|Year : 2022 | Volume
| Issue : 2 | Page : 66-74
Exergaming as a mental health intervention in the elderly: A clinical review
Ishita Bhattacharya1, Divya Ambetkar1, Vishakha Patil2, Avinash De Sousa3, Sagar Karia3
1 Independent Research Scholar and Psychologist, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
2 Department of Physiotherapy, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
3 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
|Date of Submission||18-Apr-2022|
|Date of Decision||20-Oct-2022|
|Date of Acceptance||19-Nov-2022|
|Date of Web Publication||20-Jan-2023|
Dr. Avinash De Sousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
Source of Support: None, Conflict of Interest: None
Exergames is a new arena of mental health intervention in the elderly. The present article is a clinical review on various areas where exergaming has been used to enhance mental health in the elderly. The review looks at the use of exergames in dementia, geriatric depression, as a tool for movement and to improve memory and cognition. The role of exergames in improving intellectual function, instability and falls in the elderly is also discussed. The role of exergames to improve fragility is mentioned. The review looks at the advantages and disadvantages of exergames in the elderly and the limitations of various studies done so far from a clinical and scientific rigor standpoint. The future research needs are also discussed. Exergames is a mental health intervention area in geriatric mental health that will be used more in the years to come.
Keywords: Depression, elderly, exergames, mental health
|How to cite this article:|
Bhattacharya I, Ambetkar D, Patil V, De Sousa A, Karia S. Exergaming as a mental health intervention in the elderly: A clinical review. J Geriatr Ment Health 2022;9:66-74
|How to cite this URL:|
Bhattacharya I, Ambetkar D, Patil V, De Sousa A, Karia S. Exergaming as a mental health intervention in the elderly: A clinical review. J Geriatr Ment Health [serial online] 2022 [cited 2023 Feb 5];9:66-74. Available from: https://www.jgmh.org/text.asp?2022/9/2/66/368292
| Introduction|| |
Exergames or gamercising is a portmanteau of the words exercise and gaming. It refers to video games that combine exercising with game skills. Exergames have been found to promote physical activity and well-being in several demographics, particularly where mainstream exercise is not a valid option. One demography that can benefit from the introduction of exergames is that of the elderly. India's elderly population is expected to increase by 41% by 2031. While the availability of better health care has allowed people to live longer lives, their quality of life also needs to be maintained. The typical aging body has trouble keeping up with the demands of mainstream exercising because factors such as pain, fatigue, physical illness, and disability can act as barriers to engaging in physical activities. Exergames have been used to facilitate physical activity with other demographic categories that are unable to engage in mainstream exercise such as children with cerebral palsy among other demographies., Therefore, exergaming is an exciting avenue to venture into geriatric health.
| Types of Exergames|| |
The 1982 Atari Joy board is widely considered the first real voyage into exergaming, it consisted of a balance board controller which mimicked slalom skiing. Since then a variety of exergames have come into existence, with the goal of making exercise more accessible and enjoyable. The three most common exergames and exergaming platforms that were used as interventions in the studies reviewed were Wii/Wii-Fit, Kinect, and Dance Dance Revolution (DDR). Many other studies came up with novel exergames to tackle-specific problems faced by the elderly and make their gaming experience more pleasant and beneficial.
One of the most popular exergame platforms is Nintendo Wii, which is a home video game console. It utilizes the Wii remote, a wireless remote controller for motor sensing as well as a traditional controller. The Wii-Fit boasts of yoga, bowling, aerobics, and balance exergames meant to be used alongside a Wii balance board accessory that tracks the user center of balance.
Kinect for Xbox developed by Microsoft is another popular exergaming platform that was launched in 2010. It is a motion-sensing input device that allows people to interact with the user interface by tracking body movements.
DDR is a music video game by Komani that was first introduced in 1998. It combines catchy music with rhythmic movements and physical exercise. The game setup consists of a screen, loudspeakers, and a gamepad where arrows meant to guide the players appear.
| Methodology|| |
A search for appropriate literature was undertaken from major bibliographic electronic research databases such as Google Scholar, PubMed, and PsycInfo among others. Potential papers from 2010 to 2021 were detected by combining words related to the age of the participants such as “geriatric” or “elderly;” with terms alluding to the kind of strategies employed such as “exergaming” or “active video gaming” or “gamercising;” finally, words related to specific problems associated with aging such as “dementia,” “frailty,” 'immobility,” “instability,” “geriatric depression,” and “impaired intellect” were added to ensure a variety of conditions were incorporated. Some papers were also located manually by going through the references of relevant papers.
