As the aging trend intensifies, the demands for primary medical care, assistance with activities of daily living, and measures to control the prevalence and severity of chronic conditions among older adults living in long-term care facilities and nursing homes (NHs) are also expected to increase. Aging is often associated with varying degrees of deterioration in gait performance, balance control and muscle strength, all of which are considered important risk factors for falls.1,2 The 2020 World Health Organization (WHO) Global Report on Falls Prevention in Older Age indicated that approximately 30 %−50 % of older adults who live in NHs experience falls at least once annually, and 40 % of those individuals experience recurrent falls.Anon., 3 According to statistical data, the number of falls among senior care facility residents was three times greater than that among community-dwelling older adults.4 The main reason is that older NH residents are more likely to suffer from sarcopenia, which is characterized by a loss of muscle strength and decreased physical performance, triggering falling and fall-related injuries, such as fracture, hospitalization, multiple trauma, disability and even mortality.5,6 Multiple adverse health outcomes are placing a substantial burden on the healthcare system.

According to the 2020 WHO Report on Mental Health of Older Adults, >20 % of older adults aged > 60 years suffer from mental health problems or neurologic disorders,Anon., 7 and age-related cognitive impairment has become a priority public health issue. Institutionalized older adults may exhibit a greater level of functional dependence due to cognitive decline than community-dwelling residents.8 These issues could be attributed to the environmental stimulation provided by NHs. The conflicts and changes in the psychosocial environment experienced during relocation to NHs can result in impaired cognitive function, which is known as “transfer trauma” or “relocation stress syndrome”.9 Approximately 48 % of older adults experience a clear-cut cognitive decline after institutionalization, and the dependency rate for care is as high as 30 %.10,11 Older NH residents are at greater risk of mild cognitive impairment (MCI), dementia, hospitalization and other complications, including urinary tract infections, pressure ulcers and pneumonia, due to a multidimensional decline in cognitive function.12

Depression is defined as a depressed mood and/or a loss of interest for at least 2 weeks, which might be accompanied by sleep disturbances (insomnia or lethargy), sensory disturbances (guilt or worthlessness), weight changes, irritability or psychomotor delay and fatigue.13 It is estimated that the prevalence of depressive symptoms is approximately 29 % among older NH residents, of whom 10 % have severe depressive disorders.14 The transition to institutionalization is an important stressor that may increase the risk of depression. Moreover, institutionalized older adults frequently feel lonely due to a lack of social interaction, and loneliness is also considered a major risk factor for depression.15 From the perspectives of physical and cognitive function, falling is strongly tied to decreased physical performance, and those who experience falls report emotional disturbances due to the fear of falling and loss of confidence.16 Cognitive decline frequently accompanies negative psychological problems,17 and the three main factors together produce interactive effects.

Virtual reality (VR) is a computerized system that simulates an activity, and it has been employed to promote motor learning and transfer to real-world tasks. This complementary technology bridges the gap between exercise and games and is therefore commonly termed “exergames”. Exergames combine physical activity with cognitively challenging tasks in a single session; they have the advantages of being acceptable, affordable and available and their use has become a trend in recent years.18 Exergames can detect subtle changes in participants’ activities and movements in the real world through wireless interface sensors; participants can receive instant feedback on their movements while immersed in the game's 3-dimensional (3D) world, which will stimulate motor, sensory and mental functions, thereby promoting a willingness to exercise consistently.19 Moreover, various systems are available, such as Nintendo Wii Sports, Microsoft Xbox Kinect and Dance Revolution.20 Exergames enable participants to engage in challenging tasks with visual and auditory stimuli, cues and feedback.21 Immersion in the VR environment can effectively mitigate functional decline and promote cognitive rehabilitation.22,23 Furthermore, virtual gaming is helpful for emotional regulation, real-time decision making, and social interaction to alleviate psychological symptoms.24 Currently, the difficulty levels of VR exergames can be adapted based on users’ conditions and abilities to increase their suitability for older NH residents.

A recent meta-analysis revealed that VR games can overcome the limitations of traditional exercise, improve physical function, enhance balance ability and minimize falls among older adults with impaired balance.25 However, there is insufficient evidence to support the effects of VR games on older individuals residing in NHs. Compared with community-dwelling individuals, institutionalized older adults are more likely to suffer from multiple illnesses that result in worsening somatic and mental conditions. Previous research has shown the benefits of VR training on cognition, including memory, attention and executive function, and identified the different effects between clinical and nonclinical populations.26 These findings suggest that the effects of exergames on cognitive function between different populations need to be further explored. Although a few studies have examined the effects of exergames on mental functioning,13,14 the available evidence is inadequate to reach a consensus. No meta-analysis has summarized the effects of VR exergames on physical function, cognition and depression in older NH residents.

Therefore, the purpose of this systematic review and meta-analysis was to explore the effectiveness of VR exergames in promoting physical function and cognition as well as ameliorating depressive symptoms in older NH residents. Subgroup analyses were conducted based on participants’ characteristics (age, basic physical condition) and intervention characteristics (duration, frequency and cycle, and various types of exergame systems and training formats) to optimize the selection of VR gaming programs.