Exergaming to Increase Physical Activity in Older Adults: Feasibility and Practical Implications

Purpose of Review To evaluate the feasibility of exergaming among older adults, focusing on acceptability, demand, implementation, and practicality. Additionally, to offer practical implications based on the review's findings. Recent Findings Exergaming is a safe for older adults, potentially increasing physical activity, balance, cognition, and mood. Despite these possible benefits, barriers such as unfamiliarity with equipment, complex controls, and unclear instructions may challenge older adults in exergaming. Summary Based on the experience of older adults, they found exergaming enjoyable, particularly the social interactions. Exergaming was perceived as physically and cognitively demanding, with technical and safety challenges. Introducing exergaming requires thorough familiarization, including written and video instructions, follow-up support, and home accessibility. To be able to follow improvements during exergaming as well as age-appropriate challenges are important for successful integration into daily life. Based on these findings, an ExerGameFlow model for older adults was developed which provides practical implications for future design of exergames and interventions. Supplementary Information The online version contains supplementary material available at 10.1007/s11897-024-00675-9.


Introduction
There is a growing recognition of the importance of maintaining an active lifestyle to promote physical activity in all age groups [1].Recent studies, suggest that exercising with virtual reality technology, such as exergaming, has the potential to improve physical activity in a range of individuals, including older adults [2].
Exergames (a combination of exertion and video games including strength training, balance, aerobic endurance and flexibility activities) [3,4] are promising for increasing physical activity engagement.Systematic literature reviews show that exergaming is safe and feasible in older adults, could increase motivation in becoming more physically active, could increase physical activity, balance and cognition, could decrease depressive symptoms and could facilitate healthy aging [5][6][7][8][9][10][11][12].A systematic review and meta-analysis showed that exergaming has an effect equivalent to other types of exercising on improving walking in older adults [8].
While exergaming holds potential benefits, older adults might feel unsure or discouraged to exergaming because of unfamiliar equipment, new physical movements, complicated controls, confusing displays, unclear instructions in the game or short familiarization to the exergame, and they can feel that the exergames are too fast for them to play [13][14][15][16][17][18].
Although evidence show benefits of exergaming in older adults, more information on the feasibility of exergames in older adults, in terms of the usability and acceptance of exergames in this group, could be useful for future design of exergames and interventions including exergames.Therefore, the aim of this systematic literature review was to assess the feasibility of exergaming in older adults based on the experiences of acceptability, demand, implementation, and practicality of exergames.If older adults do not enjoy exergaming, they will be less likely to play the game.A model that consists of a set of criteria that can be used to design and evaluate games with respect to player enjoyment is the GameFlow model [54].Although the GameFlow model is applicable to most game genres and platforms, this model us not used for exergames or for gaming in older adults.Therefore, we found that the model might need some adaptation to be used design exergames for older adults.Therefore, the second aim of this study was to provide practical implications for exergaming in older adults based on the results of the literature review by adapting the GameFlow model [54].

Design
This study is a systematic literature review based on studies with a qualitative design.

Literature Search
The initial search started in PubMed for identification of primary studies.A text analysis was carried out with these articles titles and abstracts and index terms identified and was applied to four online electronic databases (PubMed, Scopus, CINAHL and Web of Science), and was conducted in January 2024.The following search string was utilized across the databases: ((exergames OR exergaming OR active AND video AND games) AND (experiences OR perceptions OR attitudes OR views) AND (qualitative AND research OR qualitative AND study OR qualitative AND methods OR interview) AND (elderly OR aged OR older OR elder OR geriatric)).
For inclusion in this analysis, studies were required two be published or in press, peer-reviewed literature and in the English language.Studies that did not include older adults (aged ≥ 65 years), studies that were not explicitly related to physical activity, and studies that were not specifically related to experience in exergaming were excluded.Additionally, we excluded literature reviews, protocols, and case-studies.
The study was registered at PROSPERO International prospective register of systematic reviews: CRD42022360720.

Selection of Studies
In total 93 articles were identified by the databases, whereof 67 articles were excluded from the analysis.One article was not possible to retrieve, and two articles were focussing on expectations of exergaming and not on the experience of older adults with exergaming.In total 26 were included in this qualitative systematic literature review (Fig. 1).To strengthen the content validity, two authors (LK & PR) independently reviewed the results of each search according to the inclusion and exclusion criteria.Discussions on disagreements receded the final decision on inclusion.

