Feasibility of home-based,low-intensity exergame on cognitive function of older adults with mild cognitive impairment

Abstract

Background

Combined physical–cognitive training has shown beneficial effects on cognition in older adults with mild cognitive impairment (MCI). However, most interventions employ moderate-to-high intensity, which may limit accessibility for individuals with health concerns. Whether low-intensity exercise provides similar cognitive benefits remains inconclusive. Delivering such training through home-based exergame may improve adherence. This study evaluated the feasibility of a home-based, low-intensity exergame for older adults with MCI.

Methods

Older adults with MCI completed 50-min exergaming sessions, triweekly, for 4 weeks. Feasibility outcomes, including recruitment, adherence, adverse events, enjoyment, and cognitive and physical performance, were evaluated at baseline and post-intervention. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA), 10-word recall test, digit span, and verbal fluency tests. Physical performance was assessed with the four-square step and five-times sit-to-stand tests.

Results

Fifteen older adults with MCI (mean age 66.07 ± 4.36 years; 75% recruitment rate) participated. The average adherence rate was 93.33% (11.2 sessions), with no adverse events or attrition reported. Enjoyment significantly increased from week 1 to week 4 (p = 0.001). Significant cognitive improvements were demonstrated for the 10-word immediate and delayed recall (p = 0.03, p = 0.002), MoCA total scores (p = 0.002), and MoCA sub-domains: executive function (p = 0.007), language (p = 0.034), and delayed recall (p = 0.001). No significant changes were observed in physical performance.

Conclusion

Home-based, low-intensity exergaming is a safe, feasible, and enjoyable approach for older adults with MCI. Preliminary findings suggest potential cognitive benefits of low-intensity exergaming in improving cognitive function, which warrant confirmation in a large-scale, rigorous randomized controlled trial.

Keywords

Feasibility low-intensity exergame MCI home-based exercise cognition

Introduction

Currently, more than 55 million people have dementia worldwide.¹ Dementia exerts a multi-faceted impact across physical, psychological, social, and economic dimensions, affecting not only individuals living with the condition but also their caregivers, families, and society. Although dementia is irreversible and currently has no effective treatment, an initial sign of dementia commonly recognized as mild cognitive impairment (MCI) is reversible.² MCI has been proposed as a condition of intermediate symptomatology between the cognitive changes of aging and fully developed symptoms of dementia.³ Consequently, interventions aimed at preventing cognitive decline and enhancing cognitive function in older adults with MCI would significantly reduce the incidence of dementia. At present, there are no pharmacological treatments that have been proven to be effective for MCI.⁴ As a result, non-pharmacological approaches are increasingly recognized as crucial in the management of MCI. Exercise is regarded as one of the promising methods for improving cognitive function, lowering the risk of dementia, and improving physical performance and general quality of life in individuals with cognitive impairment.^5,6 Several studies have revealed that combined physical–cognitive exercise exerts the most profound effects on cognitive function and physical function in MCI.^7–9

Previous studies have primarily focused on moderate to vigorous exercise. However, certain older individuals may have limitations or contraindications, such as arthritis, hypertension, or heart disease, which restrict their participation in exercise programs. Recently, there has been a growing interest in investigating the effects of low-intensity exercise on cognitive function. A limited number of studies found that low-intensity exercise could improve memory¹⁰ and other cognitive functions^11–15 in older adults without cognitive impairment. Therefore, it remains uncertain whether low-intensity exercise would be advantageous for individuals with MCI.

