Published on in Vol 8, No 2 (2020): Apr-Jun

Preprints (earlier versions) of this paper are available at, first published .
Effectiveness of Exergaming in Improving Cognitive and Physical Function in People With Mild Cognitive Impairment or Dementia: Systematic Review

Effectiveness of Exergaming in Improving Cognitive and Physical Function in People With Mild Cognitive Impairment or Dementia: Systematic Review

Effectiveness of Exergaming in Improving Cognitive and Physical Function in People With Mild Cognitive Impairment or Dementia: Systematic Review


1Xiangya School of Nursing, Central South University, Changsha, China

2Xiangya-Oceanwide Health Management Research Institute, Central South University, Changsha, China

3National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, China

4Xiangya School of Public Health, Central South University, Changsha, China

5School of Nursing, University of Texas Health Science Center, San Antonio, TX, United States

6Henan Children's Hospital, Zhengzhou, China

Corresponding Author:

Hui Feng, PhD, Prof Dr

Xiangya School of Nursing

Central South University

No. 172 Tongzipo Road



Phone: 86 82650292


Background: Individuals with mild cognitive impairment and dementia have impaired physical and cognitive functions, leading to a reduced quality of life compared with those without such impairment. Exergaming, which is defined as a combination of exercise and gaming, is an innovative, fun, and relatively safe way to exercise in a virtual reality or gaming environment. Therefore, exergaming may help people living with mild cognitive impairment or dementia to overcome obstacles that they may experience regarding regular exercise and activities.

Objective: The aim of this systematic review was to review studies on exergaming interventions administered to elderly individuals with mild cognitive impairment and dementia, and to summarize the results related to physical and cognitive functions such as balance, gait, executive function, and episodic memory.

Methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, PsycINFO, Amed, and Nursing Database for articles published from the inception of the respective databases to January 2019. We included all clinical trials of exergaming interventions in individuals with mild cognitive impairment and dementia for review. The risk of bias was independently evaluated by two reviewers using the Cochrane Collaboration and Risk of Bias in Non-randomized Studies of Interventions tools.

Results: Ten studies involving 702 participants were included for review. There was consistent evidence from 7 studies with a low risk of bias showing statistically significant effects of exergaming on cognitive functioning in people with mild cognitive impairment and dementia. With respect to physical function, 3 of 5 full-scale studies found positive results, and the intensity of most games was classified as moderate.

Conclusions: Overall, exergaming is an innovative tool for improving physical and cognitive function in people with mild cognitive impairment or dementia, although there is high heterogeneity among studies in terms of the duration, frequency, and gaming platform used. The quality of the included articles was moderate to high. More high-quality studies with more accurate outcome indicators are needed for further exploration and validation of the benefits of exergaming for this population.

JMIR Serious Games 2020;8(2):e16841



Mild cognitive impairment is a term used to identify people who are at risk of developing dementia, but the cognitive impairment is so mild that it does not affect daily activities. Symptoms of mild cognitive impairment include memory impairment, language difficulties, attention deficits, disorientation, and altered visuospatial skills [1]. The prevalence of mild cognitive impairment in individuals older than 65 years is approximately 3% to 22% [2-4]. In addition, 5% to 15% of these cases progress to dementia annually, whereas the incidence of mild cognitive impairment in the general population is 1% to 2% per year [5-7].

Dementia is characterized by a group of chronic and progressive symptoms caused by various brain illnesses that affect memory, thinking, behavior, and ability to perform daily activities [8]. Dementia currently affects approximately 50 million people worldwide and is expected to affect 82 million people by 2030 and 152 million by 2050 [9,10]. Dementia is the second leading cause of disability in individuals aged 70 years or older and the seventh leading cause of death worldwide [10,11]. In 2015, the cost of dementia care was estimated at US $818 billion, equivalent to 1.1% of the global gross domestic product, which ranges from 0.2% for low- and middle-income countries to 1.4% for high-income countries. It is estimated that the cost of caring for people with dementia worldwide will increase to US $2 trillion by 2030, which could undermine social and economic development globally and overwhelm health and social services, especially long-term care systems [12].

Owing to the high medical and social burden of mild cognitive impairment and dementia, scientists in various fields have been searching for effective strategies to prevent or delay disease development. In view of the fact that current pharmacological treatments are not only expensive but are also accompanied by significant adverse effects [13], the Food and Drug Administration and experts in leading geriatric organizations recommended that nonpharmacologic approaches be used as the first-line treatment of cognitive impairment [14]. Nonpharmacologic approaches include, but are not limited to, reminiscence therapy [15], reality orientation [16], validation therapy [17], music therapy [18], doll therapy [19], pet therapy [20], and cognitive and physical exercise training [21]. These nonpharmacologic approaches are becoming increasingly preferred by the geriatric population because they have been shown to yield positive results, are easy to use in clinical or home settings, and are inexpensive.

In recent decades, an increasing number of studies have used games for cognitive training in people with mild cognitive impairment or dementia [22-27]. The aim of cognitive training is to maintain or improve specific cognitive functions such as attention, episodic memory, and problem-solving skills using guided training and repetitions of standardized tasks [28]. Game-based interventions are nonpharmacological readily accepted forms for training, and playing games could be an efficient mode to practice mental concentration and memory, making them appropriate for people with cognitive impairment [29-31].

Exergaming, defined as the combination of exercise and gaming, is a relatively new type of intervention in which users must perform physical movements to play games [32]. The design of the games is based on the cognitive enrichment hypothesis, which states that the behaviors of individuals (including cognitive activity, social engagement, exercise, and other behaviors) can influence their level of cognitive function [33]. One idea underlying this hypothesis is to use a rich environment to stimulate brain functioning. This rich environment is reflected when participants play these games, and there is usually a screen displaying information about the game scene. For example, the Kinect sensor incorporates an infrared light and a video camera to create a three-dimensional map in the front area, handheld controllers are also used to manipulate the games [34], and physical movements are captured by the video cameras [35] or weight-sensing platforms [36].

