Integrating Virtual Reality in Cognitive Training of Older Adults

Without Cognitive Impairment: A Systematic Review of Randomized

Controlled Trials

João Pavão

, Rute Bastardo

and Nelson Pacheco Rocha

INESC-TEC, Science and Technology School, University of Trás-os-Montes and Alto Douro, Vila Real, Portugal

UNIDCOM, Science and Technology School, University of Trás-os-Montes and Alto Douro, Vila Real, Portugal

IEETA, Department of Medical Sciences, University of Aveiro, Aveiro, Portugal

Keywords: Systematic Review, Randomized Controlled Trials, Older Adults, Cognitive Training, Virtual Reality.

Abstract: This article aimed to analyse state-of-the-art empirical evidence of randomized controlled trials designed to

assess preventive cognitive training interventions based on virtual reality for older adults without cognitive

impairment, by identifying virtual reality setups and tasks, clinical outcomes and respective measurement

instruments, and positive effects on outcome parameters. A systematic electronic search was performed, and

six randomized controlled trials were included in the systematic review. In terms of results, the included

studies pointed to significant positive impact of virtual reality-based cognitive training interventions on global

cognition, memory, attention, information processing speed, walking variability, balance, muscle strength,

and falls. However, further research is required to evaluate the adequacy of the virtual reality setups and tasks,

to study the impact of the interventions’ duration and intensity, to understand how to tailor the interventions

to the characteristics and needs of the individuals, and to compare face-to-face to remote interventions.

1 INTRODUCTION

The increase in life expectancy and population aging

have raised the prevalence of neurodegenerative

diseases, which represent a major threat to human

health (Constanzo et al., 2020; Lanctôt et al., 2023).

Considering all major groups of diseases, the diseases

of the nervous system have the greatest contribution

to the global impact on the health of populations

worldwide and are responsible for high disability

rates and global burden of disease (Cicerone et al.,

2011).

Mild cognitive impairment, an intermediate stage

between normal aging and dementia (Geda, 2012), is

characterized by an objective cognitive decline in one

or more cognitive domains (e.g., memory, attention,

information processing speed, executive functions, or

language) without any significant impairment in daily

activities and may be associated with a variety of

underlying causes, including dementia (Geda, 2012;

https://orcid.org/0000-0001-9042-2730

https://orcid.org/0000-0002-3207-3445

https://orcid.org/0000-0003-3801-7249

Constanzo et al., 2020). Dementia is a major

neurocognitive disorder that is characterized by a

cognitive decline in one or more cognitive domains in

such an extent that interferes with the individual’s

independence in daily activities (American

Psychiatric Association, 2013). Alzheimer disease is

the most common form of dementia worldwide, and

estimations pointed that in 2010 it affected more than

36 million people (Prince et al., 2015). Moreover, this

number might double every 20 years to 66 million by

2030 and to 115 million by 2050 (Prince et al., 2015;

Constanzo et al., 2020).

Patients with dementia constitute a burden for

society, not only in terms of their quality of life and

the quality of life of their relatives and caregivers, but

also in terms of the costs of healthcare and social care

systems (Cruz et al., 2013; Chiao, Wu & Hsiao, 2015;

Watson, Tatangelo & McCabe, 2019; Constanzo et

al., 2020). Therefore, efficient approaches to deal

with the needs of an increasing number of patients are

required (Constanzo et al., 2020).

258

Pavão, J., Bastardo, R. and Rocha, N.

Integrating Vir tual Reality in Cognitive Training of Older Adults Without Cognitive Impairment: A Systematic Review of Randomized Controlled Trials.

DOI: 10.5220/0012710500003699

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 10th International Conference on Information and Communication Technologies for Ageing Well and e-Health (ICT4AWE 2024), pages 258-266

ISBN: 978-989-758-700-9; ISSN: 2184-4984

Since epidemiological studies identified several

modifiable risk factors for dementia (e.g., diabetes,

hypertension, hypercholesterolemia, depression,

physical frailty, unhealthy dietary habits, smoking,

excessive alcohol consumption, low education, or

low social support level) (World Health Organization,

2019; Solomen et al., 2021), healthier lifestyles might

decrease dementia incidence and be translated into

individual and societal benefit (Altomare et al.,

2021).