Once all relevant studies were identified, the topics and names of authors and date of publication were examined to ensure that no duplication had taken place. Only studies where the participants were 65 years or older were retained, the participants could vary along the lines of gender, nationality, race, and both mental and physical health. There are multiple ways to classify older adults, the most common way prescribes classifying people aged 65–74 years as young-old, 75–84 years as middle-old, and people aged 85 years and above as the oldest old. Systematic reviews were not reviewed again and studies that utilized mobile health applications to promote well-being in the elderly were also discarded. Studies employing commercial exergames and those that were carried out with the intention to develop novel exergames suited to the needs of the elderly were analyzed. Of the total 50 identified records, only 35 were actually reviewed [Table 1], [Figure 1].
| Exergames and Their Use in Dementia|| |
Due to the rapid aging of society, it is inevitable that specific attention will need to be paid to age-related diseases. Dementia is one of the most extensive reasons for disability in the elderly. While there is no treatment available that can cure or reverse the progression of this disease, interventions can be employed to assist with symptom control, alleviate suffering and promote a better standard of living. Cohen et al. found that a game specifically designed for patients with Alzheimer's had a positive impact on their interest, satisfaction, and overall quality of life. A 2011 study used Hasegawa's Dementia Scale-revised to understand the mental status of individuals with Alzheimer's, the Multidimensional Observation Scale for Elderly Subjects to evaluate behavioral changes, and Kohs block-design tests (Kohs) to examine visuospatial and constructive function in elderly individuals with dementia. An improvement was noted in all three dimensions after regular use of exergames. Concerns that the elderly living with dementia would not be able to shift to a new technology were put to rest when a study found that people living with dementia were able to understand and successfully engage with the scenarios in the exergame in question. The participants also indicated that they enjoyed playing the virtual reality exergame and were motivated to continue exercising with the exergame while they typically gave up when they reached that point of physical activity with traditional exercise. Another study noted an improvement in the sense of security and self-confidence of the elderly with dementia after the introduction of an exergame. Some of them were able to re-establish daily activities that they had given up on. Playing exergames in a group setting enabled greater communication and establishment of new relationships as well as an increase in a general sense of well-being and enabled people with dementia to age with dignity. Task-specific improvements were noted after a short period of training suggesting that the correct usage of motor-cognitive exergames can elicit a positive response in the elderly with dementia.
| Exergames and their Use in Geriatric Depression|| |
Exergaming was found to be a viable intervention among older adults with subsyndromal depression. Retention, adherence, mental health-related quality of life, cognitive functioning, and depressive symptoms were found to significantly improve amongst community-dwelling older adults with subsyndromal depression as a result of exergaming. Similar results were found in a quasi-experimental study where one group of older adults received Wii-Fit exergame training while the other received a health education program on self-efficacy theory. Significant improvements in depressive symptoms, mobility, balance, and mental health-related quality of life were found as a result of exergame training. Among elderly women with osteoarthritis, exergaming was found to relieve symptoms of mild depression and improve quality of life. Exergames were found to elicit higher positive emotions than traditional exercise. These positive emotions, in turn, improve symptoms of subthreshold depression among older adults. Dance exergames performed on unstable ground with visual perturbations were found to decrease depressive symptoms in elderly fallers among community-dwelling elderly women.
| Exergames and Their Use in Other Geriatric Conditions|| |
In 1976, Bernard Isaacs coined the term “Geriatric Giants” to describe the chronic ailments of old age: immobility, instability, incontinence, and impaired intellect. Improper management of these symptoms often leads to poor outcomes and contributes to earlier mortality.
| Immobility|| |
While short periods of bed rest can be beneficial for the health of the elderly, long-term immobility can lead to functional decline and lowered quality of life. Exergame training can prove to be a sustainable alternative to home exercise training. It was found to significantly improve functional mobility, balance, and quality of life among geriatrics in a training period as short as 6 weeks. Exercising through virtual reality exergames was found to positively influence short-term memory and mobility in institutionalized older adults. An iPad-based neuroexergame was found to be beneficial for the executive functioning of elderly individuals with mild cognitive impairment.
