SEARCHSYSTEMATIC_REVIEWgeriatrics, neurology

systematic_review·geriatrics, neurology, psychiatry, cognitive_neurology, rehabilitation_medicine·PMC10134019

Serious Games for Learning Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis

Journal of Medical Internet Research · 8 authors, 6 centres

AI SUMMARY

FIDELITY 100%

POPULATIONOlder adults (mean age 74 years, range 66-81.2) with cognitive impairment (MCI, Alzheimer disease, or other neurocognitive disorders), mean MMSE score 24.3 (range 17.9-28.1).

INTERVENTIONSerious games (cognitive training games or exergames) played on digital devices (primarily PC), typically 2-5 times per week for 7-90 minutes per session over 2-25 weeks.

COMPARISONNo intervention/sham, conventional exercises, conventional cognitive training, or other serious games.

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AGENT 01 · STRUCTURED SUMMARY

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TL;DR

This systematic review and meta-analysis of 11 randomized controlled trials found that serious games (electronic games designed for purposes beyond entertainment) can improve verbal and nonverbal learning in older adults with cognitive impairment compared to no intervention or sham interventions. Serious games were as effective as conventional exercises for verbal learning and outperformed conventional cognitive training for nonverbal learning. However, the findings are inconclusive due to very low quality of evidence, small sample sizes in most studies, and a limited number of trials available for meta-analysis, suggesting serious games should supplement rather than replace current interventions.

Full summary

4,192 CHARS

**Background:** Learning disabilities are major cognitive impairments associated with aging. Serious games—participative electronic games designed for therapeutic rather than entertainment purposes—have been proposed as a low-cost, enjoyable intervention to improve learning in older adults with cognitive impairment. Previous systematic reviews had limitations including focusing on older adults without cognitive impairment, excluding certain types of serious games, and not analyzing results by comparator type. This review aimed to evaluate the effectiveness of serious games on verbal and nonverbal learning among older adults with cognitive impairment.

**Methods:** Eight electronic databases (Google Scholar, IEEE Xplore, ACM Digital Library, Embase, MEDLINE, PsycINFO, CINAHL, Scopus) were searched on July 22, 2022. Forward and backward reference list checking was also performed. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane Risk-of-Bias 2 tool. Only RCTs published after 2010 in English were included. The population was older adults (>60 years) with any type of cognitive impairment. The intervention had to be a digital serious game played for therapeutic purposes. The outcome was learning (verbal or nonverbal). Meta-analyses used random effects models with standardized mean difference (SMD). Quality of evidence was assessed using GRADE.

**Key Results:** Of 559 citations retrieved, 11 RCTs (2%) met all eligibility criteria. Studies were published between 2012 and 2022, conducted in 7 countries (most from France: 3/11, 27%). Sample sizes ranged from 20 to 114 participants (mean 56.7, SD 33.9). Mean age was 74 years (SD 4.21). MCI was the most common condition (8/11, 73%). Most serious games were cognitive training games (10/11, 91%) played on PCs (9/11, 82%). Intervention periods ranged from 2 to 25 weeks.

FOR VERBAL LEARNING

A meta-analysis of 5 RCTs comparing serious games to no/sham interventions (after sensitivity analysis removing one study with baseline imbalance) showed a statistically significant difference favoring serious games (SMD 0.33, 95% CI 0.02-0.64, P=.04). This was clinically important (effect outside MCID boundaries of -0.165 to 0.165). Heterogeneity was low (I²=11%, P=.34). Subgroup analysis showed no difference in effect between MCI and AD patients (P=.89). A meta-analysis of 2 RCTs comparing serious games to conventional exercises found no significant difference (SMD 0.01, 95% CI -0.75 to 0.77, P=.98), with substantial heterogeneity (I²=65%, P=.09).

FOR NONVERBAL LEARNING

A meta-analysis of 4 RCTs comparing serious games to no/sham interventions showed a statistically significant difference favoring serious games (SMD 0.58, 95% CI 0.06-1.09, P=.03), which was clinically important (effect outside MCID boundaries of -0.29 to 0.29). Heterogeneity was moderate (I²=55%, P=.08). A meta-analysis of 2 RCTs comparing serious games to conventional cognitive training showed a statistically significant difference favoring serious games (SMD 1.05, 95% CI -0.65 to 1.46, P<.001), with low heterogeneity (I²=1%, P=.36).

Quality of evidence was very low for most meta-analyses (5/6, 83%) due to high risk of bias, imprecision, and/or heterogeneity. Only 3/11 (27%) studies had low overall risk of bias. Most meta-analyzed studies (6/8, 75%) had small sample sizes.