In this respect, the World Health Organization

considered dementia prevention a public health

priority (Solomen et al., 2021) and published, in

2019, the first guidelines for risk reduction of

cognitive decline and dementia (World Health

Organization, 2019). These guidelines systematize

evidence-based recommendations on interventions

covering multiple domains, including weight,

hypertension, diabetes, alcohol and tobacco

consumption, social activity, physical activity, and

cognitive training (World Health Organization, 2019;

Solomen et al., 2021).

In the context of this article, being cognitive

training a relevant component for dementia

prevention is important to study new intervention

models to improve its efficiency and availability.

Traditionally, cognitive training was based on

paper-and-pencil exercises. However, the

technological development of the last decades

promoted new ways of information exchange in all

aspects of our society, including healthcare provision

(Constanzo et al., 2020). Health services delivered or

enhanced through information technologies offer

innovative ways to provide care (Constanzo et al.,

2020), and represent a viable option to support

individuals with cognitive impairments and

potentially reducing injury, hospitalisation, and

institutionalization in residence facilities (Di Lorito et

al., 2021; Di Lorito et al., 2022).

A diverse range of new services focused on

patients with cognitive impairment have been

developed (Di Lorito et al., 2022), including

resources for the patients and caregivers (Torkamani,

2014; Gately, Trudeau & Moo, 2019), assistive

technologies (Howard et al., 2021), and cognitive

training interventions (Orrel et al., 2017; Di Lorito et

al., 2021). In terms of cognitive training,

computerised programmes, supported on different

types of interaction devices, be it computers,

handheld devices, or virtual reality (i.e., computer-

based technology that allows user to interact with

multisensory simulated environment) (Sabbagh et al.,

2020), are increasingly being used (Livingston et al.,

2020). Specifically, virtual reality allows interactions

comparable to experience a real-life setting (Diaz-

Orueta, Blanco-Campal, Lamar, Libon & Burke,

2015).

Several reviews have analysed the use of virtual

reality by patients with mild cognitive impairment

(Kim, Jung & Lee, 2022; Tam et al., 2022; Yu, Li &

Lai, 2023), Parkinson (Marotta et al., 2022),

Alzheimer (Clay et al., 2020), or other neurological

conditions (Dascal et al., 2017; Bevilacqua et al.,

2019; Montana, Tuena, Serino, Cipresso & Riva,

2019). However, to our knowledge, there are no

published reviews analysing the impact of cognitive

training based on virtual reality on older adults

without cognitive impairment.

Therefore, this systematic review of the literature

aimed to gather updated empirical evidence on

preventive cognitive training interventions based on

virtual reality for older adults without cognitive

impairment. Its objectives were to identify i) virtual

reality setups and tasks, ii) clinical outcomes and

respective measurement instruments, and iii) positive

effects on outcome parameters.

2 METHODS

This systematic review followed the guidelines of the

Preferred Reporting Items for Systematic Reviews

and Meta-Analyses (PRISMA) (Moher et al., 2010).

A review protocol was defined with explicit

descriptions of the methods to be used and the steps

to be taken (Xiao & Watson, 2019): i) search

strategies; ii) inclusion and exclusion criteria; iii)

screening procedures; and iv) synthesis and reporting.

2.1 Search Strategies

The following databases were searched: i) PubMed;

ii) Scopus; and iii) Web of Science. Eligible studies

were required to be published in English language. In

turn, there were no limits to the date of publication of

the studies.

Boolean queries were prepared to include all the

articles that have their titles, abstract or keywords

conform with the following Boolean expression:

(Computer OR “Virtual Reality” OR “Serious

Games” OR Web-based OR Mobile) AND

(Cognitive AND (Training OR Rehabilitation) AND

(“randomized controlled trial” OR RCT).

2.2 Inclusion and Exclusion Criteria

The inclusion criteria were: i) full English articles; ii)

articles published in peer-reviewed scientific

Integrating Virtual Reality in Cognitive Training of Older Adults Without Cognitive Impairment: A Systematic Review of Randomized

Controlled Trials

259

journals; iii) articles reporting randomized controlled

trials; and iv) articles reporting evidence of the

application of virtual reality to support cognitive

training of older adults without cognitive impairment.

