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Taking play seriously
The therapeutic benefits of non-digital games in older adult care
Do you like playing games? Want to apply to medical school? Want to get relevant
work experience while calling a game of bingo? If so, follow me on my journey.

I'm on this path because I want to become a doctor. I've been volunteering twice a week

in a residential care home, and this has given me many personal and
professional skills and insights that will help me on my way ... insights that can't be
learnt from a textbook.

1. Why we need to learn how to age playfully
We live in a rapidly ageing society and – according to the World Health Organisation
– humanity faces an unprecedented combination of health, social and economic
challenges on a global scale. Closer to home, over the past 40 years, the UK has
had one of the fastest changes in age structure and this looks set to continue over
the next 40 years.

We thus need to find effective, low-cost, and adaptable strategies to support healthy
ageing and to maintain the quality of life of older adults living with other health
conditions, including dementia.
So, over the past year, I've been exploring the potential health benefits of playing
traditional, non-digital games.

2. Experiential learning through reflective practice
The scientific data is encouraging. There have been increasing numbers of smaller
and larger-scale trials that have provided strong evidence to show that a regular
games programme can protect, maintain, even improve the brain health of older
adults.

But my approach has been different. I'm not using formal cognitive assessment tools.
Instead, I've adopted an experiential research method – one known as 'reflective
practice' building up my understanding about playing games in relation to successful
ageing by keeping a reflective journal.

There's a variety of reflective practice styles to choose from. Personally, I've found
the seven steps of the Gibbs' Cycle a very helpful framework for structuring the

process. Concentrating on each of the stages in turn has made me more attentive to
small yet telling details during my visits and has helped me afterwards make deeper
sense of what happened (good or bad) and what I might learn from it.

Using this discipline, I've been able to reflect more deeply on my own feelings and
reactions and those of others. For example, I might conclude from the laughter and
animated conversation that everyone seemed to enjoy my juggling interlude in a
particular bingo session, or, conversely, that a particular resident didn't really
participate in the general knowledge quiz: had I chosen the wrong topics? or was it
that she couldn't really see and hear me well enough and next time I should
rearrange the seating?

This analysis helps me connect my volunteering experience with relevant points in
the scientific literature that I've been reading and with conversations I've had with
health care professionals and to prepare ahead, creating the impetus for sensitively
adapting my games programme to meet the needs of individual residents,
experimenting with different ways of doing things and trying new activities to see
what works for them.

3. Bureaucracy, complexity and systems thinking.
Reflective practice highlight acts that are seemingly trivial yet make a real difference;
it's also a productive tool to address what doesn't go as planned for whatever
reason.

In my case, the biggest challenge that I've faced as a volunteer was getting started.
It wasn't easy to find a care home willing to take on a volunteer, and, having found
one, it took even longer getting safeguarding clearance. All told, this took three
months –months during which I couldn't be of help to the Care Home but needed
their help as I chased up on the progress of my application, and, in the end, went
through the entire process again from scratch.

I took some cold comfort in learning that the NHS Volunteering Taskforce has
highlighted such delays as a widespread problem that needs addressing. Even so,
the waiting game was frustrating and increasingly stressful.
There were some positives – at least in hindsight. The bureaucratic process
encouraged me to work out who does what in the Care Home and piece together a
bigger picture of our complex social and health care system. And, reflecting on my
own reactions, taught me why it is so important for medics to be systems thinkers, so
patients don't fall through gaps – like my DBS form.

4. Time to play! Choosing and adapting the right games
At last, it was time to meet the residents.
Sitting down to chat with someone you don't know can be daunting. Especially if you
don't always catch what they are saying. Offering to play a game together is already
a useful tool for a volunteer. It's an easy way to make an initial connection and each
game comes with its own rules, so no-one needs to try and find things to say.

That said, I've found that games provide good prompts for conversations, once
you've got going. A crossword solution, for example, can be used to ask a follow-up
question: Have you ever been to Paris? Have you ever seen a flamingo? That sort
of thing...

Practical adjustments also help: a large monitor makes a crossword easier to see;
rearranging the chairs enables more than one person to join in.
Another important tip: a recent scientific study confirms what I've discovered through
practice – it's important to find games where the challenge isn't too great; if a puzzle
is too difficult, motivation declines, and the mind begins to wander. With crosswords,
for example, I've found it helps to fill in a few of the solutions to get things going.
When I've got things right, the time flies for all of us ... and I've learnt I must keep an
eye on my watch so we dont run into lunchtime. Having got this wrong on a couple
of occasions, I've learnt that routine matters, both for staff and for residents,
especially those with dementia.

Crosswords remain a staple each week. Although over time, I've kept adding new
games including matching pairs, word cricket – a complicated letter and number-
based game taught to me by one of the residents when I asked what he used to
enjoy playing when he was younger – and general knowledge quizzes. I've even
tried out magnetic darts, tallying up the scores with the players.

Wooden jigsaws – the sort designed for learning geography – have also been
popular: the pieces are large and easier to handle. But the challenge remains
interesting and again, the pieces can be prompts for conversations about family in
other parts of the country or holidays overseas.

I'm constantly impressed by the long-term recall and crystalised knowledge of the
older residents and the size of their vocabulary.

5. The ageing brain, neuroplasticity and cognitive reserve
Since beginning my visits, I've noticed that we are getting through more puzzles –
evidence of both increased engagement and improved processing speed.