Exergames have been gradually implemented in rehabilitation [37,38], education [39], and other fields [40], and have been widely accepted by a range of populations from children [41,42] to the elderly [43,44]; moreover, positive results were found for individuals with various diseases such as dementia [45], stroke [46], Parkinson disease [34], multiple sclerosis [47], cystic fibrosis [48], and cancer [49]. Recent studies have demonstrated the feasibility, acceptability, and effectiveness of exergaming in improving physical functions such as gait and balance [50], motion control [51], and exercise capacity [52]. Exergaming has been found to be an acceptable method of exercising among older adults [53,54], and is also proven to be safe [55,56], easy to use [53], and enjoyable [53,54].

To the best of our knowledge, there is only one systematic review [57] that has synthesized the existing evidence of exergaming in individuals with dementia. However, due to the limitation of the retrieval strategy, the systematic review included only 3 articles involving a study with an exergaming-integrated training method and two studies using Nintendo Wii training methods. However, few systematic reviews have examined the effectiveness of exergames in improving the physical and cognitive functions in individuals with mild cognitive impairment or dementia. In addition, the latest classification of exergaming includes not only Wii but also handheld controllers, and physical movements captured by video cameras or weight-sensing platforms. Therefore, we conducted a systematic review with a high degree of evidence using the Joanna Briggs Institute methodology for systematic reviews of effectiveness evidence [58]. In reviewing the current literature, we focused on whether an exergaming intervention can indeed be beneficial to the rehabilitation of people with mild cognitive impairment and dementia.

Search Strategy

The search strategy was developed by a researcher who has conducted reviews and a university-level statistics professor. We initially conducted a limited search (with modifications as needed) in the Medline and Embase databases to identify articles relevant to the topic. The text contained in the titles and abstracts of the related articles as well as the index words used to describe the articles were adopted to develop a complete search strategy for the related databases. A combination of search terms was used to identify relevant papers (exergam* or activ* n3 video n3 gam* or activ*) AND (dementia* or alzheimer* or mild cognitive impair* or cognitive impair*), where * represents a wild card allowing the use of other suffixes, and n3 represents the adjacent retrieval operator, which allows three words to be inserted between two words and reverses the order of the words. For more details regarding the search terms, definitions, and variations of input, see Multimedia Appendix 1.

Two authors (Yinan Z and XY) independently identified studies published from the inception of the databases to January 2019. The language was restricted to English by searching the following databases systematically: Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, PsycINFO, Amed, and Nursing Database.

The systematic review is registered with PROSPERO: CRD42019124994. The reporting of the review is consistent with the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines [59].

Article Selection

Two reviewers (Yinan Z and XY) independently reviewed the list of potential articles found by the search strategy after removing duplicates with Mendeley reference management software. The inclusion criteria of this review were as follows: (1) randomized controlled trials (RCTs), cluster RCTs, quasiRCTs, and controlled clinical trials; (2) participants were people diagnosed with mild cognitive impairment or dementia; (3) exergaming interventions that combined real-time motions with engaging video games that can help motivate individuals to exercise; (4) comparators included groups who underwent routine exercise, other specific interventions, or no comparative group; and (5) health outcomes reported related to cognitive and physical functions, such as cognitive function, balance and gait, overall physical function, quality of life, behavioralist and neuropsychiatric symptoms, and number of falls. To synthesize more comprehensive evidence, we included both the pilot study and the full-scale study when available.

Data Extraction

Data were extracted from studies included in the review by two independent reviewers (Yinan Z and XY) using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument [58].

The extracted data included specific details about the author, year of publication, country, study design, populations, study methods, interventions, control group, outcomes, and measurements, along with outcomes of significance to the review objective. Any disagreements that arose between the reviewers were resolved through discussion or consultation with a third reviewer. The authors of the articles were contacted to request missing or additional data when required.

Study Quality Assessment

Two reviewers independently examined the risk of bias of the included studies using the Cochrane Collaboration tool for assessing the risk of bias [60] (adapted from Higgins and Altman [61]) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) [62]. Any disagreements that arose between the reviewers were resolved through discussion with a third reviewer. Because some of the studies included were pilot studies with small sample sizes, we used Cohen d [63] to calculate the effect size.

Data Analysis

A narrative synthesis was conducted since there were insufficient data available for a statistical meta-analysis. After extracting the required data from relevant journal articles, a descriptive summary was created to summarize the interventions and assess the exergaming interventions used to improve cognitive and physical functions among people with dementia. We calculated Cohen d using the Psychometrica program [64]. Because an analysis based on changes from baseline is considered to be more effective and powerful than a comparison based on the final value, for each study, the differences between the baseline and final mean and SD values were included in the analysis; such a baseline change analysis removes a component of interperson variability from the analysis. In articles that did not report SDs, we calculated the SDs from the reported means, along with SEs, 95% CIs, and other relevant information [65].

Search Results

A total of 697 potentially relevant studies were identified in the initial search. After duplicates were removed, the titles and abstracts of 592 records were screened for relevance according to the inclusion criteria, and 30 potentially relevant studies were identified. After viewing the full texts, 20 studies were excluded from the review. In 11 studies, the interventions were multimodal or multicomponent, excluding exergaming. In 7 studies, the participants were elderly but did not have a diagnosis of mild cognitive impairment or dementia. One study was a single-case feasibility study, and another study did not explore the outcome of physical and cognitive function. Finally, 10 articles were included in this study [45,50,52,66-72] (Figure 1).

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.
View this figure


Half of the studies (n=5) were conducted in the United States and the remaining studies were conducted in Germany, Greece, the Netherlands, France, and Pakistan. A total of 702 participants were recruited for these 10 studies, and the data of 597 participants were analyzed after removing duplicates. The mean age of the participants in 9 of the 10 (90%) included studies was 79.8 (SD 7.2) years, and 408 (58.1%) were women. In 8 studies, all participants were diagnosed with mild cognitive impairment or dementia, including mild Alzheimer disease and dementia, whereas the elderly people participating in the other 2 studies included those with and without mild cognitive impairment or dementia. More details on the participants, interventions, comparisons, outcome measures, and results of the included studies are shown in Multimedia Appendix 2.