| Instability|| |
Instability and falls in the elderly are common effects of declining mobility as well as the cause of it. Falls are a major health concern in adults over the age of 70 years because fall-related complications increase with age, falls are also linked to increased morbidity and mortality. One of the primary reasons behind falls in older adults is impaired standing balance due to the deterioration of the underlying vestibular system, vision, and proprioception systems. Our nervous system engages in sensory reweighting, i.e., it prefers reliable sensory information over unreliable information during balance; older adults experience difficulty in switching between these systems. The functional capacities of the elderly that suffered from minor injuries were found to be comparable regardless of whether they received community-based exercise or through home-based exergaming, thereby making exergames a viable alternative to community-based exercising. Exergames that require head movements while the vision is held steady at one point can function as vestibulo-ocular reflex training and improve sensory reweighting. Virtual reality-based exergaming was found to have a better clinical influence on postural balance in older women than traditional strength and balance training. An improvement in the balance of older veterans with mild to moderate balance problems was noted when they participated in a Wii-Fit interactive video-game-led physical exercise program. The balance among most of the elderly population was found to be improved as a result of exergaming.
Exergaming was found to contribute to the prevention of falls by safely improving motor functions by providing appropriate exercise intensity. A 2020 study utilizing a novel exergaming mat system found that the exergame in question not only increased the dual-task ability of walking but also reduced fall risk, thereby making it a suitable alternative to traditional exercise programs. Motor functions such as lower limb muscle strength, balance, and walking were found to improve as a result of exergaming. Merely 12 weeks of video games-based physical training was found to improve postural control, cardiovascular endurance, functional fitness or lower limb strength, and motor agility amongst older adults. A 2020 study found that exergames have the potential to reduce pain and improve balance in the elderly with chronic musculoskeletal pain, thereby mitigating their fall risk.
| Impaired Intellect|| |
Exergaming can function as a dual-task activity that stimulates different brain regions which has a greater influence on cognition than multicomponent exercise. Mental health, narrow walk-time, and self-reported balance confidence of older adults improved as a result of interactive dance video games. Adding a cognitive element adds to the benefits of computer-based motor interventions aimed at improving foot placement and gait among older adults.
The virtual-reality enhanced exercise proved advantageous not only for physical health but also to the cognitive functioning of older adults. Executive functioning of older adults was found to improve as a result of engagement in virtual reality-enhanced cyber-cycling over a span of 3 months. Moreover, cyber-cycling also reduced the progression of mild cognitive impairment. Furthermore, the cognitive benefit of exergaming was found to have a direct relationship with the difficulty of the tasks involved, with the benefits increasing as the difficulty levels increase. These findings have significant implications in the realm of healthy aging.
| Exergames and their Use in Fragility Management|| |
Unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low walking speed, and low physical activity are the phenotypes of frailty. Frail older adults have a high chance of becoming physically dependent and therefore experience a decrease in quality of life. Both multi-component exercise regimes as well exercising through exergame were found to be delay frailty status, allowing the elderly to remain physically independent for longer. Kinect-based exergames were found to be beneficial in the reversal of three of the 5 frailty phenotype, namely weakness, slow walking speed, and low activity level. Exergames were also found to significantly reduce exhaustion, unlike combined exercise.
| Advantages of Exergames as Therapy|| |
According to the model proposed by Lieberman et al., exergaming improves health and reduces health-care costs by positively impacting the following four factors: (a) self-concept: by reducing the stigma; (b) self-efficacy: by improving motivation and confidence; (c) physical skills and wellness: by improving body image; and (d) communication and social support by encouraging engagement. According to the 2007 National Health Interview Survey from the Centers for Disease Control and Prevention Healthy People 2010 Database, only 14% of adults aged 65–74 years old and 7% over 75 years of age reported regular exercise. Exergames have been found to show great promise in facilitating adherence to exercise in elderly in-home rehabilitation settings. Individuals using conventional exercise were found to express frustration while those engaging in exergaming expressed enthusiasm.
A study conducted on adults aged 70–97 found that they are open to using technology-based exercise programs at home especially because it reduced problems that they typically faced during mainstream excising such as lack of time, inability to travel, dislike for exercising in public, and group setting as well as financial constraints. A 2021 study aimed to co-design a bowling-based exergame tailored to the requirements of elderly players found that the exergame not only enhances adherence and motivation but also positively influences the general fitness of the participants. This study also concluded that older people performed better and showed greater improvement in general fitness when they played with peers.
