position of the food of the picture that appears on the screen.

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The architect

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Select the option that corresponds to the fruits of the picture that appears on the screen.

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Ferris wheel of letters Select the word that can be formed from the letters that appear on the screen.

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Calendar Select the option that corresponds to the date shown on the calendar. 

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Supermarket shelves

Select the option that corresponds to the position of the food of the picture that appears on the screen.

Select the correct option in less than 20 s.

The architect

Select the option that corresponds to the figure shown in the picture.

Select the correct option in less than 15 s.

Select the option that corresponds to the number of a certain symbol indicated in each sequence.

Select the correct option in less than 20 s.

Fruit basket

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6 option in less than 20 s.

Fruit basket

Select the option that corresponds to the fruits of the picture that appears on the screen.

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Categories Select the option that corresponds to the word that does not correspond to that category of words.

Select the correct option in less than 20 s.

Press the button with the number that appears on the screen.

Select the correct option in less than 15 s.

Clock needles Select the option that corresponds to the time shown in the clock.

Select the correct option in less than 20 s.

Which figure is it?

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Select the option that corresponds to the figure shown in the picture.

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Soup of Symbols corresponds to the number of a certain symbol indicated in each sequence.

Select the correct option in less than 20 s.

Fruit basket

Select the option that corresponds to the fruits of the picture that appears on the screen. 

Press the button with the number that appears on the screen.

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The highest number number displayed on the screen.

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Select the option that corresponds to the action or activity shown in the image.

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Clock needles Select the option that corresponds to the time shown in the clock. 

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Situations Select the option that corresponds to the action activity shown in the imag

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Remember and select the option that corresponds to image shown in the previo image.

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Situations Select the option that corresponds to the action or activity shown in the image.

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Sequence of functional scopes Press the button with the number that appears on the screen.

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Supermarket shelves

Select the option that corresponds to the position of the food of the picture that appears on the screen. 6 Select the correct option in less than 20 s.

The architect

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Select the option that corresponds to the action or activity shown in the image. 6 Select the option in 20 s.

Press the button with the number that appears on the screen.

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Select the option that corresponds to the position of the food of the picture that appears on the screen. 6 Select the option in 20 s.

Select the option that corresponds to the figure shown in the picture. 6 Select the option in 15 s.

Select the option that corresponds to the number of a certain symbol indicated in each sequence. 6 Select the option in 20 s.

Select the option that corresponds to the fruits of the picture that appears on the screen. 6 Select the option in 20 s.

Select the option that corresponds to the word that does not correspond to that category of words. 6 Select the option in 20 s.

Press the button with the number that appears on the screen.

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Clock needles Select the option that corresponds to the time shown in the clock. 

Select the option that corresponds to the word hidden in word soup. 6 Select the option in 20 s.

Remember and select the option that corresponds to the image shown in the previous image.

Select the option in 15 s.

Select the word that can be formed from the letters that appear on the screen.

Select the option in 20 s.

Press the button with the number that appears on th screen.

Select the option that corresponds to the positio the food of the picture tha appears on the screen.

Select the option that corresponds to the figure shown in the picture.

Select the option that corresponds to the numbe certain symbol indicated i each sequence.

Select the option that corresponds to the fruits o picture that appears on th screen.

Select the option that corresponds to the word t does not correspond to tha category of words.

Press the button with the number that appears on th screen.

Clock needles Select the option that corresponds to the time sh in the clock.

Select the option that corresponds to the figure shown in the picture.

Select the option that corresponds to the word hidden in word soup.

Remember and select the option that corresponds to image shown in the previo image.

Select the word that can b formed from the letters th appear on the screen. Select the option in 20 s.

Remember and select the option that corresponds to the numbers of boxes shown in the previous screen. 6 Select the option in 20 s.

Select the option that corresponds to the action or activity shown in the image. 6 Select the option in 20 s.

Press the button with the number that appears on the screen.

Select the option in 15 s.

Select the option that corresponds to the position of the food of the picture that appears on the screen. 6 Select the option in 20 s.

Select the option that corresponds to the figure shown in the picture. 6 Select the option in 15 s.