Types of Interventions

There were two main categories of exergame interventions implemented in the included studies. The first category corresponded to exergaming training such as balance training, flexible training, and aerobic training, and the second category corresponded to virtual reality-based situational tasks such as riding a bike in a park, crossing roads while avoiding cars, and shopping in a supermarket. The median duration of the intervention was 8 weeks (range 4-24 weeks), although many of the studies used durations ranging from 6 to 8 weeks. Nine articles reported the duration of the sessions, ranging from 30 to 120 minutes, and some studies reported duration ranges, as the completion time was determined by the participants in some cases.

The exergames in 5 studies were implemented on sensor-based platforms [50,67,68,71,72] such as Nintendo Wii-Fit and FitForAll; 4 studies used video camera systems such as Xbox 360 Kinect, X-Torp, and Bike Labyrinth to capture physical movements [52,66,69,70]; and another study used a handheld controller [45]. The interventions were administered by a researcher [45,50,68-70,72], therapist [66], clinical doctor [52], and family caregiver [71]. In the study of Bamidies et al [67], the intervention was carried out in a group setting with psychologists, physical education instructors, researchers, or nurses.

Outcome Measures

Different indices, including balance, gait, executive function, episodic memory, working memory, emotions, and cognitive performance, were used to evaluate the effects of the exergaming interventions on cognitive and physical functions.

Physical Functioning

Physical function was evaluated in 7 full and pilot studies; however, only 3 of these studies showed positive results. Schwent et al [72] used 3 wearable sensors attached to both the lower legs and the lower back of the participants who were instructed to stand for 30 seconds with their feet close together; they were then instructed to stand with their eyes open and closed so that their balance could be assessed, and the authors found a significant result on balance (P<.05). Two studies assessed balance using the Berg Balance Scale (BBS), and one showed that the mean BBS score improved to more than 45 points in both groups with the intervention; scores between 41 and 56 points indicate that an individual’s balance function is good, and for elderly people, these scores indicate that they can walk independently. The BBS score improved significantly over time for both groups (P<.001); however, there were no significant group-by-time interaction effects on the BBS scores (P=.56) [50].

Cognitive Functioning

Cognitive function was evaluated in all 10 studies included in the systematic review. Among the 6 full-scale studies, 4 showed positive results. Wiloth et al [45] used a task-specific assessment that included temporal and spatial outcome parameters to measure motor-cognitive performance, and found that exergaming training significantly improved the duration and accuracy parameters (P<.001) Bamidis et al [67] used the average Z-standardized scores of episodic memories, working memory, and executive function to assess global cognition, and found significantly improved global cognition in the experimental group compared to the control group (P=.002). Amjad et al [66] used the Mini-Mental State Examination and Montreal Cognitive Assessment to test participants’ cognitive abilities and found significant interaction effects of the group and time factors on both scores (P<.001). They also used the Trail Making Test to assess executive functions, which showed significant improvement (P<.001). Another study found that the psychomotor speed of the exergame training group was significantly higher than that of the control group after 12 weeks (P=.004) and there was a maintenance effect observed at the 24-week follow-up (P=.003); part A of the short form of the Trail Making Test and parts I and II of the abbreviated Stroop Color Word Test were used to assess psychomotor speed. In 4 pilot studies, no positive results were found on cognitive function [69].

Risk of Bias

Eight RCTs and two pretest-posttest studies with a control group design (quasiRCTs) were included in the review. The 8 RCTs were assessed for risk of bias using the Cochrane Collaboration tool [60], which includes the following 7 items: (a) generation of random sequences (selection bias), (b) allocation concealment (selection bias), (c) blinding of the participants and personnel (performance bias), (d) blinding of the outcome assessment (detection bias), (e) incomplete outcome data (attrition bias), (f) selective outcome reporting (reporting bias), and (g) other biases. Two reviewers rated the studies to have “low risk,” “high risk,” or “unclear risk” for each of the categories listed above, corresponding to the green, red, and yellow filled circles, respectively, shown in Figure 2. Moreover, the two quasiRCTs were assessed using the ROBINS-I tool, which has been widely used for evaluating nonrandomized studies. The evaluation results are shown in Table 1.

Figure 2. Risk of bias summary.
View this figure
Table 1. Risk of bias assessment according to the ROBINS-Ia tool.
Risk of biasBamidis et al [67]Ben-Sadoun et al [52]
Confounding factorsLowModerate
Selection of participantsLowSerious
Classification of interventionLowLow
Deviation from intended interventionsLowLow
Missing dataLowLow
Measurement of outcomesLowLow
Selective reportingLowLow
Overall judgmentLowHigh

aRisk of Bias in Non-randomized Studies of Interventions.

This is the first systematic review that synthesized the existing evidence of exergaming interventions administered to elderly individuals with mild cognitive impairment or dementia and to explore the effect of exergaming interventions on their cognitive and physical functions. The interventions identified in this review differed greatly across studies. The duration and frequency of the interventions also varied greatly; the duration ranged from 4 to 24 weeks, and the total intervention duration ranged from 3 to 36 hours. The frequency ranged from 1 to 5 times a week, and the median was 3, which is consistent with the study of Manera et al [73]. However, after analysis, there was no evidence that longer and more frequent interventions lead to greater improvements in function. Although exergaming is a combination of gaming and exercise, due to the diversity of the platforms used to manage the exergame interventions, it was difficult to determine which exergame was the best for improving cognitive and physical functions. Nevertheless, many studies used sensor-based platforms such as Nintendo Wii. Half of the interventions were carried out in the community, and the rest were administered in hospitals, rehabilitation wards, or nursing homes, indicating that exergaming interventions could be implemented in both environments, but were more common in a community setting. Alzheimer’s Disease International estimated that globally, approximately 84% of elderly patients with dementia currently live in a community [74]. The World Health Organization’s “Rehabilitation 2030” campaign launched in 2017 pointed out that rehabilitation programs should follow a holistic approach for chronic disease management, optimize independence, and prolong community engagement [75]. Because it is inexpensive [49], safe [55,56], and easy to use [53], exergaming can be performed unsupervised even for community-dwelling healthy older adults [76,77]. Exergaming interventions are gradually being used as a physical cognitive rehabilitation tool for elderly people with mild cognitive impairment or dementia living at home in the community.

