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Meta-Analysis
. 2024 Sep 25;9(9):CD013853.
doi: 10.1002/14651858.CD013853.pub2.

Exergaming for dementia and mild cognitive impairment

Alexandra Voinescu  1 , Themis Papaioannou  1 , Karin Petrini  1   2 , Danaë Stanton Fraser  1
Affiliations
Meta-Analysis

Exergaming for dementia and mild cognitive impairment

Alexandra Voinescu et al. Cochrane Database Syst Rev. .

Abstract

Background: Dementia and mild cognitive impairment are significant contributors to disability and dependency in older adults. Current treatments for managing these conditions are limited. Exergaming, a novel technology-driven intervention combining physical exercise with cognitive tasks, is a potential therapeutic approach.

Objectives: To assess the effects of exergaming interventions on physical and cognitive outcomes, and activities of daily living, in people with dementia and mild cognitive impairment.

Search methods: On 22 December 2023, we searched the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (Clarivate), LILACS (BIREME), ClinicalTrials.gov, and the WHO (World Health Organization) meta-register the International Clinical Trials Registry Portal.

Selection criteria: We included randomised controlled trials (RCTs) that recruited individuals diagnosed with dementia or mild cognitive impairment (MCI). Exergaming interventions involved participants being engaged in physical activity of at least moderate intensity, and used immersive and non-immersive virtual reality (VR) technology and real-time interaction. We planned to classify comparators as inactive control group (e.g. no treatment, waiting list), active control group (e.g. standard treatment, non-specific active control), or alternative treatment (e.g. physical activity, computerised cognitive training). Outcomes were to be measured using validated instruments.

Data collection and analysis: Two review authors independently selected studies for inclusion, extracted data, assessed the risk of bias using the Cochrane risk of bias tool RoB 2, and assessed the certainty of the evidence using GRADE. We consulted a third author if required. Where possible, we pooled outcome data using a fixed-effect or random-effects model. We expressed treatment effects as standardised mean differences (SMDs) for continuous outcomes and as risk ratios (RRs) for dichotomous outcomes, along with 95% confidence intervals (CIs). When data could not be pooled, we presented a narrative synthesis.

Main results: We included 11 studies published between 2014 and 2023. Six of these studies were pre-registered. Seven studies involved 308 participants with mild cognitive impairment, and five studies included 228 individuals with dementia. One of the studies presented data for both MCI and dementia separately. Most comparisons exhibited a high risk or some concerns of bias. We have only low or very low certainty about all the results presented below. Effects of exergaming interventions for people with dementia Compared to a control group Exergaming may improve global cognitive functioning at the end of treatment, but the evidence is very uncertain (SMD 1.47, 95% 1.04 to 1.90; 2 studies, 113 participants). The evidence is very uncertain about the effects of exergaming at the end of treatment on global physical functioning (SMD -0.20, 95% -0.57 to 0.17; 2 studies, 113 participants) or activities of daily living (ADL) (SMD -0.28, 95% -0.65 to 0.09; 2 studies, 113 participants). The evidence is very uncertain about adverse effects due to the small sample size and no events. Findings are based on two studies (113 participants), but data could not be pooled; both studies reported no adverse reactions linked to the intervention or control group. Compared to an alternative treatment group At the end of treatment, the evidence is very uncertain about the effects of exergaming on global physical functioning (SMD 0.14, 95% -0.30 to 0.58; 2 studies, 85 participants) or global cognitive functioning (SMD 0.11, 95% -0.33 to 0.55; 2 studies, 85 participants). For ADL, only one study was available (n = 67), which provided low-certainty evidence of little to no difference between exergaming and exercise. The evidence is very uncertain about adverse effects of exergaming compared with alternative treatment (RR 7.50, 95% CI 0.41 to 136.52; 2 studies, 2/85 participants). Effects of exergaming interventions for people with mild cognitive impairment (MCI) Compared to a control group Exergaming may improve global cognitive functioning at the end of treatment for people with MCI, but the evidence is very uncertain, (SMD 0.79, 95% 0.05 to 1.53; 2 studies, 34 participants). The evidence is very uncertain about the effects of exergaming at the end of treatment on global physical functioning (SMD 0.27, 95% -0.41 to 0.94; 2 studies, 34 participants) and ADL (SMD 0.51, 95% -0.01 to 1.03; 2 studies, 60 participants). The evidence is very uncertain about the effects of exergaming on adverse effects due to a small sample size and no events (0/14 participants). Findings are based on one study. Compared to an alternative treatment group The evidence is very uncertain about global physical functioning at the end of treatment. Only one study was included (n = 45). For global cognitive functioning, we included four studies (n = 235 participants), but due to considerable heterogeneity (I² = 96%), we could not pool results. The evidence is very uncertain about the effects of exergaming on global cognitive functioning. No study evaluated ADL outcomes. The evidence is very uncertain about adverse effects of exergaming due to the small sample size and no events (n = 123 participants). Findings are based on one study.