The exclusion criteria were: i) articles not

reporting randomized controlled trials; ii) articles

reporting the use of technologies other than virtual

reality (e.g., augmented reality) to support cognitive

training; iii) articles reporting the application of

cognitive training to populations other than older

adults without cognitive impairment (e.g., older

adults with mild cognitive impairment or Parkinson);

iv) articles not reporting primary studies (e.g.,

editorials, surveys or reviews); v) articles without

abstracts or authors’ identification; and vi) articles

whose full texts were not available. Moreover,

articles reporting on studies already covered by other

included references were also excluded: when two

articles reported on the same study in different venues

the less mature one was excluded.

2.3 Screening Procedures

All retrieved references were imported to a

spreadsheet Excel and checked for duplicates. Then,

the titles and abstracts of all references were screened

according to the predefined review inclusion and

exclusion criteria. Full texts of potentially relevant

articles were retrieved and independently screened by

two randomly chosen authors, to verify if the

inclusion and exclusion criteria were meet. If a

consensus could not be reached between the two

authors, a third author was consulted.

2.4 Synthesis and Reporting

In addition to general inclusion and exclusion criteria,

the included studies were assessed against the

Physiotherapy Evidence Database (PEDro) scale,

which is considered a reliable and effective scale for

the evaluation of randomized controlled trials (De

Morton, 2009).

Moreover, tabular and narrative syntheses were

prepared to systematize the virtual reality setups and

tasks, and the experimental characteristics of the

studies: i) studies’ type (i.e., feasibility or efficacy);

ii) participants’ characteristics (i.e., number, mean

age, and where they live); iii) duration of the studies;

iv) outcomes and respective measurement

instruments; vi) delivery forms (i.e., individual versus

group intervention, and face-to-face versus remote

interventions); and vii) compliance and attrition (i.e.,

number of dropouts versus the number of participants

that completed the interventions.

Finally, the authors systematize the significant

impacts of the cognitive training interventions on

clinical outcomes that were reported by the included

studies.

3 RESULTS

3.1 Selection of the Studies

The electronic literature search was performed in

June 2023 and 2999 references were retrieved. Then,

913 references were removed because they were

duplicated, did not report primary studies (e.g.,

editorials), or did not have abstracts or the

identification of the respective authors.

During the title and abstract screening, 2078

references were excluded. Some excluded references

were focused on cognitive training supported on

computerized solutions other than virtual reality or

despite reporting the use of virtual reality the

respective research studies did not target older adults

without cognitive impairment.

After the full-text analysis, two articles were

removed, one because reported a research protocol

and the other because the mean age of the participants

was 44 years old.

Therefore, the final list of the retrieved articles

contained six studies (Eggenberger, Schumacher,

Angst, Theil & de Brui, 2015; Mirelman et al., 2016;

Htut, Hiengkaew, Jalayondeja & Vongsirinavarat,

2018; Boller, Ouellet & Belleville, 2021; Kwan et al.,

2021; Zukowski, Shaikh, Haggard & Hamel, 2022)

that were included in this systematic review.

3.2 Quality Assurance

The PEDro scale comprises 11 items: eligibility

criteria, randomization, concealment, baseline,

blinding of subjects, therapists and assessors,

subjects’ retention, intention to treat analysis,

between-group comparison, and measures of

variability. For each study, when an item was

verified, a point was added up to its total score. As the

result of the application of the PEDro scale, one study

was classified as excellent, four as good, and one as

fair.

3.3 Virtual Reality Setups and Tasks

In terms of virtual reality setups (Table 1) fully

immersive environments and semi-immersive

environments were equally distributed (i.e., three

articles each). In turn, in what concerns the tasks

ICT4AWE 2024 - 10th International Conference on Information and Communication Technologies for Ageing Well and e-Health

260

performed by the participants, all tasks comprised

simultaneously cognitive training and physical

exercise.

3.4 Experimental Characteristics of the

Studies

Three of the included studies (Boller et al., 2021;

Kwan et al., 2021; Zukowski et al., 2022) aimed to

assess the feasibility of virtual reality cognitive

training interventions. The remainder studies

(Eggenberger et al., 2015; Mirelman et al., 2016; Htut

et al., 2018) were efficacy studies.