Quality Appraisal of the Studies
For quality appraisal, the Critical Appraisal Skill Programme (CASP UK, 2020) systematic checklist were used to evaluate the rigour of studies (Supplement Table 1).Irrespective of the assessment criteria used to evaluate the quality of the methods in the articles, all relevant studies in the emerging field of exergaming were incorporated if they were deemed to have meaningful results.The quality appraisal serves to demonstrate strengths and weaknesses in method and substance (Supplement Table 1).All articles were summarized based on relevant information about title, authors, settings, method, authors conclusions (Table 1).

Analysis of Studies
All of the included articles were categorised using a qualitative deductive content analysis [19], based on Bowen´s four areas of focus of feasibility [20]: (1) Acceptability, how the participants reacted to the exergaming; (2) Demand, demand of exergaming; (3) Implementation of exergaming, extend, likelihood, and the way exergaming can be implemented in the participants life) (4) Practicality, the extent to which an exergaming can be delivered when resources, time, commitment, or some combination thereof are constrained in some way.The other areas of focus of Bowens framework [20] (adaptation, integration and expansion) were not chosen as this qualitative literature review is focussed on the feasibility of existing interventions and not assess the adaptation, integration and expansion of these interventions.As this study is based on qualitative findings, we also did not include the area of focus: limited-efficacy testing.In the analysis, we used the content in the qualitative result section as the meaningful units and they were read through several times to get familiar with them.A deductive approach goes from the areas of focus to observation to confirmation and often used when existing knowledge is used in a new context [21].In our study, the existing knowledge was Bowens framework [20] of feasibility research.The new context was exergaming in older adults.The meaningful units were extracted and transferred to Nvivo and unconstrained categorization matrix were developed based Bowen´s [20] four areas of feasibility (Acceptability, Demand, Implementation & Practicality).All the meaningful units under each feasibility area were coded by LK and PR.[22] In the next step, subcategories were developed under each of the four areas of focus, following the principles of inductive content analysis [19].The subcategories were discussed among all authors till agreement was reached.Effect sizes for each of the four areas of feasibility (categories) were calculated by the frequency of occurrence (number of articles divided by the total number of articles included in this literature review) for extracting more meaning from those data and verifying the presence of a category or subcategories, and to avoid the possibility of over or underweighting findings [23,24].

Studies Characteristics
In total 26 articles were included in this literature study including a qualitative design.Twelve studies were performed in Europe, seven articles included older adults in USA, three in Canada, two in Australia, one in Asia and one in Africa.Ten studies specifically included older adults with a disease; six studies included patients with stroke, two studies included patients with heart failure, one study included patients with multiple sclerosis, one study included patients with major neurocognitive disorder.Fourteen studies used a commercial exergame platform (e.g.Nintendo Wii or Microsoft Xbox360) and 12 studies developed or adapted an exergame (see Table 1).The literature study showed that most of the qualitative findings were based on content analysis.There were methodological shortcomings in the way the data analyses were presented in the articles included, and in many of the articles where quantitative and qualitative methods are used, the qualitative part functions more as an embellishment of the quantitative data.For further quality appraisal of the articles included in this literature review see supplement Table 1.
The feasibility of exergaming in older adults was presented by four categories based on the areas in the framework for feasibility studies by Bowen [20].The first category, acceptability of exergaming, had two subcategories: enjoyment and social interaction, and functioning in daily life.The second category, demand of exergaming had three subcategories: physical and cognitive demanding, technical challenges, and safety.The third category, implementation of exergaming had three subcategories: follow improvement  and being challenged, exergaming in daily life and suitable for age group.The fourth category, practicality of exergaming had two subcategories: familiarization and home environment (see Fig. 2).

Acceptability of Exergaming
Bowen defines acceptability as the reactions to the intervention, in this case the exergaming.Participants found exergaming enjoyable, especially with social interaction.Exergaming was seen a part of functioning in daily life.In total 23 studies included results on the category acceptability of exergaming (effect size 88%).

Exergaming was Related to Improved Functioning in Daily Life
Some participants perceived that exergaming could improve their functioning in their daily life, [26,36,43,45] increase their physical activity and balance [14,25,30,32,34,35,38,43,44,46] and could increase cognitive function [14,30,38,43,44].Exergaming was seen as a good addition to rehabilitation [31,38].Participants could feel more confidence and empowered in performing their physical tasks and this made them aware that they could do more thinks that they initially assumed [36,37,46].Exergaming was seen as a possible activity for promoting active ageing.