With current technologies, game-based exercises (exergames or exergaming) allow simultaneous physical and cognitive exercise. Exergames tailored for older adults have demonstrated safety, ease of use, and enjoyment,^16–18 and they are suitable for exercise in both institutional settings and home environments. Previous studies demonstrated that exergames improve physical functions (e.g. balance, mobility, physical fitness, and gait) and cognitive function (e.g. executive functions, memory, and processing speed) among healthy older adults, older adults with metabolic syndrome, MCI, and dementia.^16,17,19 Consistent with typical exercise programs, the physical component of exergames is often delivered at a moderate to high intensity.^19–21 Only a few studies have examined the benefits of low-intensity, exergames in older adults. One study investigated the effects of low-intensity, Kinect™-based Kaimai-style Qigong exercises over a 12-week period in older adults with type 2 diabetes. Findings revealed improvements in both cognitive function and balance.²² Another study showed that exergaming-based Tai Chi led to enhancements in executive function, gait speed, and reduced the dual-task cost of speed during cognitive dual-task walking in older adults with MCI.²³ Moreover, these studies utilized exergames in a center-based format, which, despite supporting effective training, has been associated with low adherence due to common barriers such as transportation difficulties, scheduling conflicts, and family responsibilities.²⁴ In contrast, home-based exergame training has demonstrated clinical efficacy in improving specific cognitive domains among older adults with MCI.²⁵ Building on this evidence, this study aimed to evaluate the feasibility of a home-based, low-intensity exergame for older adults with MCI.

Methods

Study design

This feasibility study was a prospective single-arm, pre–post design trial with a 4-week home-based program to evaluate the feasibility of low-intensity, combined physical–cognitive exercise for individuals with MCI. Feasibility was assessed through recruitment rates, adherence, attrition, adverse events, cognitive function, physical performance, and enjoyment of the exercise program. The study protocol was approved by the Human Ethical Review Board of the primary investigator's institution (approval number: AMSEC-67EX-100).

The sample size for this feasibility study was based on recommendations for pilot studies, which suggest approximately 15 participants are sufficient to assess feasibility and to detect medium effect sizes with 90% power and a two-sided 5% significance level.²⁶

Recruitment and participants

Fifteen community-dwelling older adults with MCI were enrolled in this feasibility study. Participants were recruited from local communities and via social media advertisements (Facebook and LINE) for over 1 month. They were eligible to participate if they (1) aged 60 years or older; (2) met the DSM-V criteria for MCI which include subjective cognitive complaint, objective cognitive impairment, preserved independence, and absence of dementia.²⁷ Objective cognitive impairment was assessed using the Montreal Cognitive Assessment (MoCA), with scores <26/30 required for inclusion. The absence of dementia was confirmed using the mental state examination T10 (MSET-10) (<22/29), and functional independence was evaluated through an interview; (3) comprehend instruction; and (4) had normal physical performance (as indicated by the short physical performance battery (SPPB) > 9 points.^28,29 Exclusion criteria were having (1) depressive symptoms (determined by the geriatric depression scale, Thai geriatric depression scale > 6 points),³⁰ (2) neurological conditions that affect cognition and mobility (e.g. Parkinson's disease, stroke, multiple sclerosis, and Alzheimer′s disease (AD)), (3) acute or/and chronic disease that could not be controlled (e.g. arthritis, asthma, hypertension, diabetes mellitus, and coronary artery disease), and (4) uncorrected visual or hearing impairment.

Interested individuals first completed a telephone pre-screening interview. Eligible individuals at this stage were invited to an in-person screening visit. During the visit, trained assessors administered the MoCA, MSET-10, and other assessments to determine whether they met MCI criteria and other study requirements. Of the 20 individuals who completed the screening, 15 met all eligible criteria and were subsequently enrolled in this study.

Flow diagram of the study procedure is shown in Figure 1.

Figure 1.

Flow diagram of the study procedure.

Intervention

A low-intensity combined physical–cognitive exercise was delivered through an exergame developed by our research team.¹⁸ The exergame was designed to target both physical (aerobic capacity, balance, coordination) and cognitive (memory, attention, executive function) domains. Previous validation and system usability testing showed high content validity and good acceptance among older adults, indicating that the exercise and game components were well aligned with the intended intervention goals and that older adults were able to use the exergaming system without difficulty.¹⁸

A detailed description of the exergame is presented in Table 1. There were three games (road runner, ocean diver, and moving and memorizing). Each game had three difficulty levels that adjusted to participants’ abilities, with immediate feedback provided to support engagement. Participants advanced to the next level when they achieved a score above 50% at their current level. Training sessions lasted 50 min, including a 7-min warm-up, 36 min of exercise (12 min per game), and a 7-min cool-down, and were scheduled three times per week for 4 weeks in a home-based format.

