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Floor view of people playing a dancing exergame
Image Credits: BeFitt (CC BY-NC-ND 2.0)

The Effects of Exergaming on Cognitive Decline in Older Adults: A Systematic Review

Abstract 

The overwhelming majority of research has shown that physical exercise benefits the physical and mental well-being of older adults. However, with the increasing risk of Alzheimer’s disease and other neurodegenerative diseases in older adults in the U.S., alternative methods of preventing further cognitive decline have become a topic of interest [1]. Exergaming, a form of exercise that combines physical exercise with mental stimulation, has been shown to improve the cognitive function of older adults [3, 4, 6-10]. However, the methods of analyzing the specific cognitive benefits of exergames and their further implications have been widely varied [3, 4, 6-10]. Thus, this review not only identifies trends within the methods but also communicates the implications for future studies. The results of this review point to the need for more standardized practices of measuring the cognitive benefits of exergames in older adults. 

Introduction 

As the U.S. population continues to age, the cognitive decline in older populations becomes a problem of imminent concern. According to the U.S. Census Bureau, between 1990-2020, the U.S. population aged 65 and older has grown nearly five times faster than the total population [1]. The amount of people with age-associated neurodegenerative dementias is also increasing rapidly [2]. For example, the number of people diagnosed with Alzheimer’s disease is projected to increase to 13.8 million people by 2050 [2].  Cognitive decline in older adults is of particular concern because it limits their ability to complete dual tasks. Dual tasks demand the simultaneous coordination of physical movements and cognitive activities (such as talking while walking) and their impairment contributes to dangers including increased risk of falling [3]. Therefore, it is imperative that treatments and prevention strategies are developed. While it has been well-documented that physical exercise has a positive effect on the well-being of older adults by preventing cognitive decline, reducing depression, and supporting mental health [4], a fairly new form of exercise that combines both physical exercise and cognitive ability called exergaming has arisen in recent years [3]. One example of an exergame is Dance Dance Revolution, where participants move their feet to press on arrows located on a touch-sensitive platform (physical exercise) following directions on a screen (cognitive ability). There are various forms of exergames, but the one thing they all have in common is the combination of “game-like” mental stimulation and physical activity [2-10]. This literature review examines the different methods used in research studies that analyze the effects of exergaming on cognitive function in older adults and discusses future implications in preventing cognitive decline.

Methods of Analyzing the Cognitive Effects of Exergaming on Older Adults 

Most of the current research compares physical exercise to exergames to analyze the cognitive effects of exergaming on older adults. Yet, another research method compares one form of an exergame to another to analyze the unique cognitive benefits certain exergames may present. While there is a clear cognitive benefit from exergames, the specificities of such benefits are less defined. Because there is a lack of standardization in the methods performed, there are varying results and types of cognitive benefits found. The importance of looking at the methods used to conduct such studies can be seen when examining the implications of the results.

Figure 1
Figure 1: EMAT Exergaming Focused on Incorporating Diverse Muscular Strength, Aerobics, and Balance with Mat Interaction. Image Credits: Peng, Tien, Lin, Peng and Song (CC BY 4.0)

Studies that focus on the cognitive effects of physical exercise compared to exergaming [3, 5-8] are of particular interest when examining whether exergaming presents a unique benefit over physical exercise. However, there is not a universal form of physical exercise researchers use as their basis of comparison, making it difficult to determine whether exergaming has universal benefits over physical exercise. One study compared participants in dance-based, static balance (eg. standing) and dynamic balance (eg. walking) exercises to a group that participated in ladder-type, three-by-three grid-type, and circle-type mat exergames with simultaneous cognitive physical training (EMAT) [7]. The EMAT exergame participants completed three types of exergames that worked to incorporate diverse muscular strength, aerobics, and balance training movement with mat interaction [7].

In contrast, another study looked at a group of older adults that participated in traditional versus exergame versions of Tai Chi. The exergame version involved a Kinect system to capture the movements of the participants while they imitated a virtual Tai Chi coach and responded to their movements with instant feedback [6]. These differences in methods comparing physical exercises to exergames show that the field lacks standardization for evaluating the cognitive effect of exergames. 