Select the option that corresponds to the number of a certain symbol indicated in each sequence. 6 Select the option in 20 s.

Select the option that corresponds to the fruits of the picture that appears on the screen. 6 Select the option in 20 s.

Select the option that corresponds to the word that does not correspond to that category of words. 6 Select the option in 20 s.

Press the button with the number that appears on the screen.

Select the option in 15 s.

Clock needles Select the option that corresponds to the time shown in the clock. 

Feasibility will be considered in terms of the success of processes for recruiting and retaining participants and implementing the incentives program. The primary implementation-related outcome is the adherence to treatment (i.e., number of games and days completed during the intervention period), the reaction or response time and the number of success and failures in each game per day. These parameters are automatically recorded in real time by the Health Arcade prototype. We will consider as a measure of implementation success a score of at least 30 points per session. Secondary implementation-related outcomes are self-perceived grade of difficulty, satisfaction, enjoyment per game and session; perceived difficulties in handling the prototype hardware. These parameters are assessed by content validation questionnaire based on the Delphi Method.

Effectiveness was evaluated by comparing functional capacity and cognitive status outcomes at pre-and immediately post-intervention (with a minimum intervention duration of three consecutive days) or when completing a maximum of nine days of intervention. The functional capacity of participants will be evaluated by the Short Physical Performance Battery (SPPB), the total score ranging from 0 (worst) to 12 points (best) [26] which includes balance, gait, and rising from a chair test. The standing balance test consists of the ability to maintain the standing position for 10 s with three different foot position: parallel, semi-tandem, and tandem. Measurement of walking speed, the time needed to progress for 4 linear meters at the patient's usual speed, assigning a different score according to the speed. Chair sit-to-stand evaluates the ability to stand from a chair 5 times in a row without using the arms. The SPPB test is considered a valid instrument for detecting frailty and predicting disability, institutionalization, and mortality [27, 28] .

The cognitive function will be screened by the Mini Mental State Examination (MMSE) test [29] , Spanish version [30] , which has been widely used to determine cognitive decline. The principle cognitive domains assessed are orientation to time (5 points), orientation to place (5 points), 

Feasibility will be considered in terms of the success of processes for recruiting and retaining participants and implementing the incentives program. The primary implementation-related outcome is the adherence to treatment (i.e., number of games and days completed during the intervention period), the reaction or response time and the number of success and failures in each game per day. These parameters are automatically recorded in real time by the Health Arcade prototype. We will consider as a measure of implementation success a score of at least 30 points per session. Secondary implementation-related outcomes are self-perceived grade of difficulty, satisfaction, enjoyment per game and session; perceived difficulties in handling the prototype hardware. These parameters are assessed by content validation questionnaire based on the Delphi Method.

Effectiveness was evaluated by comparing functional capacity and cognitive status outcomes at pre-and immediately post-intervention (with a minimum intervention duration of three consecutive days) or when completing a maximum of nine days of intervention. The functional capacity of participants will be evaluated by the Short Physical Performance Battery (SPPB), the total score ranging from 0 (worst) to 12 points (best) [26] which includes balance, gait, and rising from a chair test. The standing balance test consists of the ability to maintain the standing position for 10 s with three different foot position: parallel, semi-tandem, and tandem. Measurement of walking speed, the time needed to progress for 4 linear meters at the patient's usual speed, assigning a different score according to the speed. Chair sit-to-stand evaluates the ability to stand from a chair 5 times in a row without using the arms. The SPPB test is considered a valid instrument for detecting frailty and predicting disability, institutionalization, and mortality [27, 28] .

The cognitive function will be screened by the Mini Mental State Examination (MMSE) test [29] , Spanish version [30] , which has been widely used to determine cognitive decline. The principle 

Feasibility will be considered in terms of the success of processes for recruiting and retaining participants and implementing the incentives program. The primary implementation-related outcome is the adherence to treatment (i.e., number of games and days completed during the intervention period), the reaction or response time and the number of success and failures in each game per day. These parameters are automatically recorded in real time by the Health Arcade prototype. We will consider as a measure of implementation success a score of at least 30 points per session. Secondary implementation-related outcomes are self-perceived grade of difficulty, satisfaction, enjoyment per game and session; perceived difficulties in handling the prototype hardware. These parameters are assessed by content validation questionnaire based on the Delphi Method.