Table 1.

Characteristics of the exergame.

Participants used either a provided laptop/computer with a camera or their own device and received training to operate the exergaming system at home. Before the intervention, a home visit was conducted to assess the environment, setup the system, and provide step-by-step instructions. The exergame was displayed on a 15-in. screen positioned at the eye level, approximately 1.5 m away, with safety recommendations given. Family members or caregivers were encouraged to assist as needed. During the familiarization phase, a heart rate monitor was used to keep exercise within 30–39% heart rate reserve (HRR), ensuring a low-intensity level and later through self-reported rate of perceived exertion (RPE) within 9–11/20. Participants completed two supervised home-based sessions before independent training (Figure 2).

Figure 2.

Examples of a participant undertaking the low-intensity, exergame at home.

Outcome measures

Demographic characteristics of the participants including age, weight, body mass index (BMI), and education level were recorded at baseline. Recruitment rates, adherence, adverse events, enjoyment, cognitive function, and physical performance were used to indicate the feasibility of the exergame. Enjoyment rating scores were determined after 1 and 4 weeks of exercise. Lastly, cognitive function and physical performance were assessed at baseline and the end of the 4 weeks of exercise.

Recruitment rate

Detailed records were maintained throughout the recruitment process to document the number of individuals screened for study participation. The reason for ineligibility was documented for individuals who did not meet the inclusion and exclusion criteria. Likewise, for eligible individuals who declined to participate, their reason was also documented.

Adherence, attrition, and adverse events

Exercise adherence was monitored using both the participant's exercise diary and the exergame application. Adherence to the intervention was measured as the percentage of attended exercise sessions. Attrition was calculated by tracking the number of participants who withdrew or were lost to assessment at the end of the study and comparing this figure to the initial number of participants enrolled. Participants were instructed to immediately report any adverse events during the study, such as injuries, falls, fatigue, and so on, or any exercise-related harm.

Enjoyment

The enjoyment experienced during engagement in the home-based, low-intensity exergame was assessed using the Physical Activity Enjoyment Scale (PACES).³¹ PACES is an 8-item scale questionnaire that measures the level of enjoyment using a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Enjoyment scores were obtained by summing the item responses. A higher score indicated a greater level of enjoyment. Enjoyment was measured after 1 and 4 weeks of exercise.

Cognitive function outcomes

Cognitive outcomes were assessed using standardized tools with established validity and reliability in older adults. The MoCA was used to evaluate global cognitive function. MoCA covers several cognitive domains, including visuospatial abilities, attention, language, memory, and executive function. The MoCA scores range from 0 to 30, with higher scores indicating better cognitive function.³² The MoCA has demonstrated good reliability (intraclass correlation coefficient, ICC = 0.92).³² The 10-word recall test assessed memory using 10 nouns that were read aloud by the examiner with a 2-s interval between each word. Participants were instructed to listen and repeat as many words as possible (immediate recall trial). After a 5-min delay, each participant was asked to recall as many words as possible (delayed recall trial).³³ The 10-word recall test has shown good test–retest reliability.³⁴ The digit span test was used to assess attention, with participants recalling sequences of digits in both forward and backward order. Sequences started at two digits, with two trials for each length (nine digits for forward recall and eight digits for backward recall). The sum of both orders was calculated.³⁵ The digit span test has demonstrated good reliability (ICC = 0.77).³⁶ Language was assessed using the verbal fluency test which has shown good reliability (ICC = 0.79).³⁷ Participants were asked to name as many animals as possible within 60 s, and the assessor recorded the number of animals mentioned. All outcomes were assessed at baseline and the end of the 4 weeks.

