Study on the Use of Exergames to Support Older Adults With Psychosis

Feasibility of Exergame-based Cognitive-motor Training in Older Psychotic Inpatients: a Randomized Controlled Trial

This study aims to explore a new, engaging approach to support older adults with psychosis-an umbrella term that includes conditions such as schizophrenia, late-onset schizophrenia, and psychotic symptoms resulting from other medical or psychiatric conditions like dementia, delirium, mood disorders, or delusional disorder. As the aging population grows, a rising number of older adults are living with schizophrenia and related disorders, facing not only psychiatric symptoms like hallucinations and delusions but also cognitive impairments, reduced mobility, social isolation, and physical decline. These combined challenges significantly affect daily functioning and quality of life. At present, there are no psychosis treatment guidelines specifically tailored for people aged 60 and above, though general principles from younger populations can be adapted. Evidence suggests that integrating physical and cognitive rehabilitation into standard psychiatric care may enhance treatment outcomes for this age group. One promising method is the use of "exergames"-interactive video games that combine physical movement with cognitive challenges. These games typically require users to perform body movements such as stepping or shifting weight in response to visual and auditory cues, thereby training functions like attention, memory, balance, coordination, and executive function. Exergames offer a playful and stimulating alternative to conventional exercises and are often better accepted by older patients because of their engaging and motivating nature. Previous studies have shown that older adults with schizophrenia not only tolerate these games well but may also experience improvements in mood, cognitive function, and physical activity levels. However, past research has been limited by small sample sizes, lack of control groups, and short intervention periods. This current study, conducted at the Psychiatric University Hospital in Basel, Switzerland, seeks to examine the feasibility and benefits of using an exergame system called Dividat Senso in a more structured and controlled setting. After being screened for eligibility, participants will be randomly assigned to one of two groups. The intervention group will receive usual psychiatric inpatient care, extended with exergame-based motor-cognitive training using the Dividat Senso platform. This device requires full-body interaction, targeting both cognitive functions (such as attention, memory, and executive skills) and physical abilities (such as balance and coordination). The control group will also receive usual care, but instead of exergames, they will participate in traditional strength and balance exercises taken from the Otago falls prevention program. Both groups will train three times a week for four weeks, with each session lasting approximately 20 minutes-totaling 12 sessions. All participants will complete assessments before the intervention begins (T1) and again after four weeks (T2), to measure changes in physical activity, mental well-being, and cognitive performance. By using a structured program and comparing two active interventions, this study aims to generate more robust and generalizable findings on how technology-based, body-and-brain training can support the mental and physical health of older adults with psychosis. If proven feasible and effective, exergame-based rehabilitation could become a valuable and enjoyable addition to psychiatric treatment programs for elderly patients.

Elderly patients with psychosis can be categorized into three groups: those with a history of schizophrenia, those with a new diagnosis of schizophrenia (late-onset), and those experiencing hallucinations or delusions due to other conditions such as dementia, delirium, delusional disorder, mood disorders, or paranoid personality disorders. The elderly population with schizophrenia represents a growing segment of older adults, with an estimated prevalence of 4-6% among people over 65 years old and around 10% among those over 85. Core features associated with psychosis include hallucinations, which are perceptions without external stimuli, and delusions, which are fixed false beliefs maintained despite evidence to the contrary. Other symptoms linked to psychosis include thought interference, thought disorder, apathy, social withdrawal, and blunted affect. Currently, there are no specific guidelines for managing primary psychotic disorders in adults aged 60 and older, but some general principles can be adapted from guidelines for other age groups. Existing recommendations for adults under 60 emphasize addressing not only psychiatric symptoms but also other health factors that affect overall well-being. Given the significant impact of cognitive and physical impairments, social isolation, and sensory deficits on symptoms in older adults, an integrated approach addressing both mental and physical health could improve treatment outcomes in this population. Research has shown that greater severity of schizophrenia symptoms and neurocognitive impairments are associated with reduced levels of physical activity, and that effective physical activity interventions should include components that enhance cognition and reduce psychiatric symptoms. One specific form of physical activity is exergaming, which combines physical exercise with cognitive stimulation through gameplay. Exergames involve multisensory stimuli, including auditory, visual, and somatosensory modalities, requiring engagement of various cognitive functions such as executive functions, visual and verbal memory, attention, and other multidimensional cognitive processes. Exergames offer several advantages over conventional exercise in enhancing cognitive functions by integrating cognitive demands into physical tasks. Furthermore, exergames promote better long-term adherence to exercise due to their gamified and motivational nature. Previous studies suggest that video game-based physical activity programs have higher acceptability and adherence rates among older adults with schizophrenia. Similar results were observed in chronic psychiatric inpatient populations, where full-body interaction during computerized cognitive training led to cognitive improvements and reduced depressive symptoms. Additionally, video game-based physical activity programs have increased the frequency of self-reported physical activity among older adults with schizophrenia. Meta-analytical evidence suggests that virtual reality exergames may positively influence cognition and depression in older populations. However, current evidence is limited by small sample sizes, low participant heterogeneity, inadequate training duration and frequency, and lack of control groups. To obtain generalizable findings on the feasibility and effects of exergame-based motor-cognitive training in inpatient settings for older patients with psychosis, future research should include frequent, structured training sessions, heterogeneous samples, and control groups. Technological advancements over recent decades have increased the availability of digitalized motor-cognitive training options. One such option is the use of a "step plate" for exergame training, such as the Dividat Senso. These exergames specifically target cognitive functions essential for daily living, including executive functions, attention, as well as physical abilities like balance and coordination. The games are played through body movements and weight shifting. To examine the feasibility and effects of exergame-based motor-cognitive training in older psychiatric inpatients, we plan to use the Dividat Senso device. After eligibility screening, participants undergo baseline assessment (T1) and are randomly assigned to one of two groups. The intervention group receives conventional treatment at the psychiatric hospital extended by technology-based motor-cognitive training using Dividat Senso. The control group receives conventional treatment plus strength and balance exercises from the Otago falls-prevention program. The intervention lasts four weeks, with participants requested to engage in short training sessions three times per week for 20 minutes each, totaling 12 sessions. After the intervention period, all participants undergo a post-intervention assessment (T2).

Inclusion Criteria:

• Diagnosed psychotic disorders
• Able to provide a signed informed consent
• Age ≥ 55 years
• MoCA ≥ 20
• Physically able to stand for at least 3 minutes without external support (self-report)

Exclusion Criteria:

• Insufficient knowledge of the German language to understand the instructions, the games, and the assessments
• Mobility, cognitive, sensory and/or psychiatric limitations or comorbidities that impair the ability to play the exergames and/or conduct the pre-/post assessments