In a previous literature review, the effectiveness of exergaming training in improving cognitive function was investigated in people with mild cognitive impairment or dementia. The results were consistent with those reported in the study of Karssemeijer et al [69], showing that exergame training significantly improved the psychomotor speed in elderly people with dementia compared with the control group that adopted normal exercise. Moreover, positive results were found in the study of Amjad et al [66] in elderly individuals with mild cognitive impairment, showing improvements in overall cognitive abilities and executive function, and in the study of Bamidis et al [67] in elderly individuals who were healthy or had mild cognitive impairment.

Four of the five formal studies reported that the exergaming intervention improved cognitive function, which is encouraging. In recent years, more and more studies have applied exergames to the cognitive rehabilitation in elderly people with mild cognitive impairment or dementia. The aim of cognitive rehabilitation is to use individualized intervention strategies to address cognitive impairment [78]. Previous studies have shown that an effective approach to treating cognitive impairment requires a highly individualized approach that focuses on the common goals of patients and is interactive [79], and an exergaming intervention meets these criteria. Wiloth et al [45] assigned participants to tasks of different difficulty levels according to their cognitive performance and the intervention was implemented in the presence of the clinicians. In the study of Bamidi et al [67], a group of psychologists, physical education instructors, researchers, and nurses helped each elderly person design a plan that included aerobic, resistance, and strength exercises. However, due to the small sample size, short intervention duration [70-72], and lack of specific exercises [72], a positive result was not obtained in several other preliminary experiments [50,70-72]. In addition, some studies reported “small” to “moderate” effect sizes for the cognitive function results [50,52,72,80].

In the current study, the instrumental activities of daily living and activities of daily living were used to evaluate the independence in performing physical activities of the subjects for three interventions, but only one study showed positive results. However, variations in activities of daily living performance are expected since the extent to which patients with Alzheimer disease lose the ability to perform activities of daily living varies widely [81]. Balance and gait speed are the most widely used physical measurements for evaluating physical function since gait speed [82-84] and functional decline [85] are predictors of survival among elderly people. Four studies included balance in the outcome measures, three of which found positive results and the other found a moderate effect size in physical function among participants with neurodegenerative diseases. These results indicate that exergames do improve postural control in older adults compared to walking training [50,71,72,85]. This conclusion can be supported by the theory of planned behavior, which postulates that subjective norms and behavioral attitudes determine individual behavioral intentions and the latter determines individual behaviors [86]. An interesting result was found with respect to use of the same exergaming intervention (Nintendo Wii-Fit) and control intervention (walking program), both of which lasted for 8 weeks. One study showed no significant group-by-time interaction effects on the BBS scores (P=.56) [50], but the other showed that among the participants who completed the test, there was a significant group-by-time interaction effect on the primary outcome measure, the BBS score (P<.05) [71], which we consider to be a very promising result. This discrepancy may have been partly caused by a small sample size or low test efficiency. Additional studies with sufficient sample sizes and high quality should be conducted to verify the results.

According to the literature review, in addition to cognitive and physical functions, we also found that exergames affect other outcomes. Apathy is a common neuropsychiatric syndrome observed across many neurocognitive and psychiatric disorders. In the study of Valeria et al [87], 20 experts reported that information and communications technology is “very appropriate” for apathy nonpharmacological treatment. Among all the studies included in this review, none of the studies using measurement tools detected changes in apathy before and after the intervention; however, we found some benefits in terms of motivation and compliance.

Motivation or compliance was evaluated or explored in 70% of the studies reviewed. All 7 studies that evaluated motivation or compliance agreed that the exergames increased or enhanced the participants’ motivation to engage in rehabilitation activities. Although exercise therapy has been recommended to improve the cognitive and physical functions in people with dementia or mild cognitive impairment in recent years [88], there are still many barriers to exercise, such as lack of motivation and limited access to exercise facilities [89]. Exergames provide sensory feedback through auditory, visual, and tactile stimulation [90], and can further maintain the motivation of individuals [66]. Therefore, exergaming interventions have a high adherence rate among rehabilitation methods. Ben-Sadoun and colleagues [52] found that both groups in the study experienced only positive emotions, which was consistent with previous findings on exergames in subjects with mild cognitive impairment and Alzheimer disease. In the study of Hughes et al [68], the majority of participants were “very much” satisfied with the intervention. An open-label RCT among elderly people with mild cognitive impairment showed that exergaming interventions can reduce individuals’ fear of falling compared with no training [72].

Despite the positive impact, some limitations of our study must be considered when interpreting the results. The studies included in this review varied substantially in terms of the consoles used, games played, participants’ stages of mild cognitive impairment or dementia, and the outcomes assessed, making analyses of the effects of exergaming difficult, and a meta-analysis could not be performed. To gather comprehensive evidence, we included pilot studies with small sample sizes. Therefore, it is difficult to draw firm conclusions from the results of the analyses due to the limited statistical power.

This is the first systematic review that assessed the effectiveness of exergaming interventions in improving the cognitive and physical functions of elderly people with mild cognitive impairment or dementia. The studies included in the analysis were heterogenous in terms of the modalities used to administer the interventions, health outcome evaluations performed, and outcomes assessed. Overall, exergame interventions can improve cognitive and physical function to some extent, and more high-quality studies with more accurate outcome indicators are needed for further exploration.


We sincerely thank the library of Central South University for its help in the retrieval process of this research. This work was supported by the Special Funding for the Construction of Innovative Provinces in Hunan (grant no. 2019SK2141), the China Oceanwide Holding Group Project Fund (contract no. 143010100), and the Key Laboratory of Nursing Science of Hunan province (grant no. 2017TP1004).

Conflicts of Interest

None declared.

Multimedia Appendix 1

Search strategy.

DOCX File , 17 KB

Multimedia Appendix 2

Study characteristics.