Physical performance outcomes

The Four-Square Step Test (FSST) was administered to assess dynamic standing balance and mobility. This test requires participants to step forward, backward, and sideways to the right and left. Participants stood in square 1, facing square 2 and were instructed to step as quickly as possible into each square in the following sequence: 2, 3, 4, 1, 4, 3, 2, and 1. Two FSST trials were completed, with the best time recorded as the score.³⁸ Additionally, the Five Times Sit-to-Stand Test was administered to assess lower extremity strength. Participants sat comfortably with their arms crossed over their chests and their backs supported by the chair. They were asked to perform the test by standing up fully (hip and knee extension) and then sitting back down. A stopwatch was used to measure the time in seconds from the initial to the final seated position.³⁹ All outcomes were assessed at baseline and the end of the 4 weeks.

Statistical analyses

Descriptive statistics were used to describe the characteristics of participants, adherence rate, adverse events, rating scores on the PACES, cognitive function, and physical performance. The normality of the data was tested using the Shapiro–Wilk test. As the assumptions for parametric statistics were not met, non-parametric tests were used to analyze the data. The Wilcoxon signed-rank test was employed to compare the outcome measures before and after the 4-week exercise period. The significance level was set at p < 0.05. Data analysis was conducted using SPSS (version 21.0; IBM Corp.).

Results

Characteristics of participants

The mean age of the participants was 66.07 ± 4.36 years, and the mean BMI was 24.18 ± 2.84 kg/m². Participants were mostly university graduates (66.67%). The participant characteristics are shown in Table 2.

Table 2.

Baseline demographic characteristics of participants (n = 15).

Characteristics	Mean (SD) or n (%)
Age (years), mean (SD)	66.07 (4.36)
Gender (female, n (%))	8 (53.33)
Education status, n (%) High school graduate University graduate Post-graduate	3 (20) 10 (66.67) 2 (13.33)
BMI (kg/m²), mean (SD)	24.18 (2.84)
TGDS, mean (SD)	2.27 (1.24)
SPPB, mean (SD)	11.8 (0.41)

BMI: body mass index; TGDS: Thai Geriatric Depression Scale (total score = 15 points); SPPB: short physical performance battery (total score = 12 points)

Recruitment rate, adherence, attrition, and adverse events

Twenty older adults were recruited. Of these, five scored above 26 points on the MoCA, while the remaining 15 met the criteria for MCI and all other study requirements, resulting in a 75% recruitment rate. The recruitment process took 1 month. Adherence to the exercise program was high, with participants completing an average of 11.2 out of 12 sessions (93.33%). Heart rate recordings during familiarization confirmed that exercise intensity maintained at low-intensity levels (30–39% of HRR). Throughout training, all participants reported RPE scores of 9–11, consistent with low-intensity exertion. No musculoskeletal complaints, injuries, falls, or adverse events were reported. There were no dropouts from the exercise sessions, resulting in a 0% attrition rate.

Enjoyment

The average PACES score across the eight items rose from 5.58 ± 0.39 (range 4.75–6.13), after the first week to 6.47 ± 0.53 (range 5.25–7.00) after 4 weeks, suggesting increased enjoyment and satisfaction with the exergame. The Wilcoxon signed-rank test showed that PACES scores significantly increased at the end of the exercise period compared to the first week of exercise (p = 0.001).

Cognitive and physical performance

The Wilcoxon signed-rank test indicated that MoCA total score and 10-word recall test (immediate and delayed recall) were significantly increased at the end of the exercise period compared to baseline (p = 0.002 and 0.022 respectively). The specific items of the MoCA related to visuospatial/executive, language, and delayed recall were improved at the end of the exercise period compared to baseline (p = 0.007, 0.034, and 0.001, respectively). No significant differences were observed in physical performance measures (Table 3).

Table 3.