Authors' conclusions: Overall, the evidence is very uncertain about the effects of exergaming on global physical and cognitive functioning, and ADL. There may be an improvement in global cognitive functioning at the end of treatment for both people with dementia and people with MCI, but the evidence is very uncertain. The potential benefit is observed only when exergaming is compared with a control intervention (e.g. usual care, listening to music, health education), and not when compared with an alternative treatment with a specific effect, such as physical activity (e.g. standing and sitting exercises or cycling). The evidence is very uncertain about the effects of exergaming on adverse effects. All sessions took place in a controlled and supervised environment. Therefore, we do not know if exergaming can be safely used in a home environment, unsupervised.

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Conflict of interest statement

Alexandra Voinescu: none known Themis Papaioannou: none known Karin Petrini: none known Danaë Stanton Fraser: none known

Figures

1
1
1.1
1.1. Analysis
Comparison 1: Exergaming vs control at the end of treatment for people with dementia, Outcome 1: Exergaming vs control at the end of treatment: change in global physical functioning (composite)
1.2
1.2. Analysis
Comparison 1: Exergaming vs control at the end of treatment for people with dementia, Outcome 2: Exergaming vs control at the end of treatment: change in global cognitive functioning (composite)
1.3
1.3. Analysis
Comparison 1: Exergaming vs control at the end of treatment for people with dementia, Outcome 3: Exergaming vs control at the end of treatment: change in activities for daily living (ADL)
2.1
2.1. Analysis
Comparison 2: Exergaming vs alternative treatment at the end of treatment for people with dementia, Outcome 1: Exergaming vs alternative treatment at the end of treatment: change in global physical functioning (composite)
2.2
2.2. Analysis
Comparison 2: Exergaming vs alternative treatment at the end of treatment for people with dementia, Outcome 2: Exergaming vs alternative treatment at the end of treatment: change in functional status and physical performance
2.3
2.3. Analysis
Comparison 2: Exergaming vs alternative treatment at the end of treatment for people with dementia, Outcome 3: Exergaming vs alternative treatment at the end of treatment: change in global cognitive functioning (composite)
2.4
2.4. Analysis
Comparison 2: Exergaming vs alternative treatment at the end of treatment for people with dementia, Outcome 4: Exergaming vs alternative treatment at the end of treatment: change in lower limb functioning
3.1
3.1. Analysis
Comparison 3: Exergaming vs control at the end of treatment for people with MCI, Outcome 1: Exergaming vs control at the end of treatment: change in global physical functioning (composite)
3.2
3.2. Analysis
Comparison 3: Exergaming vs control at the end of treatment for people with MCI, Outcome 2: Exergaming vs control at the end of treatment: change in global cognitive functioning (composite)
3.3
3.3. Analysis
Comparison 3: Exergaming vs control at the end of treatment for people with MCI, Outcome 3: Exergaming vs control at the end of treatment: change in activities of daily living (ADL)
3.4
3.4. Analysis
Comparison 3: Exergaming vs control at the end of treatment for people with MCI, Outcome 4: Exergaming vs control at the end of treatment: change in lower limb functioning
3.5
3.5. Analysis
Comparison 3: Exergaming vs control at the end of treatment for people with MCI, Outcome 5: Exergaming vs control at the end of treatment: change in general cognition
3.6
3.6. Analysis
Comparison 3: Exergaming vs control at the end of treatment for people with MCI, Outcome 6: Exergaming vs control at the end of treatment: change in attention, processing speed, working memory
7.1
7.1. Analysis
Comparison 7: Exergaming vs control at follow‐up for people with MCI, Outcome 1: Exergaming vs control at follow‐up: change in global cognitive functioning (composite)
7.2
7.2. Analysis
Comparison 7: Exergaming vs control at follow‐up for people with MCI, Outcome 2: Exergaming vs control at follow‐up: change in general cognition
