JMIR Publications

ABSTRACT

Background:

Cognitive decline and falls are interrelated health challenges in aging populations, with cognitively impaired older adults experiencing nearly twice the fall risk of cognitively intact individuals. Exergaming has emerged as a promising approach to deliver integrated cognitive-motor training; however, most existing systems were developed for general adult populations and lack design features tailored to the specific needs of high-risk older adults, such as safety supports, adaptive difficulty, and culturally relevant content. Moreover, research examining exergame-based interventions among socially vulnerable older adults—who often bear a disproportionate burden of both cognitive decline and fall risk—remains limited.

Objective:

This research aimed to evaluate the effects of a pressure-sensor-based exergaming intervention (Brain Step) on cognitive function, physical function, and body composition in low-income older adults living alone. The study consisted of two sequential phases: Study 1, a single-arm pilot study to assess feasibility, safety, and preliminary efficacy; and Study 2, a randomized controlled trial (RCT) to examine intervention effects. Secondary objectives included exploring whether baseline cognitive-fall risk status moderated intervention effects and examining associations between game performance metrics and health outcomes.

Methods:

Study 1 (n=15) was a 12-week single-arm pilot to assess feasibility and refine protocols. Study 2 was a parallel-group RCT conducted at a senior welfare center in Seoul, South Korea. Thirty-one low-income older adults living alone (mean age 81.5 years, 81% female) were randomly assigned to intervention (n=16) or control (n=15) groups. The 16-week intervention featured custom-developed hardware with safety bars and arcade-style games progressing from single-task physical training to cognitive-motor dual-task challenges. Outcome measures included cognitive function (K-MMSE, MoCA-K), physical function (Berg Balance Scale, Timed Up and Go, 30-second Sit-to-Stand), and sarcopenia related indicators (appendicular skeletal muscle mass (ASM), appendicular skeletal muscle mass index (ASMI), and grip strength). Descriptive statistics and generalized estimating equations were conducted to examine intervention effects over time.

Results:

In Study 1, significant improvements were observed in balance (Berg Balance Scale, P<.001; Cohen’s d (d) = 0.54), mobility (Timed Up and Go, P=.001, d = -0.42; Figure-8 Walk, P=.002, d = 0.34), lower extremity strength (30-second Sit-to-Stand, P=.007), and cardiorespiratory endurance (2-Minute Step Test, P=.017), with cognitive improvement in K-MMSE visuospatial function (P=.020, d = 0.53); however, ASM (P=.041) and ASMI (P=.047) showed modest decreases. Risk-stratified analyses revealed significant time × risk interactions for K-MMSE recall (P=.043, d = 0.94) and attention (P=.006, d = -1.31), with high-risk participants improving in recall and low-risk participants improving in attention. In Study 2, GEE analysis revealed a nominally significant group × time interaction for ASM (P = .039; d = 0.39), with the intervention group maintaining muscle mass while the control group declined. Risk-stratified analyses showed a significant three-way interaction for K-MMSE recall (P = .014; high-risk d = 0.73). The findings did not maintain significance after correction for multiple testing.

Conclusions:

These sequential studies provide preliminary evidence that a culturally adapted, pressure-sensor-based exergaming intervention delivered through Community Care services may benefit muscle mass preservation and cognitive function in high-risk socially vulnerable older adults. Adequately powered trials enriched for high-risk populations are needed to confirm these findings. Clinical Trial: Trial Registration: ClinicalTrials.gov NCT06664229; https://clinicaltrials.gov/study/NCT06664229