This lack of standardization is further illustrated by several other studies that looked at one form of exergame compared to another to analyze their cognitive benefits [9, 10]. One study compares a balance exergame to a puzzle exergame [9]; another study evaluates a balance exergame against a dance exergame [10]. These studies help clarify whether one exergame has more of a benefit to the cognitive function of older adults over another exergame. However, a clear trend in the types of compared exergames has not been determined, which further exemplifies the large differences in methods used to evaluate the cognitive benefits of exergames. 

The lack of standardization of the methods used to evaluate the cognitive benefits of exergames makes it difficult to gain insight from the results of such studies. The first method utilizes a comparison of physical exercise to exergames, while the second general method compares different exergames to each other to observe cognitive benefits. Although both results show a positive cognitive benefit of exergaming on the participants, they present different findings based on their methods. If there was greater consistency with the methods used, this would allow researchers to better understand and tailor exergames to target specific aspects of improvement in cognitive function for older adults, such as those that target the ability to do dual-task walking. However, due to the lack of standardization of methods this has led to a scattered array of findings for future improved aspects of cognitive function. 

Aspects of Improved Cognitive Function as a Result of Exergaming

All peer-reviewed research studies examined showed there was some cognitive benefit of older adults using exergames [3, 5-10]. However, because multiple types of tests were used to evaluate various aspects of older adult cognitive function, it is difficult to quantify such results. 

Some studies found that exergaming improved executive function and led to greater activation of the prefrontal cortex (PFC) [3, 10]. Others found that global (overall) cognitive function was improved in older adults as a result of exergaming [3, 6]. Typically, studies that looked at global cognitive function utilized the Montreal Cognitive Assessment (MoCA) which validates a trend in standardization between studies using this method [3, 6, 7]. However, studies that focused on the improvement of executive function in older adults after participating in an exergaming intervention [3, 5, 8, 10] used multiple different types of tests to evaluate this aspect of cognitive function. Executive function, as opposed to global cognitive function, is a domain-specific area of cognition and refers to the ability to plan and execute goal-directed behaviors, abstract reasoning, and judgment [11]. Even a slight impairment in executive function can affect the ability of an individual to perform Instrumental Activities of Daily Living (IADL) and can impact quality of life [11]. There seemed to be the most variance among the tests evaluating this domain-specific function, with some using the Stroop Colour and Word Test (SCWT) in combination with the Trail Making Test [3], the Eriksen flanker test, and an electroencephalogram (EEG) scan [8]. Other studies used a combination of the SCWT, the N-back test, and the backward digit span to evaluate improvements in executive function [5]. Variance can also be seen in what test was used to evaluate each aspect of cognitive function, as the SCWT was used in some studies to evaluate executive function [3, 4] while in another study it was used as a way to evaluate global cognitive function [6]. However, there seems to be some standardization in tests used to evaluate certain aspects of improved cognitive function, and specifically the MoCA test has been used most universally [3, 6, 7].

Figure 2
Figure 2: Improved Aspects of Exergaming Leading to a Higher Quality of Life

The types of tests used to measure and evaluate improvements in cognitive function in older adults are varied. Nevertheless, the benefits of exergames can be seen in global cognitive function and executive function for older adults to reduce fall risk and perform daily activities. Therefore, although a lack of standardization can make it difficult to quantify such results, there is evidence from the vast array of tests that exergames can present unique cognitive benefits to improve the overall quality of life of older adults. Knowledge of these benefits can then be used to guide areas of future exergame research and to implement exergames that target and slow the decline of specific cognitive functions. 

Future Directions in the Field of Exergaming 

Many studies point to exergaming as an alternative way to help prevent cognitive decline in older adults as well as aspects of executive function and dual-task walking [3, 5-10]. Exergaming has been shown to improve overall cognitive function, aspects of executive function, and dual-task walking. However, there are varied conclusions about how such improvements can positively impact older adults in the future. 

Some studies state that exergames have a positive effect in preventing fall risk in older adults [6, 9]. One study found that changes to the PFC included bilateral reduction in prefrontal brain activity, an increase in hemispheric PFC activity asymmetry, and an increase in differentiation of PFC related to walking speed. These activities were more similar to those of young adult brain functions and were correlated with improved performance in executive function and processing speed [9]. They concluded that older adults may benefit from such additional cognitive resources by allowing them to focus their attention on other processes while walking, thus reducing their fall risk. Another study found older adults that participated in exergaming exhibited improvements in executive function and gait speed during cognitive dual-task walking [6]. This further points to decreases in risk of falling among older adults as studies have shown that declines in gait control speed and variability in dual-task walking contribute to a higher risk of falling in older adults who have mild cognitive impairment [6]. While there are some differences in the conclusions the studies have drawn, their focus on the role of exergames in PFC activation and executive function, as well as physical activity, exhibits the need for future studies to explore the impacts of exergames on walking and the risk of falling in older adults.