Effectiveness was evaluated by comparing functional capacity and cognitive status outcomes at pre-and immediately post-intervention (with a minimum intervention duration of three consecutive days) or when completing a maximum of nine days of intervention. The functional capacity of participants will be evaluated by the Short Physical Performance Battery (SPPB), the total score ranging from 0 (worst) to 12 points (best) [26] which includes balance, gait, and rising from a chair test. The standing balance test consists of the ability to maintain the standing position for 10 s with three different foot position: parallel, semi-tandem, and tandem. Measurement of walking speed, the time needed to progress for 4 linear meters at the patient's usual speed, assigning a different score according to the speed. Chair sit-to-stand evaluates the ability to stand from a chair 5 times in a row without using the arms. The SPPB test is considered a valid instrument for detecting frailty and predicting disability, institutionalization, and mortality [27, 28] .

The cognitive function will be screened by the Mini Mental State Examination (MMSE) test [29] , Spanish version [30] , which has been widely used to determine cognitive decline. 

Feasibility will be considered in terms of the success of processes for recruiting and retaining participants and implementing the incentives program. The primary implementation-related outcome is the adherence to treatment (i.e., number of games and days completed during the intervention period), the reaction or response time and the number of success and failures in each game per day. These parameters are automatically recorded in real time by the Health Arcade prototype. We will consider as a measure of implementation success a score of at least 30 points per session. Secondary implementation-related outcomes are self-perceived grade of difficulty, satisfaction, enjoyment per game and session; perceived difficulties in handling the prototype hardware. These parameters are assessed by content validation questionnaire based on the Delphi Method.

Effectiveness was evaluated by comparing functional capacity and cognitive status outcomes at pre-and immediately post-intervention (with a minimum intervention duration of three consecutive days) or when completing a maximum of nine days of intervention. The functional capacity of participants will be evaluated by the Short Physical Performance Battery (SPPB), the total score ranging from 0 (worst) to 12 points (best) [26] which includes balance, gait, and rising from a chair test. The standing balance test consists of the ability to maintain the standing position for 10 s with three different foot position: parallel, semi-tandem, and tandem. Measurement of walking speed, the time needed to progress for 4 linear meters at the patient's usual speed, assigning a different score according to the speed. Chair sit-to-stand evaluates the ability to stand from a chair 5 times in a row without using the arms. The SPPB test is considered a valid instrument for detecting frailty and predicting disability, institutionalization, and mortality [27, 28] .

The cognitive function will be screened by the Mini Mental State Examination (MMSE) test [29] , Spanish version [30] , which has been widely used to determine cognitive decline. The principle Oculo-manual coordination control

Feasibility will be considered in terms of the success of processes for recruiting and retaining participants and implementing the incentives program. The primary implementation-related outcome is the adherence to treatment (i.e., number of games and days completed during the intervention period), the reaction or response time and the number of success and failures in each game per day. These parameters are automatically recorded in real time by the Health Arcade prototype. We will consider as a measure of implementation success a score of at least 30 points per session. Secondary implementation-related outcomes are self-perceived grade of difficulty, satisfaction, enjoyment per game and session; perceived difficulties in handling the prototype hardware. These parameters are assessed by content validation questionnaire based on the Delphi Method.

Effectiveness was evaluated by comparing functional capacity and cognitive status outcomes at pre-and immediately post-intervention (with a minimum intervention duration of three consecutive days) or when completing a maximum of nine days of intervention. The functional capacity of participants will be evaluated by the Short Physical Performance Battery (SPPB), the total score ranging from 0 (worst) to 12 points (best) [26] which includes balance, gait, and rising from a chair test. The standing balance test consists of the ability to maintain the standing position for 10 s with three different foot position: parallel, semi-tandem, and tandem. Measurement of walking speed, the time needed to progress for 4 linear meters at the patient's usual speed, assigning a different score according to the speed. Chair sit-to-stand evaluates the ability to stand from a chair 5 times in a row without using the arms. The SPPB test is considered a valid instrument for detecting frailty and predicting disability, institutionalization, and mortality [27, 28] .