Table 2 present the experimental characteristic of

the studies. The number of participants varied from

17 (Kwan et al., 2021) to 302 (Mirelman et al., 2016),

and their mean age varied from 67.3 (Boller et al.,

2021) to 78.9 (Eggenberger et al., 2015) years old. In

four of the studies (Eggenberger et al., 2015; Boller

et al., 2021; Kwan et al., 2021; Zukowski et al., 2022)

the participants were older adults living

independently in the community, while in two studies

(Mirelman et al., 2016; Htut et al., 2018) the

participants were older adults living in residence

facilities. One study (Mirelman et al., 2016) included

older adults without cognitive impairments and older

adults with Parkinson disease that were taking

antiparkinsonian medication. The remainder studies

only included participants without cognitive

impairments, although (Boller et al., 2021)

considered older adults with subjective memory

complaints, but, in terms of inclusion criteria

neuropsychological were performed to determine

whether the participants were cognitively intact.

One of the feasibility studies (Zukowski et al.,

2022) consisted in a single training session. The other

two feasibility studies had a duration of two weeks

(Boller et al., 2021) and eight weeks (Kwan et al.,

2021). The longest efficacy study (Eggenberger et al.,

2015) was conducted during six months and the other

two efficacy studies were conducted during eight

(Htut et al., 2018) and six weeks (Mirelman et al.,

2016).

Table 1: Virtual reality setups and tasks.

Authors, Year Immersive Level Virtual Reality setups Tasks

Eggenberger et al.,

2015

Semi-immersive Treadmill positioned with a large

screen and a pressure sensitive

platform

Dancing, treadmill walking, or

treadmill walking with simultaneous

verbal memory training

Mirelman et al.,

2016

Semi-immersive Treadmill positioned with a large

screen and a Kinect

Real life challenges such as

obstacles, multiple pathways, and

distracters that require continued

adjustments of steps

Htut et al., 2018 Semi-immersive X-box 360 Games of X-box 360 such as Light

Raise (stepping forward, backward,

or sideward) or Virtual Smash

(moving upper and lower limbs with

slightly bending trunk to crush the

box on the left, right, and front)

Boller et al., 2021 Full-immersive Head-mounted display, wireless

position sensors and, handheld

controllers

Virtual shop and virtual car ride

Kwan et al., 2021 Full-immersive Head-mounted display, wireless

handheld controllers, and an under-

desk ergometer with adjustable

cycling resistance

Travel in the virtual world through

cycling on an ergometer while

simultaneously participating in

cognitively demanding daily living

tasks (e.g., find a bus stop, reporting

lost items or bird watching)

Zukowski et al.,

2022

Semi-immersive Treadmill positioned with a large

screen

Treadmill walking

Integrating Virtual Reality in Cognitive Training of Older Adults Without Cognitive Impairment: A Systematic Review of Randomized

Controlled Trials

261

Table 2: Experimental characteristics of the studies (participants, outcomes, and respective measurement instruments).

Authors, Year Number of

participants

(mean age)

Outcomes Instruments

Eggenberger et al.,

2015

89 (78.9) Memory Executive Control Task, Paired-Associates

Learning Task, and Logical Memory subtest

(Story Recall) and Digit Forward and Backward

tasks from Wechsler Memor

Scale-Revise

Attention A

e Concentration Test

(

A and B

)

Information

processing speed

Trail Making Test (A and B), and Digit Symbol

Substitution Task from Wechsler Adult

Intelli

ence Scale

Training enjoyment Physical Activity Enjoyment Scale

Mirelman et al., 2016 302 (73.8) Attention NeuroTrax

Executive function NeuroTrax

Falls Incident rate of falls during the 6 months after the

end of trainin

Walking spee

Electronic instrument

Walking variabilit

Electronic instrument

Balance Short Physical Performance Battery

Daily activities and

community

artici

ation

Physical Activity Scale for

the Elderly

Qualit

of life Short Form 36 Health Surve

Questionnaire

Htut et al., 2018 84 (75.8) Global cognition MoCA and Timed Up and Go test Cognition