In contrast, some studies focus solely on the improved cognitive function of older adults using exergames [3, 6]. One study looked at the same game content for exergame training against video game training (which lacks the physical component of exergaming) and found older adults who participated in the exergame training group exhibited greater benefits in learning and memory [3]. As such, they point to possible future research into how specific exergames can be designed to ameliorate the cognitive function of both healthy older adults and those with neurodegenerative disease [3]. Additionally, another study looking at the blood flow patterns associated with exergames found that those who participated in the exergame group showed decreased hemodynamic responses in the PFC [6]. This could be interpreted as improved neural efficiency in that a lower amount of energy may be needed in the PFC to more effectively perform the same cognitive task after an exergame intervention [6]. These studies have shown that there are a variety of avenues for future research into how exergames can benefit cognitive function. Future studies should examine the mechanisms by which exergames impact neural efficiency in older adults.

Figure 3
Figure 3: Differing Directions of Study Leading to Varied Conclusions for Future Research

While most studies generally align with the notion of increased cognitive function in older adults who use exergames, there are varied conclusions on the directions of future research. Depending on the study performed and the conclusions drawn, future research will likely explore the impacts of exergames on dual-task walking activities to decrease fall risk and evaluate the cognitive benefits of more specifically designed exergames on older populations.

Conclusion 

Overall, while this literature review has elucidated that there is a general consensus that exergames have benefits on the cognitive function of older adults, it also exemplifies the lack of standardization in the field of exergame research which impacts the direction of future studies. It is clear that to quantify the specific benefits of exergames on the treatment or prevention of cognitive decline in older adults, future studies should utilize similar treatments and tests to obtain a larger sample of data. This data can then be analyzed and applied to wider communities. In turn, this will hopefully allow for greater insight into how the cognitive decline of older adults can be mitigated through the engagement of both physical and cognitive abilities via more specially tailored exergames.

Author's Note

Cognitive health, especially in older adults, is a topic that is very meaningful to me. As someone who has had grandparents and family that have experienced Alzheimer’s and Dementia, I was interested in learning about ways in which the physical and mental health of older adults could be improved through exercise. Thus, in my research of this topic, I came across the new and upcoming field of exergaming. I hope to spread awareness of exergaming and how it can be more widely used to improve the cognitive function and memory of older adults.  

References

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7. Peng HT, Tien CW, Lin PS, Peng HY, Song CY. Novel mat exergaming to improve the physical performance, cognitive function, and dual-task walking and decrease the fall risk of community-dwelling older adults. Frontiers in Psychology. 2020;11. doi:https://doi.org/10.3389/fpsyg.2020.01620 

8. Wu S, Ji H, Won J, Jo EA, Kim YS, Park JJ. The effects of exergaming on executive and physical functions in older adults with dementia: Randomized controlled trial. 2023;25:e39993-e39993. doi:https://doi.org/10.2196/39993 

9. Müller H, Baumeister J, Ellen Marie Bardal, Beatrix Vereijken, Skjæret-Maroni N. Exergaming in older adults: The effects of game characteristics on brain activity and physical activity. Frontiers in Aging Neuroscience. 2023;15. doi:https://doi.org/10.3389/fnagi.2023.1143859

10. Eggenberger P, Wolf M, Schumann M, de Bruin ED. Exergame and balance training modulate prefrontal brain activity during walking and enhance executive function in older adults. Frontiers in Aging Neuroscience. 2016;8. doi:https://doi.org/10.3389/fnagi.2016.00066 

11. Johnson, Julene K, et al. “Executive Function, More than Global Cognition, Predicts Functional Decline and Mortality in Elderly Women.” The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, U.S. National Library of Medicine, Oct. 2007, www.ncbi.nlm.nih.gov/pmc/articles/PMC2049089/. 

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