**Clinical Implications:** Serious games show potential for improving verbal and nonverbal learning in older adults with cognitive impairment, but the evidence is insufficient to recommend replacing current interventions. The authors recommend serious games be used as supplements rather than replacements until higher-quality evidence is available. Key research gaps include: lack of studies comparing serious games to conventional cognitive training and exercises; absence of studies using mobile devices or VR headsets; short intervention periods (≤12 weeks in 73% of studies); lack of follow-up data; and small sample sizes. Game developers should collaborate with medical experts to create serious games for mobile and VR platforms, designed specifically for older adults with cognitive impairment.

PICO

PPOPULATION

Older adults (mean age 74 years, range 66-81.2) with cognitive impairment (MCI, Alzheimer disease, or other neurocognitive disorders), mean MMSE score 24.3 (range 17.9-28.1).

IINTERVENTION

Serious games (cognitive training games or exergames) played on digital devices (primarily PC), typically 2-5 times per week for 7-90 minutes per session over 2-25 weeks.

OOUTCOME

Verbal learning and nonverbal learning measured by standardized neuropsychological tests (e.g., WMS-IV-VPA-I, CVLT, RAVLT, ROCFT, FCSRT, DMS48).

STUDY TYPE

systematic_review

SPECIALTY

geriatrics

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10134019

Serious Games for Learning Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis

Journal of Medical Internet Research

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ABSTRACT

Background Learning disabilities are among the major cognitive impairments caused by aging. Among the interventions used to improve learning among older adults are serious games, which are participative electronic games designed for purposes other than entertainment. Although some systematic reviews have examined the effectiveness of serious games on learning, they are undermined by some limitations, such as focusing on older adults without cognitive impairments, focusing on particular types of serious games, and not considering the comparator type in the analysis. Objective This review aimed to evaluate the effectiveness of serious games on verbal and nonverbal learning among older adults with cognitive impairment. Methods Eight electronic databases were searched to retrieve studies relevant to this systematic review and meta-analysis. Furthermore, we went through the studies that cited the included studies and screened the reference lists of the included studies and relevant reviews. Two reviewers independently checked the eligibility of the identified studies, extracted data from the included studies, and appraised their risk of bias and the quality of the evidence. The results of the included studies were summarized using a narrative synthesis or meta-analysis, as appropriate. Results Of the 559 citations retrieved, 11 (2%) randomized controlled trials (RCTs) ultimately met all eligibility criteria for this review. A meta-analysis of 45% (5/11) of the RCTs revealed that serious games are effective in improving verbal learning among older adults with cognitive impairment in comparison with no or sham interventions ( P =.04), and serious games do not have a different effect on verbal learning between patients with mild cognitive impairment and those with Alzheimer disease ( P =.89). A meta-analysis of 18% (2/11) of the RCTs revealed that serious games are as effective as conventional exercises in promoting verbal learning ( P =.98). We also found that serious games outperformed no or sham interventions (4/11, 36%; P =.03) and conventional cognitive training (2/11, 18%; P <.001) in enhancing nonverbal learning. Conclusions Serious games have the potential to enhance verbal and nonverbal learning among older adults with cognitive impairment. However, our findings remain inconclusive because of the low quality of evidence, the small sample size in most of the meta-analyzed studies (6/8, 75%), and the paucity of studies included in the meta-analyses. Thus, until further convincing proof of their effectiveness is offered, serious games should be used to supplement current interventions for verbal and nonverbal learning rather than replace them entirely. Further studies are needed to compare serious games with conventional cognitive training and conventional exercises, as well as different types of serious games, different platforms, different intervention periods, and different follow-up periods. Trial Registration PROSPERO CRD42022348849; https://tinyurl.com/y6yewwfa

CITATION EXPORT

Alaa Abd-alrazaq, Israa Abuelezz, Rawan AlSaad et al.. Serious Games for Learning Among Older Adults With Cognitive Impairment: Systematic Review and Meta-analysis. Journal of Medical Internet Research. (2023). https://doi.org/10.2196/43607

AUTHORS

8 · 6 CENTRES

Alaa Abd-alrazaq, Israa Abuelezz, Rawan AlSaad, Eiman Al-Jafar, Arfan Ahmed, Sarah Aziz, Abdulqadir Nashwan, Javaid Sheikh

1 AI Center for Precision Health, Weill Cornell Medicine-Qatar Doha Qatar
2 Division of Information and Computing Technology, College of Science and Engineering, Hamad Bin Khalifa University, Qatar Foundation Doha Qatar
3 College of Computing and Information Technology, University of Doha for Science and Technology Doha Qatar
4 Department of Health Informatics and Information Management Kuwait University Kuwait Kuwait
5 Department of Nursing, Hazm Mebaireek General Hospital, Hamad Medical Corporation Doha Qatar
6 Department of Public Health, College of Health Sciences, QU Health, Qatar University Doha Qatar

EDITOR / REVIEWER

Amaryllis Mavragani, Khaldoon Dhou, Patrick Manser