Balance Berg Balance Scale and Timed Up-an

-Go

Muscle strength 5 Times Sit to Stand and Handgrip Strength

Falls Fall Efficac

Scale International

Exercise effort

erception

Borg CR-10 scale

Trainin

ment Questionnaire

Boller et al., 2021 40 (67.3) Memory Word Recall Task, and Multifactorial Memory

Questionnaire

Kwan et al., 2021 17

(

74.0

)

Global co

nition Montreal Co

nitive Assessment

sical frailt

level Fried Frailt

Phenot

e scale

Walking spee

Timed Up-an

-Go

Feasibility (i.e.,

adherence, adverse

outcomes, and

successful learnin

Intervention attendance rate of completers,

intervention completion rate, level of engagement

in ergometer cycling, Virtual Reality Sickness

Questionnaire, and trend in com

letion time

Zukowski et al., 2022 60

(

71.6

)

Global co

nition Montreal Co

nitive Assessment

Attention Trail Making Test (A and B), and Stroop Colour-

Word Test

Information

rocessing spee

Wechsler Adult Intelligence Scale

Walkin

10-meter Walk Test, and Timed U

-an

-Go

Mobilit

Timed U

-an

-Go

Balance Four S

uare Ste

Test

Lower extremity

stren

30-second Sit-to-Stand Test

Visual acuit

Snellen Test

Daily activities and

community

artici

ation

Physical Activity Scale for the Elderly, Activities-

specific Balance Confidence Scale

As can be seen in Table 2, in addition to cognitive

functioning (e.g., global cognition, memory, attention

or information processing speed) and physical

functioning (e.g., walking speed and variability,

balance, or muscle strength) the clinical outcomes

also include daily activities and community

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participation (Mirelman et al., 2016; Zukowski et al.,

2022), and quality of life (Mirelman et al., 2016).

Moreover, two studies also measured nonclinical

outcomes, such as training enjoyment (Eggenberger

et al., 2015) or feasibility (Kwan et al., 2021).

In two studies (Eggenberger et al., 2015; Boller et

al., 2021) the cognitive training was delivered in

small groups (i.e., six participants (Eggenberger et

al., 2015) and four or five participants (Boller et al.,

2021)). All the other studies considered individual

interventions. Moreover, none of the included studies

implemented remote interventions, which means that

all the interventions were face-to-face.

Concerning compliance and attrition, globally,

474 participants completed all the interventions and

assessments. Dropouts due to health issues or

personal reasons were reported in five studies

(Eggenberger et al., 2015; Mirelman et al., 2016;

Boller et al., 2021; Kwan et al., 2021; Zukowski et

al., 2022), and its rate ranged from 3% of the single

session study reported by Zukowski et al. (2022) to

47%, the dropout rate reported by Eggenberger et al.

(2015). In what respects the remainder study (i.e.,

(Htut et al., 2018)) it is unclear if all participants

completed all the interventions and assessments.

3.5 Clinical Outcomes

In terms of clinical outcomes, the preventive

cognitive training interventions based on virtual

reality had significant positive impacts on cognitive

and physical functioning.

Three studies (Eggenberger et al., 2015; Htut et

al., 2018; Kwan et al., 2021) reported significant

impacts on cognitive functioning: i) Htut et al. (2018)

reported that the scores of Montreal Cognitive

Assessment of the virtual reality group were

significantly greater that the controls, and the average

time of the Timed Up and Go test Cognition from the

virtual reality group significantly decreased when

compared to controls; ii) Kwan et al. (2021) reported

a significantly larger improvement in global

cognition for the virtual reality group when compared

to control group; and iii) Eggenberger et al. (2015)

reported a significant performance improvement in

the intervention groups of the information processing

speed.

In turn, two studies (Mirelman et al., 2016; Htut

et al., 2018) reported significant impacts on physical

functioning: i) walking variability - Mirelman et al.

(2016) reported that walking variability during

obstacle negotiation was significantly lower in the

virtual reality group; ii) balance - Mirelman et al.

(2016) reported that the scores on the

Short Physical

Performance Battery

improved significantly in the

virtual reality group, while Htut et al. (2018) reported

that the scores on the Berg Balance Scale and the

Timed Up and Go performance time after exercise of

the intervention groups were better than the controls;

iii) muscle strength - Htut et al. (2018) reported a

significant increase in the left and right handgrip

strength after the virtual reality exercises; and iv) falls

- Mirelman et al. (2016) reported that incident rate of

falls was significantly lower in the virtual reality

group while Htut et al. (2018) reported a significant

decrease in Fall Efficacy Scale International scores

after exercise.