Cognitive function and physical performances at baseline and after 4 weeks of home-based, low-intensity exercise (n = 15)

Variables	Baseline, median (range)	Post-training, median (range)	p-Value
Cognitive function outcomes MoCA total score Visuospatial/executive function	23.00 (15–25) 4.00 (3–5)	26.00 (20–29) 5.00 (3–5)	0.002* 0.007*
• Naming	3.00 (3–3)	3.00 (3–3)	1.000
• Attention	6.00 (6–6)	6.00 (6–6)	0.470
• Language	2.00 (0–3)	2.00 (0–3)	0.034*
• Abstraction	2.00 (0–2)	2.00 (0–2)	0.414
• Delayed recall	1.00 (0–3)	3.00 (0–5)	0.001*
• Orientation	6.00 (6–6)	6.00 (5–6)	0.317
10-word recall test (n) Immediate recall	5.00 (4–7)	6.00 (5–8)	0.031*
• Delayed recall	2.00 (0–5)	4.00 (1–7)	0.022*
Digit span forward-backward (n)	15.00 (10–22)	16.00 (10–21)	0.344
Verbal fluency (n)	23.00 (16–30)	22.00 (12–36)	0.674
Physical performances Five-time sit-to-stand test (s)	7.66 (4.77–10.68)	7.29 (4.63–11.37)	0.875
Four square step test (s)	8.52 (5.98–12.38)	8.05 (5.66–9.83)	0.124

Note. A higher score on the MoCA, digit span, verbal fluency, and 10-word recall tests indicate better performance. For physical performance assessments, a lower completion time reflects better performance.

*Significance level <0.05.

Discussion

To the best of our knowledge, this is the first interactive, low-intensity physical and cognitive exercise delivered through a home-based exergame designed for older adults with MCI. The study's findings demonstrate that home-based, low-intensity exergame was safe and feasible for older adults with MCI, as evidenced by a high adherence rate, absence of adverse events, sustained enjoyment, and improved cognitive function observed after 4 weeks. The high adherence rate of 93.33% observed in this study exceeds the commonly accepted 70% threshold for exercise adherence in individuals with MCI.⁴⁰ It is worth noting that this adherence rate was not based solely on participants’ self-reports through exercise diaries but was corroborated by data automatically recorded within the exergame application, enhancing the reliability of the adherence measure.

Our findings support the use of an innovative exergame that integrates physical and cognitive exercises to enhance motivation and enjoyment, thereby promoting consistent exercise participation.⁴¹ Exergames tailored for older adults have been demonstrated to be safe, user-friendly, and enjoyable, contributing to high adherence rates.^16,17 Participants demonstrated high engagement throughout the intervention. Engagement was reflected in both enjoyment and adherence. Enjoyment, as measured by the PACES, increased from a mean score of 5.58 after week 1 to 6.47 after week 4, suggesting that participants found the intervention increasingly satisfying. Adherence was also high, with participants completing an average of 93.3% of scheduled sessions, showing consistent participation.

In this study, user engagement may have been sustained through two key features of the exergame design. First, gamification elements, such as rewards and sensory feedback, likely enhance enjoyment and motivation. Second, the adaptive difficulty feature could help maintain an optimal level of challenge, ensuring that exercise remains stimulating, thereby promoting continued engagement over time.^16,42 In addition, the home-based format could address common barriers to participation, such as transportation difficulties, time constraints, and financial burden, while providing a familiar environment that further supported long-term adherence.⁴³ However, the computer screen used in this study was relatively small (15-in.) which may have limited visibility and overall immersion for some participants. Future implementations could benefit from larger display formats (e.g. televisions or projectors), simplified user interfaces, and enhanced accessibility features such as adjustable font sizes and contrast settings.