PDF File (Adobe PDF File), 155 KB

  1. Viggiano D, Wagner CA, Martino G, Nedergaard M, Zoccali C, Unwin R, et al. Mechanisms of cognitive dysfunction in CKD. Nat Rev Nephrol 2020 Mar 31. [CrossRef] [Medline]
  2. Hänninen T, Hallikainen M, Tuomainen S, Vanhanen M, Soininen H. Prevalence of mild cognitive impairment: a population-based study in elderly subjects. Acta Neurol Scand 2002 Sep;106(3):148-154. [CrossRef] [Medline]
  3. Ganguli M, Dodge HH, Shen C, DeKosky ST. Mild cognitive impairment, amnestic type: an epidemiologic study. Neurology 2004 Jul 13;63(1):115-121. [CrossRef] [Medline]
  4. Petersen RC, Roberts RO, Knopman DS, Geda YE, Cha RH, Pankratz VS, et al. Prevalence of mild cognitive impairment is higher in men. The Mayo Clinic Study of Aging. Neurology 2010 Sep 07;75(10):889-897 [FREE Full text] [CrossRef] [Medline]
  5. Huang P, Fang R, Li B, Chen S. Exercise-Related Changes of Networks in Aging and Mild Cognitive Impairment Brain. Front Aging Neurosci 2016;8:47. [CrossRef] [Medline]
  6. Petersen RC, Roberts RO, Knopman DS, Boeve BF, Geda YE, Ivnik RJ, et al. Mild cognitive impairment: ten years later. Arch Neurol 2009 Dec;66(12):1447-1455 [FREE Full text] [CrossRef] [Medline]
  7. Roberts RO, Knopman DS, Geda YE, Cha RH, Pankratz VS, Baertlein L, et al. Association of diabetes with amnestic and nonamnestic mild cognitive impairment. Alzheimers Dement 2014 Jan;10(1):18-26 [FREE Full text] [CrossRef] [Medline]
  8. World Health Organization. 10 Facts on Dementia. 2018 Nov 13.   URL: [accessed 2019-12-31]
  9. Diagnostic and Statistical Manual of Mental disorders DSM-5, 5th edn. Washington, DC: American Psychiatric Association; 2013.
  10. World Health Organization. 2017. Dementia   URL: [accessed 2019-12-31]
  11. World Health Organization. 2017 Nov 17. Dementia: number of people affected to triple in next 30 years   URL: [accessed 2019-12-31]
  12. Wajda DA, Mirelman A, Hausdorff JM, Sosnoff JJ. Intervention modalities for targeting cognitive-motor interference in individuals with neurodegenerative disease: a systematic review. Expert Rev Neurother 2017 Mar 12;17(3):251-261. [CrossRef] [Medline]
  13. Kavirajan H, Schneider LS. Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: a meta-analysis of randomised controlled trials. Lancet Neurol 2007 Sep;6(9):782-792. [CrossRef] [Medline]
  14. American Geriatrics Society, American Association for Geriatric Psychiatry. The American Geriatrics Society and American Association for Geriatric Psychiatry recommendations for policies in support of quality mental health care in U.S. nursing homes. J Am Geriatr Soc 2003 Sep;51(9):1299-1304. [CrossRef] [Medline]
  15. Dempsey L, Murphy K, Cooney A, Casey D, O'Shea E, Devane D, et al. Reminiscence in dementia: a concept analysis. Dementia (London) 2014 Mar 01;13(2):176-192. [CrossRef] [Medline]
  16. Woods B, O'Philbin L, Farrell EM, Spector AE, Orrell M. Reminiscence therapy for dementia. Cochrane Database Syst Rev 2018 Mar 01;3:CD001120 [FREE Full text] [CrossRef] [Medline]
  17. Neal M, Barton Wright P. Validation therapy for dementia. Cochrane Database Syst Rev 2003(3):CD001394. [CrossRef] [Medline]
  18. Robinson L, Hutchings D, Dickinson HO, Corner L, Beyer F, Finch T, et al. Effectiveness and acceptability of non-pharmacological interventions to reduce wandering in dementia: a systematic review. Int J Geriatr Psychiatry 2007 Jan;22(1):9-22. [CrossRef] [Medline]
  19. Mitchell G. Use of doll therapy for people with dementia: an overview. Nurs Older People 2014 May;26(4):24-26. [CrossRef] [Medline]
  20. Williams E, Jenkins R. Dog visitation therapy in dementia care: a literature review. Nurs Older People 2008 Oct;20(8):31-35. [CrossRef] [Medline]
  21. Karssemeijer EGA, Aaronson JA, Bossers WJ, Smits T, Olde Rikkert MGM, Kessels RPC. Positive effects of combined cognitive and physical exercise training on cognitive function in older adults with mild cognitive impairment or dementia: A meta-analysis. Ageing Res Rev 2017 Nov;40:75-83. [CrossRef] [Medline]
  22. Perrot A, Maillot P, Hartley A. Cognitive Training Game Versus Action Videogame: Effects on Cognitive Functions in Older Adults. Games Health J 2019 Feb;8(1):35-40. [CrossRef] [Medline]
  23. Maillot P, Perrot A, Hartley A. Effects of interactive physical-activity video-game training on physical and cognitive function in older adults. Psychol Aging 2012 Sep;27(3):589-600. [CrossRef] [Medline]
  24. Savulich G, Piercy T, Fox C, Suckling J, Rowe JB, O'Brien JT, et al. Cognitive Training Using a Novel Memory Game on an iPad in Patients with Amnestic Mild Cognitive Impairment (aMCI). Int J Neuropsychopharmacol 2017 Aug 01;20(8):624-633. [CrossRef] [Medline]
  25. Cohen GD, Firth KM, Biddle S, Lloyd Lewis MJ, Simmens S. The first therapeutic game specifically designed and evaluated for Alzheimer's disease. Am J Alzheimers Dis Other Demen 2008;23(6):540-551. [CrossRef] [Medline]
  26. Yamaguchi H, Maki Y, Takahashi K. Rehabilitation for dementia using enjoyable video-sports games. Int Psychogeriatr 2011 May;23(4):674-676. [CrossRef] [Medline]