So, what might be going on inside the brain?

The brain is our command centre, housing billions of nerve cells – or neurons – that
control both body and mind – influencing our planning, organising, attention,
problem-solving, our short- and long-term memory, as well as our behaviour and
emotions.

Neurons are connected together by the synapses, forming a vast communications
network – our brain's white matter. With use – or lack of use – these connections are
strengthened or weakened, allowing the brain to adapt – this is known as its
neuroplasticity.

As we age, the structure of the brain gradually changes ... beginning already in our
40s. The dark, wrinkled outer layer of the brain – the cerebral cortex – gets thinner:

especially in the frontal lobe and hippocampus – regions critically associated with
memory.

The white matter begins to shrink and the brain generates fewer chemical
messengers – or neurotransmitters – such as dopamine, serotonin and oxytocin.
These are important 'memory' hormones as they relay signals between nerve cells
and are implicated in the proper functioning of cognitive regions like the pre-frontal
cortex.

But it's not all downhill! In normal ageing we tend not to forget long-term skills and
habits. We continue to get better at some things, including abstract and verbal
reasoning – as I've witnessed doing crossword puzzles – and older adults typically
have a higher emotional intelligence compared to younger people – something I've
appreciated during my visits. One resident never forgets to ask how my project is
going!

And something really fascinating that I've discovered from scientific literature, is that
neuroplasticity of the brain means that it can compensate functionally for the
structural changes brought about by normal ageing. One example is that older
adults are more likely to use both sides of the brain for short-term memory rather
than just the left hemisphere. In fact, behavioural studies and brain imaging suggest
that these compensatory processes may be at work in some people with
degenerative. Two people may have brains that show similar signs of the plaques
and tangles associated with Alzheimer's Disease, but one may not show any
symptoms.

The concept of 'cognitive reserve' explains the difference. By exercising our brain
and strengthening those synaptic connections, we build up this important reserve
that enables the brain to withstand and adapt to damage from ageing or disease.
Games, it seems, are excellent forms of brain exercise. And the research suggests
that it is never too early nor too late to begin.

6. Loneliness, bingo and the health benefits of positive social interaction
But it would be a mistake to think of games simply as tools for cognitive stimulation,
something that much be better undertaken through a digital therapy programme.
Behavioural studies repeatedly return to the risks of loneliness and depression for
older adults and how these impact on both cognitive function and general wellbeing.
Returning to brain imaging studies have linked loneliness to a reduction in volume of
parts of the brain that we have seen are crucial for cognitive and emotional function:
the frontal white matter and, deep within the brain, the putamen and global pallidus,
associated with the release of those all-important neurotransmitters such as
dopamine.

Positive social interaction, on the other hand, is known to trigger these 'happy'
hormones which I also described as 'memory' hormones, stimulating those same
parts of the brain that shrink under conditions of loneliness.

And this is not only good for our thinking and for our morale, but also for our body as
these same neurotransmitters are also stress-busting hormones, inhibiting the
release of cortisol that is bad for our immune system and cardiovascular health.
Which takes me to bingo... Bingo isn't bridge: it's a game of chance that requires no
skill. But that's precisely its value. It can be played by anyone and everyone,
including newcomers and those with dementia. Bingo, I've discovered, is party time.
I've seen –and enjoyed – the strong sense of collective atmosphere, focus,
concentration and laughter that lifts everyone's mood, including mine. Those
dopamine messengers are contagious!

While it's true that there are aspects of bingo that stimulate cognitive functions – it
requires a degree of concentration, short-term memory and hand/eye coordination to
move the counters – this is to miss the point. As an anthropologist puts it: bingo has
a lot to teach us about living well in the community, allowing people to become part
of something bigger than themselves. I's also fundamentally about having fun and
enjoying being human, for which we need others around us. [Tim Clare]

7. Win-win. Towards a conclusion
Using a structured method of reflective practice, informed by leading scientific
research of others, I have seen from the happy faces, focussed eyes, animated
conversation, increased processing speed and willingness to try out new things and
also contribute new ideas, that traditional games do indeed have great potential as
an effective strategy for ageing well by ageing playfully.
Traditional games are low in cost and easy for a volunteer to adapt to suit the
interests and needs of different individuals and contexts.
In so doing, they can also check several of the Care Quality Commission boxes for
the Care Home and – as importantly – benefit the volunteer, their health, sense of
purpose, and, indeed, their career plans.
I continue to enjoy my visits and learn ever more about person-centred care, the
wider social and health systems in which that care is provided, and... as importantly
... about myself. As I begin the process of applying to med school, I know that the
experience, distilled through the structured discipline of reflective practice, has
enabled me to develop – and articulate – many personal and professional skills that I
can use for my personal statement and at interview. Hopefully, I will be able to draw
on these across a future career in medicine.

8. Looking to the future
Social care has come a very long way since the days of the Victorian workhouse
when older adults, unable to support themselves, were provided with basic
necessities in exchange for labour.
But has today's society really left behind all the prejudices rooted in the Western
work ethic that values productivity, hard-graft and discipline ... and looks down on
older adults and play?

Volunteering in a care home has taught me to take play seriously. It's perhaps not
too much of an exaggeration to say that it holds the secret to a healthy old age – our
own, and that of others.

Looking ahead, will the AI revolution free up more time for cross-generational social
interaction and play? Or will it replace the people – old and young – who are
ultimately the glue that binds us together?

YOUR MOVE!