The present study revealed the benefit of a home-based, low-intensity exergame in improving global cognitive function as reflected by the MoCA score. The observed MoCA mean score changes between pre- and post-exercise (3.0 points) exceeded a standard error of measurement of 1.5 points,⁴⁴ suggesting that the cognitive gains are attributed to the exergame rather than the measurement variability. This finding aligns with previous research indicating that low-intensity exercise can lead to significant improvements in MoCA.⁴⁵ Improvement of MoCA total scores was primarily due to enhancements in the visuospatial/executive function, delayed recall, and language performance. These domain-specific improvements are consistent with the design of the exergame, which targeted memory, visuospatial ability, and executive function (e.g. planning, sequencing, and inhibition). Similarly, previous studies demonstrated that exergames can improve specific cognitive functions including memory and executive function in older adults with MCI.²⁵ Although attention was engaged throughout the exergame training, no significant improvement was observed. One possible explanation is that the digit span test may have limited sensitivity in detecting subtle changes in attention. Previous studies have also reported no significant improvement in attention following exergame.^41,46,47 An alternative explanation may be that attention, particularly in older adults with MCI, may require prolonged intervention to elicit measurable changes.

Previous studies have demonstrated that exergames can improve executive function in older adults with MCI.^23,25 These functions are frequently engaged during physical–cognitive interactive gameplay that demands physical effort, ongoing decision-making, adaptation, and problem-solving. Both physical exercise and cognitive training improve physiological cascades that play an important role in increasing cerebral blood flow and neuroplasticity, including neurotrophic factors that support neurogenesis, increased brain volume, neural activity, and neural connectivity.^48,49 Thus, improvements in memory, executive function, and global cognitive function may be due to the synergistic effects of the combined exercise.⁵⁰ Our findings that exergame training improved global cognition, memory, and executive function align with a recent meta-analysis demonstrating similar cognitive benefits of virtual reality based exergaming in individuals with MCI.⁴¹

Contrary to our hypothesis, physical performance did not significantly improve after 4 weeks of intervention. The lack of physical improvement may be attributed to the short intervention duration and the inclusion criteria used in this study. Although a few studies reported improvements in physical function after 4 weeks of exergaming, most studies utilized longer training periods, typically about 12 weeks.^23,51,52 Additionally, our inclusion criteria required participants to have relatively high SPPB scores to ensure safety during unsupervised, home-based exercise, which resulted in the recruitment of a well-functioning participant group. Together, these factors may have reduced the potential to detect significant improvement in physical performance, instead of demonstrating the maintenance of their functional level. This is in line with previous studies that have observed only modest increases in SPPB scores among well-functioning older adults.^53,54 These findings support the notion that the potential for improvement is greater among individuals with lower initial functional capacity.

Limitations

This study has certain limitations. A significant number of participants had a high educational background, which might restrict the applicability of the findings to a broader population. In addition, this study employed a single-group, pre- and post-test design to explore the feasibility of the intervention program. Given the small sample size and lack of a control group, a methodologically robust randomized controlled trial is warranted to further evaluate the effectiveness of low-intensity, home-based exergame.

Conclusion

This preliminary study demonstrates that low-intensity exergaming in a home setting is safe, feasible, and enjoyable for older adults with MCI. Home-based low-intensity exergame may potentially offer a positive influence on cognitive function. Nevertheless, further confirmation in a large-scale randomized controlled trial is required.

Footnotes

Acknowledgments

The authors would like to express their sincere gratitude to all participants for their dedication, time, and effort during the training and assessment sessions.

ORCID iDs

Sirintip Kumfu

Teerawat Kamnardsiri

Sirinun Boripuntakul

Somporn Sungkarat

Ethical approval and consent to participate

The research protocol has been approved by the Human Ethical Review Board of the Faculty of Associated Medical Sciences, Chiang Mai University, Thailand (approval number: AMSEC-67EX-100). All participants provided written informed consent prior to participation.

Author contributions

SK: writing—original draft, conceptualization, writing—review and editing, methodology, data curation, and formal analysis. TK: writing—original draft, conceptualization, software, and writing—review and editing. SB: conceptualization, methodology, and writing—review and editing. SS: writing—original draft, conceptualization, methodology, writing—review and editing, formal analysis, and funding acquisition. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Research Council of Thailand (NRCT): N42A660640 (SS) and the research fund for graduate students, Faculty of Associated Medical Sciences, Chiang Mai University.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability

Data will be made available on request.

Guarantor

SS.

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