  27. Venturelli M, Magalini A, Scarsini R, Schena F. From Alzheimer's disease retrogenesis: a new care strategy for patients with advanced dementia. Am J Alzheimers Dis Other Demen 2012 Nov;27(7):483-489. [CrossRef] [Medline]
  28. Brueggen K, Kasper E, Ochmann S, Pfaff H, Webel S, Schneider W, et al. Cognitive Rehabilitation in Alzheimer's Disease: A Controlled Intervention Trial. J Alzheimers Dis 2017;57(4):1315-1324. [CrossRef] [Medline]
  29. Weybright EH, Dattilo J, Rusch FR. Effects of an interactive video game (Nintendo Wii) on older women with mild cognitive impairment. Ther Recreation J 2010;44(4):271-287 [FREE Full text]
  30. Boulay M, Benveniste S, Boespflug S, Jouvelot P, Rigaud A. A pilot usability study of MINWii, a music therapy game for demented patients. Technol Health Care 2011 Aug 15;19(4):233-246. [CrossRef]
  31. Fernández-Calvo B, Rodríguez-Pérez R, Contador I, Rubio-Santorum A, Ramos F. [Efficacy of cognitive training programs based on new software technologies in patients with Alzheimer-type dementia]. Psicothema 2011 Feb;23(1):44-50. [Medline]
  32. Barry G, Galna B, Rochester L. The role of exergaming in Parkinson's disease rehabilitation: a systematic review of the evidence. J Neuroeng Rehabil 2014 Mar 07;11:33 [FREE Full text] [CrossRef] [Medline]
  33. Hertzog C, Kramer AF, Wilson RS, Lindenberger U. Enrichment Effects on Adult Cognitive Development: Can the Functional Capacity of Older Adults Be Preserved and Enhanced? Psychol Sci Public Interest 2008 Oct;9(1):1-65. [CrossRef] [Medline]
  34. Shih M, Wang R, Cheng S, Yang Y. Effects of a balance-based exergaming intervention using the Kinect sensor on posture stability in individuals with Parkinson's disease: a single-blinded randomized controlled trial. J Neuroeng Rehabil 2016 Aug 27;13(1):78 [FREE Full text] [CrossRef] [Medline]
  35. Stanmore E, Stubbs B, Vancampfort D, de Bruin ED, Firth J. The effect of active video games on cognitive functioning in clinical and non-clinical populations: A meta-analysis of randomized controlled trials. Neurosci Biobehav Rev 2017 Jul;78:34-43 [FREE Full text] [CrossRef] [Medline]
  36. Barry G, Tough D, Sheerin P, Mattinson O, Dawe R, Board E. Assessing the Physiological Cost of Active Videogames (Xbox Kinect) Versus Sedentary Videogames in Young Healthy Males. Games Health J 2016 Feb;5(1):68-74. [CrossRef] [Medline]
  37. Bulea T, Lerner Z, Gravunder A, Damiano D. Exergaming with a pediatric exoskeleton: Facilitating rehabilitation and research in children with cerebral palsy. IEEE Int Conf Rehabil Robot 2017 Jul;2017:1087-1093. [CrossRef] [Medline]
  38. Swanenburg J, Wild K, Straumann D, de Bruin ED. Exergaming in a Moving Virtual World to Train Vestibular Functions and Gait; a Proof-of-Concept-Study With Older Adults. Front Physiol 2018;9:988. [CrossRef] [Medline]
  39. Sun H, Gao Y. Impact of an active educational video game on children's motivation, science knowledge, and physical activity. J Sport Health Sci 2016 Jun;5(2):239-245 [FREE Full text] [CrossRef] [Medline]
  40. Li J, Xu X, Pham TP, Theng Y, Katajapuu N, Luimula M. Exergames Designed for Older Adults: A Pilot Evaluation on Psychosocial Well-Being. Games Health J 2017 Dec;6(6):371-378. [CrossRef] [Medline]
  41. Costa HA, Silva-Filho AC, Dias CJ, Martins VA, Mendes T, Rabelo A, et al. Cardiovascular Response of an Acute Exergame Session in Prepubertal Obese Children. Games Health J 2017 Jun;6(3):159-164. [CrossRef] [Medline]
  42. Rhodes RE, Kaos MD, Beauchamp MR, Bursick SK, Latimer-Cheung AE, Hernandez H, et al. Effects of home-based exergaming on child social cognition and subsequent prediction of behavior. Scand J Med Sci Sports 2018 Oct;28(10):2234-2242. [CrossRef] [Medline]
  43. Hsieh C, Lin P, Hsu W, Wang J, Huang Y, Lim A, et al. The Effectiveness of a Virtual Reality-Based Tai Chi Exercise on Cognitive and Physical Function in Older Adults with Cognitive Impairment. Dement Geriatr Cogn Disord 2018;46(5-6):358-370. [CrossRef] [Medline]
  44. Schättin A, Arner R, Gennaro F, de Bruin ED. Adaptations of Prefrontal Brain Activity, Executive Functions, and Gait in Healthy Elderly Following Exergame and Balance Training: A Randomized-Controlled Study. Front Aging Neurosci 2016;8:278. [CrossRef] [Medline]
  45. Wiloth S, Werner C, Lemke NC, Bauer J, Hauer K. Motor-cognitive effects of a computerized game-based training method in people with dementia: a randomized controlled trial. Aging Ment Health 2018 Sep 06;22(9):1124-1135. [CrossRef] [Medline]
  46. Li Z, Han X, Sheng J, Ma S. Virtual reality for improving balance in patients after stroke: A systematic review and meta-analysis. Clin Rehabil 2016 May;30(5):432-440. [CrossRef] [Medline]
  47. Robinson J, Dixon J, Macsween A, van Schaik P, Martin D. The effects of exergaming on balance, gait, technology acceptance and flow experience in people with multiple sclerosis: a randomized controlled trial. BMC Sports Sci Med Rehabil 2015;7:8 [FREE Full text] [CrossRef] [Medline]
  48. Tariq H. Effect of balance exercises for person with multiple sclerosis using Wii game: A systematic review of randomized and non-randomized control trials. Acta Med Int 2016;3(1):196. [CrossRef]