The cognitive function will be screened by the Mini Mental State Examination (MMSE) test [29] , Spanish version [30] , which has been widely used to determine cognitive decline. The principle cognitive domains assessed are orientation to time (5 points), orientation to place (5 points), registration of three words (3 points), attention and calculation (5 points), recalling the three words (3 points), language (8 points), and visuospatial ability (1 point). The MMSE is scored out of 30 points, with a score of ≤23 points indicating likely cognitive impairment [31] . The cognitive function will be quantified by the Cambridge Revised Screening Test for the Assessment of Mental Disorders in Old Age (CAMDEX-R) [32] , Spanish version [33] . The cognitive domains assessed are: orientation (10 points); language (30 points); memory (27 points); attention and calculation (9 points); praxis (12 point); abstract thinking (8 points); and perception (9 points). The CAMDEX-R is scored out of 105 points English version [32] and 107 points Spanish version [33] .

In addition, the ADLs will be assessed using the Barthel Index, Spanish version; scale of 100 [functional independence] to 0 [severe functional dependence]) [34] , an international, validated, and the most used tool to measure disability [35] . The mood status will be assessed by the 15-item Yesavage Geriatric Depression Scale; Spanish version; contain ten affirmative items and five negative, a score between 0-5 is normal and a score greater than 5 suggests depression) [36] . The quality of life will be assessed using the quality of life measured by the questionnaires EQ-5D-3L [37] . This instrument measures 5 dimensions of health status: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension is rated according to the following levels: (a) no problems; (b) some problems; (c) extreme problems. Additionally, it contains a visual analogy scale (VAS) to quantify perceived health of 0 [worst health state imaginable] to 100 [best health state imaginable] EuroQol-5 Dimension; Spanish version of the EQ-5D32) [37, 38] . Development of delirium will be assessed with the Confusion Assessment Method [39] . Changes in level of physical activity or mobility (step count, walking, and sedentary time per day, will be measured by accelerometer Actigraph ® (ActiGraph LLC, Pensacola, Florida, EEUU) [40] and NFC system Health Arcade). Lastly, changes in handgrip strength will be measured using a hand dynamometer (Takei 5401 Digital Dynamometer, Takei scientific instruments CO., LTD, Niigata, Japan) [41] . The maximum value will be recorded after two measurements in each hand. The measurement results are expressed in kilograms [42, 43] .

We will not report significance tests as the feasibility uncontrolled pre-post design was not designed or powered to test hypotheses or to detect change. A convenience sample size of 40 participants will be selected in accordance with published guidance for feasibility and acceptability of the technology studies [44, 45] . According to Hertzog [46] , 10-40 subjects provide estimates precise enough to meet a variety of possible aim be considered for pilot studies. In an initial analysis, we will calculate the proportion of enrolled participants out of all eligible patients, participants who adhered to the intervention, and the dropout rates. Besides, a patient satisfaction survey for the use of Health Arcade will be collected and analyzed. Descriptive statistics will be used to summarise markers of feasibility and appeal.

Hospitalization is usually a sentinel event leading to disability, especially in older adults [1] [2] [3] [4] . Although the hospitalization process gives the chance to solve the acute phases of the disease in order to restore the state of health, it can considerably affect the functional capacity of old patients. A growing number of studies are emerging focused on the iatrogenic effects and nosocomial disability developed during hospitalization, and currently these consequences are relevant in clinical practice. The iatrogenic nosocomial disability is mainly characterized by prolonged bed rest episodes, sedentary behaviours

Changes in Functional Status and the Risks of Subsequent Nursing Home Placement and Death

Risk of Continued Institutionalization After Hospitalization in Older Adults

Very Low Levels of Physical Activity in Older Patients During Hospitalization at an Acute Geriatric Ward: A Prospective Cohort Study

Recovery of activities of daily living in older adults after hospitalization for acute medical illness

The prediction of functional decline in older hospitalised patients

The Underrecognized Epidemic of Low Mobility During Hospitalization of Older Adults