Moreover, Mirelman et al. (2016) reported that

quality of life was better in the virtual reality group,

even at the 6-month follow-up.

Finally, three studies (i.e., the feasibility studies

(Boller et al., 2021; Kwan et al., 2021; Zukowski et

al., 2022)) did not report significant impacts in

clinical outcomes, although they concluded that the

use of virtual reality-based cognitive training is

feasible.

4 DISCUSSION

Six studies published between 2015 and 2022 were

included in this systematic review. This means that

the interest in conducting randomized controlled

trials to assess the impact of cognitive training

interventions based on virtual reality on older adults

without cognitive impairment is recent and did not yet

attract a significant number of researchers.

A simple search in databases such as Scopus or

Web of Science reveals that there are a huge number

of scientific articles focused on the application of

virtual reality, in general, and, in particular, to support

cognitive training interventions. Therefore, the

relatively small number of studies included in this

systematic review could be a surprise if we were not

aware that one of the inclusion criteria was the report

of randomized controlled trials. In this sense, the

number of articles included in this review is in line

with the number of articles included in other reviews

that addressed the cognitive training of older adults

with cognitive impairment using virtual reality (e.g.,

Kim et al. (2022) included six studies, Tam et al.

(2022) included eight studies, Clay et al. (2020)

included nine studies, Marotta et al., (2022) included

ten studies, and Dascal et al. (2017) included 11

studies).

Half of the studies included in this systematic

review were efficacy studies (Eggenberger et al.,

2015; Mirelman et al., 2016; Htut et al., 2018) and the

Integrating Virtual Reality in Cognitive Training of Older Adults Without Cognitive Impairment: A Systematic Review of Randomized

Controlled Trials

263

other half were feasibility studies (Boller et al., 2021;

Kwan et al., 2021; Zukowski et al., 2022).

Surprisingly the feasibility studies were more recent,

but in two of them (Boller et al., 2021; Kwan et al.,

2021), this is justified by the fact that they reported

the use of full-immersive environments (i.e., more

recent technologies).

The virtual reality setups of the fully immersive

environments included head-mounted displays,

wireless position sensors, and handheld controllers.

Additionally, Kwan et al. (2021) also included an

under-desk ergometer with adjustable cycling

resistance. In turn, in terms of semi-immersive

environments, Htut et al. (2018) reported the use of

X-Box 360 games, and Eggenberger et al. (2015),

Mirelman et al. (2016) and Zukowski et al. (2022)

reported the use of treadmills positioned with large

screens. Moreover, Eggenberger et al. (2015) also

included a pressure sensitive platform, and Mirelman

et al. (2016) a Kinect sensor.

The tasks performed by the participants include

treadmill walking (Eggenberger et al., 2015;

Zukowski et al., 2022), treadmill walking with

simultaneous verbal memory training (Eggenberger

et al., 2015), dancing (Eggenberger et al., 2015), real

life challenges such as obstacles, multiple pathways,

and distracters that require continued adjustments of

steps (Mirelman et al., 2016), virtual shop and virtual

car ride (Boller et al., 2021), travel in a virtual world

through cycling on an ergometer while

simultaneously performing cognitive tasks (Kwan et

al., 2021), and games of X-box 360 (Htut et al., 2018)

requiring the performance of physical exercises (e.g.,

stepping forward, backward, or sideward, or moving

upper and lower limbs).

Interventions were designed to be delivered face-

to-face, individually (Mirelman et al., 2016; Htut et

al., 2018; Kwan et al., 2021; Zukowski et al., 2022)

or in small groups (Eggenberger et al., 2015; Boller

et al., 2021). None of the interventions were designed

to be delivered remotely, and, therefore, it was not

possible to compare face-to-face interventions with

remote interventions.

The duration of the feasibility studies varied from

one session (Zukowski et al., 2022) to eight weeks

(Kwan et al.

