Application of Eye Tracking in Puzzle Games for Adjunct Cognitive Markers: Pilot Observational Study in Older Adults

Krebs, Christine; Falkner, Michael; Niklaus, Joel; Persello, Luca; Klöppel, Stefan; Nef, Tobias; Urwyler-Harischandra, Prabitha (2021). Application of Eye Tracking in Puzzle Games for Adjunct Cognitive Markers: Pilot Observational Study in Older Adults. JMIR Serious Games, 9(1), e24151. JMIR Publications 10.2196/24151

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Background: Recent studies suggest that computerized puzzle games are enjoyable, easy to play, and engage attentional, visuospatial, and executive functions. They may help mediate impairments seen in cognitive decline in addition to being an assessment tool. Eye tracking provides a quantitative and qualitative analysis of gaze, which is highly useful in understanding visual search behavior.

Objective: The goal of the research was to test the feasibility of eye tracking during a puzzle game and develop adjunct markers for cognitive performance using eye-tracking metrics.

Methods: A desktop version of the Match-3 puzzle game with 15 difficulty levels was developed using Unity 3D (Unity Technologies). The goal of the Match-3 puzzle was to find configurations (target patterns) that could be turned into a row of 3 identical game objects (tiles) by swapping 2 adjacent tiles. Difficulty levels were created by manipulating the puzzle board size (all combinations of width and height from 4 to 8) and the number of unique tiles on the puzzle board (from 4 to 8). Each level consisted of 4 boards (ie, target patterns to match) with one target pattern each. In this study, the desktop version was presented on a laptop computer setup with eye tracking. Healthy older subjects were recruited to play a full set of 15 puzzle levels. A paper-pencil–based assessment battery was administered prior to the Match-3 game. The gaze behavior of all participants was recorded during the game. Correlation analyses were performed on eye-tracking data correcting for age to examine if gaze behavior pertains to target patterns and distractor patterns and changes with puzzle board size (set size). Additionally, correlations between cognitive performance and eye movement metrics were calculated.

Results: A total of 13 healthy older subjects (mean age 70.67 [SD 4.75] years; range 63 to 80 years) participated in this study. In total, 3 training and 12 test levels were played by the participants. Eye tracking recorded 672 fixations in total, 525 fixations on distractor patterns and 99 fixations on target patterns. Significant correlations were found between executive functions (Trail Making Test B) and number of fixations on distractor patterns (P=.01) and average fixations (P=.005).

Conclusions: Overall, this study shows that eye tracking in puzzle games can act as a supplemental source of data for cognitive performance. The relationship between a paper-pencil test for executive functions and fixations confirms that both are related to the same cognitive processes. Therefore, eye movement metrics might be used as an adjunct marker for cognitive abilities like executive functions. However, further research is needed to evaluate the potential of the various eye movement metrics in combination with puzzle games as visual search and attentional marker.

Item Type:

Journal Article (Original Article)


04 Faculty of Medicine > University Psychiatric Services > University Hospital of Geriatric Psychiatry and Psychotherapy
04 Faculty of Medicine > Department of Head Organs and Neurology (DKNS) > Clinic of Neurology
10 Strategic Research Centers > ARTORG Center for Biomedical Engineering Research
10 Strategic Research Centers > ARTORG Center for Biomedical Engineering Research > ARTORG Center - Gerontechnology and Rehabilitation

Graduate School:

Graduate School for Health Sciences (GHS)

UniBE Contributor:

Krebs, Christine Renate, Falkner, Michael Graeme, Persello, Luca, Klöppel, Stefan, Nef, Tobias, Urwyler-Harischandra, Prabitha


600 Technology > 610 Medicine & health
500 Science > 570 Life sciences; biology




JMIR Publications




Angela Amira Botros

Date Deposited:

13 Apr 2021 11:16

Last Modified:

14 Aug 2023 10:45

Publisher DOI:


PubMed ID:





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