  49. Tough D, Robinson J, Gowling S, Raby P, Dixon J, Harrison SL. The feasibility, acceptability and outcomes of exergaming among individuals with cancer: a systematic review. BMC Cancer 2018 Nov 21;18(1):1151 [FREE Full text] [CrossRef] [Medline]
  50. Padala KP, Padala PR, Malloy TR, Geske JA, Dubbert PM, Dennis RA, et al. Wii-fit for improving gait and balance in an assisted living facility: a pilot study. J Aging Res 2012;2012:597573. [CrossRef] [Medline]
  51. Legouverneur G, Pino M, Boulay M, Rigaud A. Wii sports, a usability study with MCI and Alzheimer's patients. Alzheimemer Dementia 2011 Jul 01;7(4):S500-S501. [CrossRef]
  52. Ben-Sadoun G, Sacco G, Manera V, Bourgeois J, König A, Foulon P, et al. Physical and Cognitive Stimulation Using an Exergame in Subjects with Normal Aging, Mild and Moderate Cognitive Impairment. J Alzheimers Dis 2016 Jun 30;53(4):1299-1314. [CrossRef] [Medline]
  53. Jahn P, Lakowa N, Landenberger M, Vordermark D, Stoll O. InterACTIV: an exploratory study of the use of a game console to promote physical activation of hospitalized adult patients with cancer. Oncol Nurs Forum 2012 Mar;39(2):E84-E90. [CrossRef] [Medline]
  54. Williams MA, Soiza RL, Jenkinson AM, Stewart A. EXercising with Computers in Later Life (EXCELL) - pilot and feasibility study of the acceptability of the Nintendo® WiiFit in community-dwelling fallers. BMC Res Notes 2010 Sep 13;3:238 [FREE Full text] [CrossRef] [Medline]
  55. Skjæret N, Nawaz A, Morat T, Schoene D, Helbostad JL, Vereijken B. Exercise and rehabilitation delivered through exergames in older adults: An integrative review of technologies, safety and efficacy. Int J Med Inform 2016 Jan;85(1):1-16. [CrossRef] [Medline]
  56. Pompeu JE, Arduini LA, Botelho AR, Fonseca MBF, Pompeu SMAA, Torriani-Pasin C, et al. Feasibility, safety and outcomes of playing Kinect Adventures!™ for people with Parkinson's disease: a pilot study. Physiotherapy 2014 Jun;100(2):162-168. [CrossRef] [Medline]
  57. van Santen J, Dröes RM, Holstege M, Henkemans OB, van Rijn A, de Vries R, et al. Effects of Exergaming in People with Dementia: Results of a Systematic Literature Review. J Alzheimers Dis 2018;63(2):741-760 [FREE Full text] [CrossRef] [Medline]
  58. Joanna Briggs Institute Reviewer's Manual.: Joanna Briggs Institute; 2017.   URL: [accessed 2020-05-25]
  59. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009 Jul 21;339:b2700 [FREE Full text] [CrossRef] [Medline]
  60. Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Cochrane Bias Methods Group, Cochrane Statistical Methods Group. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011 Oct 18;343:d5928 [FREE Full text] [CrossRef] [Medline]
  61. Higgins JPT, Altman DG. Assessing risk of bias in included studies. In: Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions. Chichester, England: Wiley-Blackwell; 2008.
  62. Hinneburg I. ROBINS-1: A tool for asssessing risk of bias in non-randomised studies of interventions. Med Monatsschr Pharm 2017 Apr;40(4):175-177. [Medline]
  63. Muller K. Statistical Power Analysis for the Behavioral Sciences. Technometrics 1989 Nov;31(4):499-500. [CrossRef]
  64. Lenhard D. Psychometrica - institut for psychologische Diagnostik. 2017.   URL: [accessed 2019-12-31]
  65. Schünemann HJ, Vist GE, Higgins JPT, Santesso N, Deeks JJ, Glasziou P, on behalf of the Cochrane GRADEing Methods Group. Interpreting results and drawing conclusions. In: Higgins J, Thomas J, editors. Cochrane handbook for systematic reviews of interventions. Chichester, England: Wiley-Blackwell; 2011:359-388.
  66. Amjad I, Toor H, Niazi IK, Pervaiz S, Jochumsen M, Shafique M, et al. Xbox 360 Kinect Cognitive Games Improve Slowness, Complexity of EEG, and Cognitive Functions in Subjects with Mild Cognitive Impairment: A Randomized Control Trial. Games Health J 2019 Apr;8(2):144-152. [CrossRef] [Medline]
  67. Bamidis PD, Fissler P, Papageorgiou SG, Zilidou V, Konstantinidis EI, Billis AS, et al. Gains in cognition through combined cognitive and physical training: the role of training dosage and severity of neurocognitive disorder. Front Aging Neurosci 2015;7:152. [CrossRef] [Medline]
  68. Brummel NE, Girard TD, Ely EW, Pandharipande PP, Morandi A, Hughes CG, et al. Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 2014 Mar 21;40(3):370-379 [FREE Full text] [CrossRef] [Medline]
  69. Karssemeijer EGA, Aaronson JA, Bossers WJR, Donders R, Olde Rikkert MGM, Kessels RPC. The quest for synergy between physical exercise and cognitive stimulation via exergaming in people with dementia: a randomized controlled trial. Alzheimers Res Ther 2019 Jan 05;11(1):3 [FREE Full text] [CrossRef] [Medline]
  70. Mrakic-Sposta S, Di Santo SG, Franchini F, Arlati S, Zangiacomi A, Greci L, et al. Effects of Combined Physical and Cognitive Virtual Reality-Based Training on Cognitive Impairment and Oxidative Stress in MCI Patients: A Pilot Study. Front Aging Neurosci 2018;10:282. [CrossRef] [Medline]