Demand of Exergaming
Bowen defines demand for the exergaming as estimation of use and demand.Exergaming was seen as physical and cognitive demanding.There could be technical and safety challenges with exergaming.In total 25 studies included results on the category demands of exergaming (effect size 96%).
The participants requested that the exergaming should be more intuitive, such as a greeting message to inform the player of when the game was about to start [27,43,45].A short-cut provided in the exergame (e.g. a home button to return to the beginning screen of the exergame) was seen important, as this enabled the participants to navigate easier and could help the acceptability of exergaming [25,28,43].The possibility of music in the exergame and sounds indicating their game performance was seen as important, as this provided encouragement and entertainment value [27,29,42].It was important for participants to be able to mute the music, as feedback provided during the songs could be experienced as distracting and not beneficial to performance [29,38,39].Participants indicated that they liked summary feedback at the end of exergaming or (visual) feedback during exergaming, which should be included in exergaming [25,26,29,30,32,34,35,37,43].

Implementation of Exergaming
Bowen defines implementation regarding the extent, likelihood and in which manner exergaming can be implemented as proposed or planned.To be able to follow improvement and being challenged in the exergame was seen as important to implementation.Participants expressed how to implement exergaming into their daily life.
In total 15 studies included results on the category implementation of exergaming (effect size 58%).

Exergaming in Daily Life
Important for implementation of exergaming in the participants life, was to find routines in exergaming [25,35].Participants that were exergaming for a couple of weeks, did find the exergaming more predictable, which made it harder to maintain exergaming [26,31,35,43].
Participants found exergaming more realistic and therefore easier to implement into daily life when it involved movements that were movements related to everyday life activities or sports, for example walking or bowling [35,44,48].

Practicality of Exergaming
According to Bowen practicality refers to how exergaming can be delivered when resources, time, and commitment are constrained in some way.A good familiarisation was seen as important when starting exergaming and it was seen as convenient when exergaming was possible in the home environment.In total 12 studies included results on the category practicality of exergaming.This category had the lowest effect size of 46%.

Ensuring Sufficient Familiarisation with Exergaming
The results show the importance to a good familiarisation to the exergame, preferable given by health care professionals, to be accepted by the participants as a mode to be physically active [25,26,[35][36][37]45].It takes participant time to get comfortable to play and studies performed telephone followups and even additional home visits to help the participants in starting exergaming [25,26,35,37,45] Participants like and needed to receive clear instructions how exergaming works, form either the game itself, on paper or videos or/and from a health care professional (e.g.occupational therapist or physical therapist) [30,36,37,45].

Practical Implications for Exergaming in Older Adults
For the practical implications for exergaming in older adults, we adapted the GameFlow model [54].This model is designed for healthy adults and gaming, not exergaming in older adults.With the results of the literature review, we adapted this model and named it ExerGameFlow model for older adults (Table 2).

