View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT) Exergaming is an innovative form of exercise that combines physical activity with cognitive stimulation in a gaming environment. During the COVID-19 pandemic, exergaming has exploded in popularity and entered the mainstream through companies such as Peloton. The platform offers potential for people with dementia to be mentally and physically stimulated in a controlled, safe environment. However, such technology can be expensive, and the benefits to people with dementia are uncertain. What are the physical and cognitive benefits to exergaming in people with dementia? Reference: Van Santen J, et al. Effects of Exergaming on Cognitive and Social Functioning of People With Dementia: A Randomized Controlled Trial. J Am Med Dir Assoc 2020;21:1958–1967.e5. DOI: 10.1016/j.jamda.2020.04.018. This cluster-randomized control trial looked at community-dwelling, physically able Dutch people with dementia and sought to compare the effects of exergaming (stationary bicycle and interactive screen) with the usual activity offerings. The primary outcomes of physical activity and mobility showed no difference. There were benefits in the secondary outcomes of cognitive function and social functioning in people living with dementia and trends on distress and subjective burden and sense of competence of their caregivers. However, the study did not have enough participants to draw strong conclusions. In addition, attitudes toward and compliance with the intervention, which was implemented by day-care staff, were not reported. Decision-makers for day-care centers need more information to decide if exergaming would be a valuable addition. Exergaming is increasing in popularity and may hold potential for people with dementia. Combining exercise with a gaming environment gives people with dementia access to safe exercise without having to worry about weather, getting lost, or hazards. Furthermore, it increases the pleasure and cognitive stimulation associated with exercise, which might allow for longer periods of engagement. In this case, the participants could choose from several bicycle trips that would show on the screen as they pedaled the stationary bike. While this sounds good, there are real costs with buying the devices ($2,000 to $5,000), and the benefits are not well established for people with dementia. This study aimed to determine the benefits to exergaming in people with dementia and is part of a larger study looking at the cost-effectiveness and implementation of exergaming, which have yet to be reported. In the Netherlands, 23 day-care centers were randomized either to continuing their current activities (such as arts and crafts, music, and physical exercise such as walking outdoors) or to having current activities and exergaming offered five times per week. Exergaming was provided in the form of a stationary bike with a monitor to mimic outdoor biking, which the day-care center bought at a discounted price (around $2,000 to $5,000). The participants were included if they had dementia, lived in the community, visited the day care at least twice a week, and could participate in the interactive cycling. The data were collected at baseline, after three months, and after six months. There were 11 day-care centers in the exergaming group and nine in the control group after dropouts. The exergaming group had 68 people with dementia at baseline, 60 at the three-month follow-up evaluation, and 52 at the six-month follow-up evaluation (24% dropout). The control group had 39 participants at baseline, 34 at the three-month follow-up evaluation, and 32 at the six-month evaluation (18% dropout). The groups had no major differences when looking at age, gender, body mass index (BMI), dementia score or type, living situation, or other demographics. The average age was 79 years, gender was equally split between men and women, and the average Mini-Mental State Examination (MMSE) score was 18 to 19, suggestive of mild dementia. Of note, the participants had an average BMI of 28, and approximately 80% had previous experience with cycling. The results at baseline, three months, and six months were analyzed using an intention-to-treat (analyzed based on their group assignment, regardless of their participation in exergaming) mixed model (allowing researchers to see the effect of time, known variables, and random variables). The primary outcomes analyzed were (1) lower body function measured by the Short Physical Performance Battery (0–12 scale) and (2) minutes of total physical activity per week. There was no difference between the two groups. Of note, the average person at baseline exercised between three to five hours per week, which might be high in relation to time spent in exercise by people from other cultures. The secondary outcomes included 15 measures of cognitive, emotional, social functioning, quality of life, and physical outcomes. Only two measures were found to be statistically significant. The MMSE stayed the same in the exergaming group while it dropped by about 2 points in the control group. The Trail Making Test-A (TMT-A) was improved by six seconds in the exergaming group as compared with worsening by 15 seconds in the control group. Several issues may have limited the ability of this study to show positive effects. Power to detect a difference was estimated on secondary measures, not primary measures. Regardless, the study was likely underpowered to detect improvement on the primary outcome measures as well. In addition, because only the total activity time was reported, how much time was really spent exergaming is not clear. Finally, this Dutch population was generally fit and exercised three hours or more a week at baseline. Although benefits were seen in MMSE and TMT-A, we are interpreting them cautiously because of the overall number of tests performed, which increases the likelihood that the significant changes are due to chance as the authors indicate. We suspect the participants with advanced dementia were more likely to drop out of the study, and we wonder whether there was a difference in the dropout characteristics when comparing the exergaming and control groups. Also, the TMT-A (connecting numbers in ascending order) is a simpler and less clinically meaningful test than the TMT-B (alternating numbers and letters in ascending order), which showed no difference. However, the possibility that exercise improves or stabilizes cognitive function for individuals with dementia could in and of itself be a powerful outcome that would be meaningful and desirable for both individuals with dementia as well as their caregivers if it can be confirmed in larger studies. We hope that the researchers will publish their implementation data. What was the burden on the staff related to changing their existing workflow, especially if only one or two devices were available? After the study had been completed, did the participants continue to use the interactive bikes? While exergaming is a promising technology, we need more data to understand the benefits. This will require larger studies looking at the benefits to people with dementia across varied populations and abilities. Data are also needed on facilitators for implementation and on barriers, such as the costs and burdens of implementing exergaming. Until then, we can continue to promote exercise among persons living with dementia for myriad other reasons such as fall and injury prevention, better mobility, and enhanced quality of life. If exergaming devices are available, they may improve participation by offering an enhanced experience, which may thus provide caregivers with needed respite while the person with dementia engages in a safe activity that does not require the caregiver’s hands-on attention. Dr. Salaami is a clinical geriatric fellow at Duke University. Dr. White is professor of medicine and clinical vice-chief of geriatrics at Duke University. Dr. Oyola Little is an associate professor of geriatric medicine at Duke University.