8.1
8.1. Analysis
Comparison 8: Adverse effects, Outcome 1: Exergaming vs alternative treatment for people with dementia
9.1
9.1. Analysis
Comparison 9: Feasibility and treatment adherence, Outcome 1: Number of dropouts at the end of treatment (exergaming vs control intervention) for people with dementia
9.2
9.2. Analysis
Comparison 9: Feasibility and treatment adherence, Outcome 2: Number of dropouts at the end of treatment (exergaming vs alternative treatment) for people with dementia
9.3
9.3. Analysis
Comparison 9: Feasibility and treatment adherence, Outcome 3: Number of dropouts at the end of treatment (exergaming vs control intervention) for people with mild cognitive impairment (MCI)
9.4
9.4. Analysis
Comparison 9: Feasibility and treatment adherence, Outcome 4: Number of dropouts at the end of treatment (exergaming vs alternative treatment) for people with mild cognitive impairment (MCI)
9.5
9.5. Analysis
Comparison 9: Feasibility and treatment adherence, Outcome 5: Number of dropouts at follow‐up (exergame vs control intervention) for people with dementia
9.6
9.6. Analysis
Comparison 9: Feasibility and treatment adherence, Outcome 6: Number of dropouts at follow‐up (exergame vs control intervention) for people with mild cognitive impairment (MCI)
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NCT01000038 {published data only}
    1. NCT01000038. Wii-fit for activity, balance and gait in assisted living. https://clinicaltrials.gov/study/NCT01000038 (first received 20 October 2009).
NCT01002586 {published data only}
    1. NCT01002586. Wii-fit for improving activity, gait and balance in Alzheimer's dementia. https://clinicaltrials.gov/study/NCT01002586 (first received 23 October 2009).
NCT01393353 {published data only}
    1. NCT01393353. Cognitive training in Parkinson's disease. https://clinicaltrials.gov/study/NCT01393353 (first received 6 July 2011).
NCT02214342 {published data only}
    1. NCT02214342. Virtual reality based balance training in people with mild cognitive impairment. https://clinicaltrials.gov/study/NCT02214342 (first received 8 August 2014).
NCT02237560 {published data only}
    1. NCT02237560. The aerobic & cognitive exercise study. https://clinicaltrials.gov/study/NCT02237560 (first received 4 September 2014).
NCT03383549 {published data only}
    1. NCT03383549. Cognitive and physical home-rehabilitation by information and communications technology. Games for Older Adults Active Life (GOAL). https://clinicaltrials.gov/study/NCT03383549CT03383549 (first received 15 December 2017).
NCT03774225 {published data only}
    1. NCT03774225. The Influence of manual and verbal guidance for therapeutic results in people with Parkinson's disease. https://clinicaltrials.gov/study/NCT03774225 (first received 5 September 2018).
NCT03928405 {published data only}
    1. NCT03928405. Effect of virtual reality on balance and gait speed with Alzheimer's dementia. https://clinicaltrials.gov/study/NCT03928405 (first received 24 April 2019).
NCT04377191 {published data only}
    1. NCT04377191. The effect of different virtual reality trainings on gait, balance and posture of individuals with dementia. https://clinicaltrials.gov/study/NCT04377191 (first received 2 May 2020).
NCT04819126 {published data only}
    1. NCT04819126. Nintendo Wii virtual reality application in dementia. https://clinicaltrials.gov/study/NCT04819126 (first received 10 March 2021).
Padala 2019 {published data only}
    1. Padala KP, Malloy TR, Lensing SY, Bopp MM, Sullivan DH, Padala PR. Exercise adherence in early Alzheimer's dementia: what roles do executive function and apathy play? Alzheimer's & Dementia 15;7:P1586. [DOI: 10.1016/j.jalz.2019.09.031] - DOI
RBR‐3bq4rg {published data only}
    1. RBR-3bq4rg. Effects of gametherapy on dementia and cognitive decline in functional and cognitive capacity and biomarkers. http://ensaiosclinicos.gov.br/rg/RBR-3bq4rg (first received 19 September 2019).
TCTR20181001001 {published data only}
    1. TCTR20181001001. VR-based training to improve cognitive functions and brain activation in elderlies with mild cognitive impairment. https://www.thaiclinicaltrials.org/show/TCTR20181001001 (first received 1 October 2018).