  71. Padala KP, Padala PR, Lensing SY, Dennis RA, Bopp MM, Roberson PK, et al. Home-Based Exercise Program Improves Balance and Fear of Falling in Community-Dwelling Older Adults with Mild Alzheimer's Disease: A Pilot Study. J Alzheimers Dis 2017;59(2):565-574. [CrossRef] [Medline]
  72. Schwenk M, Sabbagh M, Lin I, Morgan P, Grewal GS, Mohler J, et al. Sensor-based balance training with motion feedback in people with mild cognitive impairment. J Rehabil Res Dev 2016;53(6):945-958 [FREE Full text] [CrossRef] [Medline]
  73. Manera V, Ben-Sadoun G, Aalbers T, Agopyan H, Askenazy F, Benoit M, et al. Recommendations for the Use of Serious Games in Neurodegenerative Disorders: 2016 Delphi Panel. Front Psychol 2017 Jul 25;8:1243. [CrossRef] [Medline]
  74. Toots A, Littbrand H, Holmberg H, Nordström P, Lundin-Olsson L, Gustafson Y, et al. Walking Aids Moderate Exercise Effects on Gait Speed in People With Dementia: A Randomized Controlled Trial. J Am Med Dir Assoc 2017 Mar 01;18(3):227-233 [FREE Full text] [CrossRef] [Medline]
  75. World Health Organization. 2017. Rehabilitation 2030: A call for action   URL: [accessed 2019-12-31]
  76. Garcia JA, Schoene D, Lord SR, Delbaere K, Valenzuela T, Navarro KF. A Bespoke Kinect Stepping Exergame for Improving Physical and Cognitive Function in Older People: A Pilot Study. Games Health J 2016 Dec;5(6):382-388. [CrossRef] [Medline]
  77. van Diest M, Stegenga J, Wörtche HJ, Verkerke GJ, Postema K, Lamoth CJC. Exergames for unsupervised balance training at home: A pilot study in healthy older adults. Gait Posture 2016 Feb;44:161-167. [CrossRef] [Medline]
  78. Wilson BA. Towards a comprehensive model of cognitive rehabilitation. Neuropsych Rehab 2002 Mar;12(2):97-110. [CrossRef]
  79. Kasper E, Ochmann S, Hoffmann W, Schneider W, Cavedo E, Hampel H, et al. Cognitive Rehabilitation in Alzheimer's Disease - A Conceptual and Methodological Review. J Prev Alzheimers Dis 2015;2(2):142-152. [CrossRef] [Medline]
  80. Hughes TF, Flatt JD, Fu B, Butters MA, Chang CH, Ganguli M. Interactive video gaming compared with health education in older adults with mild cognitive impairment: a feasibility study. Int J Geriatr Psychiatry 2014 Sep;29(9):890-898 [FREE Full text] [CrossRef] [Medline]
  81. Arrighi HM, Gélinas I, McLaughlin TP, Buchanan J, Gauthier S. Longitudinal changes in functional disability in Alzheimer's disease patients. Int Psychogeriatr 2013 Jun;25(6):929-937. [CrossRef] [Medline]
  82. Abellan van Kan G, Rolland Y, Andrieu S, Bauer J, Beauchet O, Bonnefoy M, et al. Gait speed at usual pace as a predictor of adverse outcomes in community-dwelling older people an International Academy on Nutrition and Aging (IANA) Task Force. J Nutr Health Aging 2009 Dec;13(10):881-889. [CrossRef] [Medline]
  83. Studenski S, Perera S, Patel K, Rosano C, Faulkner K, Inzitari M, et al. Gait speed and survival in older adults. JAMA 2011 Jan 05;305(1):50-58 [FREE Full text] [CrossRef] [Medline]
  84. Taekema DG, Gussekloo J, Westendorp RGJ, de Craen AJM, Maier AB. Predicting survival in oldest old people. Am J Med 2012 Dec;125(12):1188-1194. [CrossRef] [Medline]
  85. Formiga F, Ferrer A, Padros G, Montero A, Gimenez-Argente C, Corbella X. Evidence of functional declining and global comorbidity measured at baseline proved to be the strongest predictors for long-term death in elderly community residents aged 85 years: a 5-year follow-up evaluation, the OCTABAIX study. Clin Interv Aging 2016;11:437-444. [CrossRef] [Medline]
  86. Mathieson K. Predicting User Intentions: Comparing the Technology Acceptance Model with the Theory of Planned Behavior. Inform Syst Res 1991 Sep;2(3):173-191. [CrossRef]
  87. Manera V, Abrahams S, Agüera-Ortiz L, Bremond F, David R, Fairchild K, et al. Recommendations for the Nonpharmacological Treatment of Apathy in Brain Disorders. Am J Geriatr Psychiatry 2020 Apr;28(4):410-420. [CrossRef] [Medline]
  88. Law C, Lam FM, Chung RC, Pang MY. Physical exercise attenuates cognitive decline and reduces behavioural problems in people with mild cognitive impairment and dementia: a systematic review. J Physiother 2020 Jan;66(1):9-18 [FREE Full text] [CrossRef] [Medline]
  89. Belza B, Walwick J, Shiu-Thornton S, Schwartz S, Taylor M, LoGerfo J. Older adult perspectives on physical activity and exercise: voices from multiple cultures. Prev Chronic Dis 2004 Oct;1(4):A09 [FREE Full text] [Medline]
  90. Saposnik G, Levin M. Virtual Reality in Stroke Rehabilitation. Stroke 2011 May;42(5):1380-1386. [CrossRef]

BBS: Berg Balance Scale
CENTRAL: Cochrane Central Register of Controlled Trials
PRISMA: Preferred Reporting Items of Systematic Reviews and Meta-Analyses
RCT: randomized controlled trial
ROBINS-I: Risk of Bias in Non-randomized Studies of Interventions

Edited by G Eysenbach; submitted 30.10.19; peer-reviewed by E Dove, P Robert, X Yu; comments to author 11.12.19; revised version received 19.02.20; accepted 12.04.20; published 30.06.20


©Yinan Zhao, Hui Feng, Xinyin Wu, Yan Du, Xiufen Yang, Mingyue Hu, Hongting Ning, Lulu Liao, Huijing Chen, Yishan Zhao. Originally published in JMIR Serious Games (, 30.06.2020.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.