, 2021). In turn, the efficacy studies

varied from six weeks (Mirelman et al., 2016) and six

months (Eggenberger et al., 2015). However, none of

the efficacy studies assessed the impact of the

duration and intensity (e.g., number of sessions per

week) of the cognitive training interventions on

clinical outcomes.

The participants of four of the studies

(Eggenberger et al., 2015; Boller et al., 2021; Kwan

et al., 2021; Zukowski et al., 2022) lived

independently in the community, while the

participants of two of the studies (Mirelman et al.,

2016) lived in residence facilities.

A multiplicity of clinical outcomes and

measurement instruments were considered by the

included studies. Except one study (Boller et al.,

2021) that considered a single clinical outcome (i.e.,

memory), the remainder studies considered multiple

clinical outcomes, including cognitive and physical

outcomes, quality of life, daily activities, and

community participation: i) global cognition (Htut et

al., 2018; Kwan et al., 2021; Zukowski et al., 2022);

ii) memory (Eggenberger et al., 2015); iii) attention

(Eggenberger et al., 2015; Mirelman et al., 2016;

Zukowski et al., 2022); iv) information processing

speed (Eggenberger et al., 2015; Zukowski et al.,

2022); v) executive functions (Mirelman et al., 2016);

vi) walking speed (Mirelman et al., 2016; Kwan et al.,

2021; Zukowski et al., 2022), vii) walking variability

(Mirelman et al., 2016); viii) mobility (Zukowski et

al., 2022); ix) balance (Mirelman et al., 2016; Htut et

al., 2018; Zukowski et al., 2022); x) muscle strength

(Htut et al., 2018; Zukowski et al., 2022); xi) falls

(Mirelman et al., 2016; Htut et al., 2018); xii)

physical frailty level (Kwan et al., 2021); xiii) visual

acuity (Zukowski et al., 2022), xiv) quality of life

(Mirelman

et al., 2016); xv) daily activities; and xvi)

community participation (Mirelman et al., 2016;

Zukowski et al., 2022).

In terms of significant results, the studies pointed

to positive impacts of cognitive training interventions

based on virtual reality on: i) global cognition (Htut

et al., 2018; Kwan et al., 2021); ii) memory

(Eggenberger et al., 2015); iii) attention

(Eggenberger et al., 2015); iv) information

processing speed (Eggenberger et al., 2015); v)

walking variability (Mirelman et al., 2016); vi)

balance (Mirelman et al., 2016; Htut et al., 2018); vii)

muscle strength (Htut et al., 2018); and viii) falls

(Mirelman et al., 2016; Htut et al., 2018). The

application of the PEDRo scale pointed for a high

confidence level of these results. In fact, according to

the PEDro scale, five of the included studies were

classified as excellent or good.

More long-term randomized controlled trials are

needed to assess the impact of the duration and

intensity of the cognitive training interventions based

on virtual reality. Other evidence gaps are related to

the adequacy of the virtual reality setups (e.g., full

semi-immersive versus full immersive environments)

and the tasks to be performed by the participants,

since the included studies only compared participants

using or not using virtual applications. Also, is not yet

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fully clear how the interventions should be tailored to

the specific characteristics of the participants to

achieve a precision risk reduction approach (i.e.,

tailoring the right interventions for the right people

and at the right time) (Solomen et al., 2021). In this

respect, it should also be compared the impact of

face-to-face and remote cognitive training

interventions.

Like all systematic reviews, this systematic

review has limitations, namely, the dependency on

the keywords and the selected databases, or the fact

that publications not written in English were

excluded. However, the authors tried to guarantee that

study selection and the data extraction were

methodologically rigorous.

5 CONCLUSIONS

From the results of this systematic review, it is

possible to conclude that preventive cognitive

interventions based on virtual reality had positive

impacts in the cognitive (i.e., global cognition,

memory, attention, and information processing

speed) and physical (i.e., walking variability, balance,

muscle strength, and falls) functioning of older adults

without cognitive impairments. However, further

research studies are required to fulfil some evidence

gaps, such as, adequacy of the virtual reality setups

and tasks, impact of the duration and intensity of the

interventions, and how to tailor the interventions to

the characteristics and needs of the individual.

Moreover, it is also necessary to assess the impact of

remote cognitive training interventions based on

virtual reality.

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