References to ongoing studies

ACTRN12617000364370 {published data only}
    1. ACTRN12617000364370. The effect of cognitive training on cognitive function in older people with mild to moderate dementia: a single-blind randomised control trial. https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372410 (first received 5 March 2017).
ChiCTR2100043753 {published data only}
    1. ChiCTR2100043753. Construction and empirical study of community intervention program for patients with mild cognitive impairment based on immersive virtual reality cognitive training system. https://www.chictr.org.cn/showprojEN.html?proj=122518 (first received 27 February 2021).
ChiCTR2100048696 {published data only}
    1. ChiCTR2100048696. Construction and evaluation of executive function intervention program for patients with vascular mild cognitive impairment by immersive exercise and cognitive training. https://www.chictr.org.cn/showprojEN.html?proj=127466 (first received 12 July 2021).
IRCT20211110053030N2 {published data only}
    1. IRCT20211110053030N2. The effect of video games on cognitive performance and problem solving ability in the elderly. https://irct.behdasht.gov.ir/trial/71676 (first received 7 August 2023).
IRCT20220120053773N1 {published data only}
    1. IRCT20220120053773N1. Effect of virtual reality intervention on mild cognitive impairment. https://irct.behdasht.gov.ir/trial/61427 (first received 15 May 2022). [https://trialsearch.who.int/Trial2.aspx?TrialID=IRCT20220120053773N1]
ISRCTN85177142 {published data only}
    1. ISRCTN85177142. Virtual reality-based exercise in elderly people, people with Alzheimer's disease and people with schizophrenia. https://www.isrctn.com/ISRCTN85177142 (first received 25 February 2023).
KCT0008238 {published data only}
    1. KCT0008238. Effects of exercise games on improving cognitive function and health promotion in the elderly with dementia. https://cris.nih.go.kr/cris/search/detailSearch.do;jsessionid=uT8A_lSdTI... (first received 4 January 2019).
NCT03911765 {published data only}
    1. NCT03911765. Effect of digital cognitive training on the functionality of older adults with mild cognitive impairment (MCI). https://clinicaltrials.gov/study/NCT03911765 (first received 9 April 2019).
NCT04271943 {published data only}
    1. NCT04271943. The effect of aerobic and game based exercises on cognitive functions in dementia. https://clinicaltrials.gov/study/NCT04271943 (first received 14 February 2020).
NCT04415775 {published data only}
    1. NCT04415775. Changes in metabolic activity, and gait function by dual-task cognitive game-based treadmill intervention in Parkinson's disease. https://clinicaltrials.gov/study/NCT04415775 (first received 28 May 2020).
NCT04730817 {published data only}
    1. NCT04730817. VR motor-cognitive training for older people with cognitive frailty. https://clinicaltrials.gov/study/NCT04730817 (first received 26 January 2021).
NCT04732182 {published data only}
    1. NCT04732182. Telerehabilitation Alzheimer's Disease Feasibility (TADF). https://clinicaltrials.gov/study/NCT04732182 (first received 25 January 2021).
NCT04959383 {published data only}
    1. NCT04959383. Exergame balance training for patients with mild cognitive impairment. https://clinicaltrials.gov/study/NCT04959383 (first received 26 June 2021).