Discussion
This literature review provides implication on the acceptability of exergaming in older adults, the demands of exergaming, the implementation, and practicalities and gave practical implication for the development of exergames and exergame interventions for older adults.
Enjoyment in exergaming, especially when social playing is possible, and functioning in daily life were seen by older adults important for the acceptability of exergaming.Other studies show that if participants feel enjoyment during the physical activity, they increase the amount of physical activity and even are more adherent to physical activity recommendations [50,51].Also the adherence to technology driven exercise is higher due to enjoyment [52] and in gaming, player enjoyment is seen as the goal for a successful game development, as players who do not experience enjoyment will not play the game [53,54].Social interaction is a crucial aspect of computer games for older individuals [55][56][57].Therefore, exergames should enable multiplayer options for playing together or competing.Furthermore, exergaming should foster social communities both within and beyond the game environment.
Exergaming could be experienced as physical and cognitive demanding, and some technical challenges could occur.As also other studies suggests, exergames should match older adults' skill levels and preferences for challenging activities [58,59].Exergames for older adults should support skill development with easy-to-use interfaces and clear instructions [60].Studies show that older adults typically prefer puzzle and strategy games that are easy to learn but provide a challenge [59]and these could be considered in designing exergames for older adults.
While audio elements can enrich the experience, our study show that providing a mute option is beneficial.Incorporating shortcuts can aid navigation.Older adults should feel empowered and in control while exergaming, overseeing their avatars' actions and interactions.They should have autonomy over basic functions like starting or saving, with the game design preventing errors and providing support for recovery if needed.
Safety measures are crucial, requiring hazard-free environments.The physical hardware must ensure safety by preventing tripping and falling, being easily accessible for people with physical disabilities, and simple to sanitize [27,[61][62][63].
For the implementation of exergaming, it is important that they can follow improvement and that they are being challenged.This literature review shows how older adults implement exergaming in their daily life.Exergames should have clear, meaningful goals aligned with players' motivations and interests, guiding both in-game actions and associated physical activities for older adults [64][65][66].Older adults -Exergame interfaces and mechanics should be easy to learn and use -A good familiarisation to the exergame is important, either within the exergame, on paper or through videos or given personally -The surrounding of the physical activity performed with the exergame should be safe (e.g.no slippery floors) -Follow-up after familiarisation (e.g.telephone follow-ups) should be given to motivate the players to be physically active -Exergames should increase the players' skills at an appropriate pace as they progress through the exergame -Players should be rewarded during exergaming for their effort and skill development Control Players should feel a sense of control over their actions in the exergame -Players should feel a sense of control over their avatar or units and their movements and interactions in and with the exergame -Players should feel a sense of control over the exergame interface and input devices -Players should feel a sense of control over the game shell (starting, stopping, saving, etc.).A short-cut should be provided in the exergame, as this enables the players to navigate easy -Players should not be able to make errors that are detrimental to the exergame and should be supported in recovering from errors Clear Goals Exergames should provide the player with clear goals -Exergames should include clear goals in the game and on the players physical activities which they must perform Feedback Players must receive appropriate feedback at appropriate times -Players should receive feedback on the progress in the exergame and the progress of their physical activity -A summary of the exergame results and the results of the physical activity performed should be given at the end of each session -Players should always be able to access their physical activity status or score Immersion Players should experience effortless involvement in the game -Exergames physical activity should be closely related to everyday life activities or sports Social Interaction Exergames should have the possibility to play together with others -Exergaming should have the possibility to play with others or to compete within the exergame or with others -Exergames should have the ability to support social communities inside and outside the game should receive continuous feedback on both their in-game progress and physical activity levels, with comprehensive summaries provided after each session.This direct feedback enhances the exergame experience, making it more rewarding.Older adults should experience effortless involvement in the exergame, which should closely relate to everyday activities or sports.Immersion serves as a key motivator for retention [67].
For the practicalities of exergaming a good familiarisation was seen as important and the possibility to exergame at home.Post-familiarization follow-ups are recommended for sustained engagement.As also shown in other studies, exergaming should ideally be adaptable for home use, with game design enhancing concentration [68,69].

Methodological Considerations
We used available qualitative methodological checklists for evaluating the quality of the studies included in the review and analysed the results of the included articles using an established method.The articles included in this literature review limiting to English, which may have excluded some relevant literature.In addition, we choose to use four of the seven areas of focus of feasibility (acceptability, demand, implementation and practicality) [20] for deductive analysis, as this qualitative literature review is focussed on the feasibility of existing interventions and not assess the adaptation, integration and expansion of exergaming.Although, it is likely that the four areas chosen, described the feasibility of exergaming in older adults, identifying adaptation, integration and expansion of exergaming could have provided additional understanding of exergaming in older adults.

Future Research
To develop and have a deeper understanding of exergaming for older people, well-designed qualitative studies are needed that can stand on their own and provide reliable qualitative data.The results of this literature review can provide guidance for the future development and testing of exergames for older adults and exergame interventions.

Conclusion
In conclusion, exergaming presents promising to increase physical activity among older adults.Based on the experience of older adults, not only did they found exergaming enjoyable, but it also offers cognitive and physical challenges that can enhance overall well-being.However, navigating technical and safety challenges requires careful consideration and support.Thorough familiarization with written and video instructions, ongoing assistance, and ensuring home accessibility are important in successfully introducing exergaming to older adults.Moreover, the importance to be able to follow improvement and tailoring challenges to suit individual needs should be considered.By addressing these factors, exergaming could be a valuable tool in promoting active and healthy aging among older adults.

Fig. 1
Fig. 1 Flowchart for the articles included in the qualitative systematic review

Fig. 2
Fig. 2 Categories and sub-categories for the feasibility of exergaming in older adults

Table 1
Description of the articles included in the systematic review on feasibility of exergaming in older adults

Table 2
ExerGameFlow model criteria for exergaming enjoyment in older adults