Exergaming has significant implications in terms of aging. Exergames were found to promote healthy and active aging by positively impacting inter-generational perception and psychosocial well-being. Reduced loneliness and increased sociability help older adults in building and maintaining strong social relationships. Xu et al. conducted a mixed quasi-experimental study where young-old participants (aged 74 or below) and old-old participants (aged 75 or above) played exergames either alone or with adolescents or with their peers and found a significant decrease in social anxiousness and a significant increase in sociability amongst the young-old participants who played exergames with adolescents. On the other hand, sociability among old-old participants significantly improved as a result of exergaming with their peers. These findings can help aid interventions aimed at fostering social interaction amongst older adults. In addition to this, exergaming can function as a dual-task activity that stimulates different brain regions which has a greater influence on cognition than multicomponent exercise.
| Disadvantages of Exergames as Therapy|| |
An experimental study conducted in 2015 studied how gaming technology can be used as an effective balance tool for the elderly. This study found that commercially available video games are not ideal for balance training for older adults and therefore there is a need for specifically targeted video games that are sympathetic to the limitations of the dexterity and movement of the elderly.
User limitations such as arthritis, osteoporosis, and other skeletomuscular disruptions that limit mobility should be studied to prevent them from becoming barriers to exergaming.
Technical glitches during the game such as incorrect movement detection, unstable internet connection can prove to be extremely frustrating, especially for the elderly, and are a huge threat to the usability of the exergames as a replacement for supervised practice.
Limitations of the studies done so far
One of the primary limitations encountered during this review has been poor validation. Poor validation of the data has been a recurring theme across the studies reviewed in this article. Poor validation is reflected in the small sample size. Of the studies reviewed in this paper, the sample size ranged between 6 and 110.
Apart from small sample size, the research done so far has mostly studied the young-old population aged between 65 and 74 years old. Very few researchers have studied the influence of exergaming on the old-old population aged 75 and above.
Another issue with the research done so far is the lack of long-term or longitudinal studies.
Future research should address these limitations to bridge the research gap.
| Future Research Needed|| |
While the elderly benefit from exergaming, most of the commercially available exergames are not appropriate for them (Da Silva Júnior J, 2021), future research should focus on catering to the specific needs of the elderly population. The elderly, their relatives, and even experienced therapists prefer games with content that is related to the everyday life of the elderly because a point of connection between the elderly and the game content can increase the level of interest they experience and ultimately leads to better adherence. Fast-paced, reflex-oriented games depicting violence were disliked by the elderly, exergames can be used in place of traditional exercise when they are designed while being aware of the age-related needs and limitations of the elderly. Exergames can be well received by the elderly if they are tailored to the specific needs of the elderly and sufficient attention is paid to mitigating the barriers to future participation.
Exergames that target the elderly should be adjusted according to the needs of the elderly gamers, for instance, the deteriorating eyesight of the elderly should be taken into account, and graphics employed in the games should be bold, bright, and devoid of too many tiny details. The elderly might experience difficulty interacting with and navigating through the game without external help; therefore, it is important to include clear and simple in-game instructions to help them transition smoothly into the game. The text should be avoided as much as possible but if it is absolutely necessary then the font should be large and it should be accompanied by oral feedback. Motivation to adhere to an exergame-based regime increases if the games in question have a simple user-friendly interface, clear feedback, and a gradual increase in the level of difficulty of the game.
More research should also be focused on using exergames as a supplementary tool used alongside traditional physical therapy rather than attempting to replace it altogether. Both multicomponent exercise regimes as well exercising through exergame were found to be delay frailty status, allowing the elderly to remain physically independent for longer. However, exergaming can function as a dual-task activity that stimulates different brain regions which has a greater influence on cognition than multicomponent exercise. A hybrid approach combining the social and motivational benefits of using commercially available exergames and the physical benefits of supervised mainstream exercise to maximize the benefit received by the elderly. The use of exergaming technology in conjunction with physical activity is a feasible and effective strategy to not only promote upper body agility and promote overall health but also to prevent deterioration in older adults. Asynchronous games where physical exercise and cognitive gameplay do not occur at the same time can help enhance both cognitive and physical abilities while allowing the elderly to participate in exercise at a pace most comfortable to them.
| Conclusions|| |
Exergaming can prove to be a viable alternative to traditional home and physical exercise therapies because of two key elements: (a) the wide scope and applicability across a plethora of geriatric conditions; (b) additional social and cognitive benefits offered by exergaming. However, in order to make the best of the exergaming, issues such as data validation and user limitations should be tackled.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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