NCT05009524 {published data only}
    1. NCT05009524. The Interactive Physical and Cognitive Exercise System (v3) for mild cognitive impairment (MCI) (iPACES). https://clinicaltrials.gov/study/NCT05009524 (first received 23 July 2021).
NCT05158595 {published data only}
    1. NCT05158595. Exer-game balance training on dementia. https://ichgcp.net/clinical-trials-registry/NCT05158595 (first received 27 August 2021).
NCT05227495 {published data only}
    1. NCT05227495. Effects of the fully immersive leisure-based virtual reality cognitive training for community-dwelling elderly. https://clinicaltrials.gov/study/NCT05227495 (first received 23 January 2022).
NCT05235113 {published data only}
    1. NCT05235113. Remote game-based exercise program for cognitive and motor function improvement. https://clinicaltrials.gov/study/NCT05235113 (first received 5 November 2021).
NCT05387057 {published data only}
    1. NCT05387057. Effectiveness of a novel exergame-based training concept for older adults with mild neurocognitive disorder. https://clinicaltrials.gov/study/NCT05387057 (first received 18 May 2022).
NCT05402423 {published data only}
    1. NCT05402423. An integrated intervention of computerized cognitive training and physical exercise in virtual reality for people with Alzheimer's disease (JDome). https://clinicaltrials.gov/study/NCT05402423 (first received 23 January 2022). - PMC - PubMed
NCT05603533 {published data only}
    1. NCT05603533. Adherence by music to exercise in dementia: group therapy (AMUSED). https://clinicaltrials.gov/study/NCT05603533 (first received 20 October 2022).
NCT05730790 {published data only}
    1. NCT05730790. Immersive Virtual Reality for dual-task training in older adults with mild cognitive impairment: a randomized controlled trial. https://clinicaltrials.gov/study/NCT05730790 (first received 2 February 2023).
NCT05810454 {published data only}
    1. NCT05810454. iPACES v3 MCI NIA protocol copied for iPACES v4 PD NINDS (iPACES-PD). https://clinicaltrials.gov/study/NCT05810454 (first received 27 March 2023).
NCT06079411 {published data only}
    1. NCT06079411. Virtual therapeutics for MCI (VR-MCI). https://clinicaltrials.gov/study/NCT06079411 (first received 26 September 2023).
NCT06129630 {published data only}
    1. NCT06129630. Effects of Nintendo Switch on rehabilitation programs for elderly people with cognitive impairment. https://clinicaltrials.gov/study/NCT06129630 (first received 30 October 2023).
RBR‐4kdqcbt 2022 {published data only}
    1. RBR-4kdqcbt. Effect of a two-task exercise in Virtual Reality on the physical and mental point of view in the elderly: a randomized clinical trial. https://ensaiosclinicos.gov.br/rg/RBR-4kdqcbt (first received 3 February 2022).
TCTR20210530003 {published data only}
    1. TCTR20210530003. Effects of exergaming based Tai Chi on cognition and dual task gait in older adults with mild cognitive Impairment: a randomized control trial. https://trialsearch.who.int/Trial2.aspx?TrialID=TCTR20210530003 (first received 30 May 2021).
University of Missouri‐Columbia {published data only}
    1. University of Missouri-Columbia. Cognitive Training in Mild Cognitive Impairment (TRAIN-MCI). University of Missouri-Columbia 2021.

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