1. Introduction
he World Health Organization (WHO) announced that the share of aged population across the world is dramatically increasing. The world’s aged population is expected to increase from 840 million in 2013 to 2 billion in 2050 [1]. The changes that may happen in old age include a decline in cognitive abilities such as memory, attention, cognitive processing, etc. [2, 3]. In a study on 1600 older people aged ≥60 years in Amirkola County, Iran, the prevalence of cognitive impairment was reported to be 18.3%. It was measured by Mini-Mental State Exam (MMSE) which includes tests of orientation, memory, attention, recall, language, and executive functions [4]. Health and issues related to aging, such as decline in cognitive abilities are important because cognitive impairment may affect the elderly’s daily activities and require help and care. In addition to psychological and social burden, these cognitive problems may cause high medical costs [5].
Previous interventions aimed at cognitive empowerment of the elderly have focused more on one or two cognitive functions, especially the diagnostic features of Alzheimer’s and dementia and few of them have studied other cognitive abilities such as active memory, event memory, and executive functions. The present study aims to assess the effect of computer games on improving working memory, visual memory, and executive functions in the elderly.
2. Materials and Method
This is a quasi-experimental study with a pretest/posttest design using a control group conducted on 40 older people in Tehran, Iran selected using a purposive sampling method and based on the inclusion criteria and clinical interview. They were randomly assigned into intervention and control groups. The intervention group was required to play a one-hour computer game (Lumosity) at 15 sessions, while the control group did not play any computer game during this period. Lumosity is a cognitive-based game for brain training that consists of round, play, evaluation, and tips steps [10]. The data were collected in two stages of pre-test and post-test. 
Data collection tools were the Stroop Color and Word Test (SCWT), Wisconsin Card Sorting Test (WCST), Wechsler Memory Scale, 3rd edition (WMS-III). The SCWT was developed by Ridley Stroop in 1935 to measure selective attention, cognitive flexibility, and response inhibition. In Iran, Ghavami et al. prepared the computerized Persian version of this test and reported that its good validity and reliability (Cronbach’s alpha = 0.95) [6]. The WCST was developed by Grant at the University of Wisconsin in 1948 and was first introduced by Milner as a test that measures the frontal lobe function. For its Persian version, Naderi et al. showed a high reliability [8]. The WMS-III is a memory test battery composed of 18 subtests (11 primary and 7 optional). Of 11 primary subtests, 7 index scores are obtained. Saed et al. normalized this test for Iranian population in 2007 and confirmed its validity [9]. Descriptive statistics (frequency, percentage, mean, and standard deviation) and Multivariate Analysis of Covariance (MANCOVA) were used to analyze the collected data. 
3. Results
Of 40 participants, 21(50.52%) were female and 19(50.47%) were male. Table 1 presents their demographic characteristics.


There was no significant differences between the two groups in terms of demographic characteristics. The mean and standard deviation of the scores of working memory, visual memory, and executive functions in the two groups are presented in Table 2.


MANCOVA was used to examine the effect of intervention on working memory, visual memory, and executive functions in the elderly. The results revealed that computer games improved working memory and its components logical memory (F1,31=4.31, P=0.04), faces (F1,31= 20.08, P<0.001), family pictures (F1,31= 5.13; P=0.03), spatial span (F1,31= 25.02, P<0.001), and auditory reproduction (F1,31= 29.95, P<0.001) in the intervention group compared to the control group. However, for the two components of verbal paired associates and letter- number sequencing, no significant difference was found between the two groups (P>0.05). 
Moreover, the results showed a significant difference between the two groups in three components of visual memory, i.e., number of errors (F1.34= 27.71, P<0.001), number of correct answers (F1.34 = 23.82, P<0.001), and reaction time (F1.34 = 5.45, P=0.02), but not in the component of color-word interference. Moreover, the results demonstrated a significant difference between the two groups in two components of executive functions, i.e. number of correct sorts (F1.36= 54.90, P<0.001), and number of perseverative errors (F1.36= 71.73, P<0.001) after controlling the pre-test score. In other words, computer games improved the executive functions in the elderly.
4. Discussion and Conclusion
The results of the present study revealed that computer games could significantly improve working memory, visual memory, and executive functions in the elderly. The results are consistent with those of a meta-analysis study by Bediou et al. in 2018 on the effect of video games on perceptual, attentional, and cognitive skills [11], and with the results of Toril et al. on the effect of video games on active memory and episodic memory [12]. Regarding the effect of our intervention on the executive functions, this result is consistent with those Nouchi et al., and Boot et al. [13, 14].
Since computer games require constant and continuous attention to earn points, continuation of their playing can also enhance attention and concentration. High attention and concentration are also required by obtaining higher scores in the visual memory test. Short-term visual memory is the most significant component that is enhanced in computer games. Since these games have active and dynamic images, they can stimulate visual memory more, and consequently, active players of these computer games have better short-term visual memory than other people [15]. The present results are consistent with the results of Kara et al. [16]. Computer games can significantly improve cognitive functions in the elderly. It seems that the use of these games for rehabilitating and empowering the elderly can help a lot in improving their lives. 

Ethical Considerations
Compliance with ethical guidelines
The present study was approved by the Research Ethics Committee of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.REC.1397.479).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors contributions
Conceptualization, methodology, validation, analysis, research, sources, drafting, editing and finalization of writing, visualization: Prosha Moradi; Methodology: Mahdi Jafari; Supervision: Abbas Masjedi.

Conflicts of interest
The authors declare no conflict of interest.


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