Interventions to Mobilize Elderly Patients and Reduce Length of Hospital Stay

Change in Disability After Hospitalization or Restricted Activity in Older Persons

Zambom-Ferrasi, F. Effectiveness of Occupational Therapy Interventions in Acute Geriatric Wards: A Systematic Review

A Framework for Game Engine Selection for Gamification and Serious Games

Serious Games in Rehabilitation

Gamification: State of the Art Definition and Utilization

The Gamification of Learning and Instruction: Game-Based Methods and Strategies for Training and Education

A Review on Gamification and Its Potential to Motivate and Engage Employees and Customers: Employee Engagement through Gamification

A Review of Gamification for Health-Related Contexts. In Design, User Experience, and Usability. User Experience Design for Diverse Interaction Platforms and Environments

Serious Gaming and Gamification Education in Health Professions: Systematic Review

Chemotherapy-Related Neuropathic Symptom Management: A Randomized Trial of an Automated Symptom-Monitoring System Paired with Nurse Practitioner Follow-Up

The Use of Videogames, Gamification, and Virtual Environments in the Self-Management of Diabetes: A Systematic Review of Evidence

Exergaming in Older Adults: A Scoping Review and Implementation Potential for Patients with Heart Failure

Impact of Game-Based Interventions on Health-Related Outcomes in Hospitalized Older Patients: A Systematic Review

Iatrogenic Nosocomial Disability Diagnosis and Prevention

Studying Gamification: The Effect of Rewards and Incentives on Motivation

Gamification for Health Promotion: Systematic Review of Behaviour Change Techniques in Smartphone Apps

World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects

A Short Physical Performance Battery Assessing Lower Extremity Function: Association with Self-Reported Disability and Prediction of Mortality and Nursing Home Admission

Lower-Extremity Function in Persons over the Age of 70 Years as a Predictor of Subsequent Disability

Lower Extremity Function and Subsequent Disability: Consistency Across Studies, Predictive Models, and Value of Gait Speed Alone Compared With the Short Physical Performance Battery

A Practical Method for Grading the Cognitive State of Patients for the Clinician

Mini Mental State Examination: Asociación de la puntuación obtenida con la edad y grado de alfabetización en una población anciana

Screening for Dementia in Primary Care: A Comparison of the GPCOG and the MMSE

CAMDEX: A standardized instrument for the diagnosis of mental disorders in teh Elderly with the Special referente to the early detection of dementia

Responsiveness of the Rehabilitation Activities Profile and the Barthel Index

Functional Evaluation: The Barthel Index

Versión Española Del Cuestionario de Yesavage Abreviado (GDS) Para El Despistaje de Depresión En Mayores de 65 Años: Adaptación y Validación

Validation and Comparison of EQ-5D-3L and SF-6D Instruments in a Spanish Parkinson's Disease Population Sample

The Spanish version of EuroQol: A description and its applications. European Quality of Life scale

Clarifying Confusion: The Confusion Assessment Method. A New Method for Detection of Delirium

Accelerometer Data Collection and Processing Criteria to Assess Physical Activity and Other Outcomes: A Systematic Review and Practical Considerations

Midlife Hand Grip Strength as a Predictor of Old Age Disability

Muscle Strength and Mobility as Predictors of Survival in 75-84-Year-Old People

A Review of the Measurement of Grip Strength in Clinical and Epidemiological Studies: Towards a Standardised Approach

Design and Analysis of Pilot Studies: Recommendations for Good Practice

The Size of a Pilot Study for a Clinical Trial Should Be Calculated in Relation to Considerations of Precision and Efficiency

Considerations in Determining Sample Size for Pilot Studies

Assessing the Impact of Physical Exercise on Cognitive Function in Older Medical Patients during Acute Hospitalization: Secondary Analysis of a Randomized Trial

Effect of Exercise Intervention on Functional Decline in Very Elderly Patients During Acute Hospitalization: A Randomized Clinical Trial

We thank our patients and their families for their confidence in the research team.

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results. Int. J. Environ. Res. Public Health 2020, 17, 8058