Introduction: Anxiety and depression are prevalent among older adults, and digital interactive interventions have shown promise in promoting their mental well-being. However, limited research has explored the effects of different types of digital interactive interventions across various devices on anxiety and depression in older adults with different health conditions. Methods: A systematic literature review and meta-analysis were conducted using seven selected databases to identify relevant studies up to July 19, 2023. Two reviewers independently conducted study selection, data extraction, and quality appraisals. The risk of bias in the included studies was assessed using the Cochrane risk-of-bias tool. For the meta-analysis, the effect size was calculated as the standardized mean difference (SMD) using a random-effects model. Results: A total of 20 randomized control trails involving 1,309 older adults fulfilled inclusion criteria. The meta-analysis results demonstrates that the digital interactive intervention technologies had a significance on depression (SMD = −0.656 s, 95% confidence interval [CI] = −0.992 to −0.380, p < 0.001) and anxiety (SMD = −0.381 s, 95% CI = −0.517 to −0.245, p < 0.001). Physical interactive interventions demonstrated a significant effect on depression and anxiety (SMD = −0.711 s, 95% CI = −1.102 to −0.319, p < 0.001) and (SMD = −0.573 s, 95% CI = −0.910 to −0.236, p = 0.001). Similarly, immersive interactive interventions also showed a significant effect on depression and anxiety (SMD = −0.699 s, 95% CI = −1.026 to −0.373, p < 0.001) and (SMD = −0.343 s, 95% CI = −0.493 to −0.194, p < 0.001). Additionally, in the internal medicine group, significant intervention effects were observed for depression (SMD = −0.388, 95% CI = −0.630 to −0.145, p = 0.002) and anxiety (SMD = −0.325, 95% CI = −0.481 to −0.169, p < 0.001). Similarly, in the neurocognitive disorders group, significant intervention effects were found for depression (SMD = −0.702, 95% CI = −0.991 to −0.413, p < 0.001) and anxiety (SMD = −0.790, 95% CI = −1.237 to −0.342, p = 0.001). Conclusion: The results indicated that various digital interactive devices, including physical and immersive interactive devices, have a positive impact on depression and anxiety among older adults. However, mobile games were not effective in addressing depression. Digital interactive technologies did not significantly influence anxiety intervention, except for elderly individuals undergoing surgical procedures. Nevertheless, these interventions effectively addressed depression and anxiety in older individuals with neurocognitive disorders, internal medical issues, and those without health issues.

The global aging population is rapidly increasing, and by 2030, it is projected that approximately 17% of the world’s population, which is estimated to be 14 billion, will be aged 60 years or older. According to data from the World Health Organization (WHO), approximately 15% of adults aged 60 and over suffer from mental health problems [1]. In particularly, anxiety and depressive disorders have a high prevalence among the older adults population [2]. With the continuous increase in age, older adults are inevitably confronted with deteriorating soma, declining cognitive abilities [3, 4], inadequate psychological counseling, and reduced social networks [5, 6], all of which exacerbate the risk of depression or anxiety among the elderly.

Depressive and anxious can significantly disrupt the lives of older adults, impairing their basic activities of daily living, independence, and autonomy [7]. Furthermore, anxiety and depression, as persistent mental health issue, have significant impacts on the physical health of older adults [8]. Common symptoms associated with anxiety and depression include sweating, dizziness, and changes in appetite or weight [9‒11]. Although pharmacological treatment approaches are currently available for mental health interventions in the older adults, the aging issues related to drug metabolism and the vulnerability of older adults to certain side effects make it challenging to directly intervene with mental health through medication [12].

Researchers proposed that digital interactive interventions are one of the effective ways to promote older adults’ mental health [13]. These interventions can be conducted online or independently, using various digital platforms such as computers, video game consoles, and mobile devices [14]. In recent years, there has been an increasing recognition of the advantages associated with digital interventions in promoting the mental health of older adults. Despite the challenges posed by age-related physical decline, cognitive limitations, and difficulties in learning [15‒17], there has been a gradual increase in both clinical and research-based digital interventions for older adults [18, 19]. According, studies have investigated the efficacy of various digital interventions using systematic literature reviews and meta-analyses in addressing mental health issues among older adults. However, these studies have mostly employed specific technological or device classifications, such as serious game [20], virtual reality [21], and exergames [22]. In comparison, digital interactive interventions encompass a combination of diverse devices, technologies, and modes of interaction [23]. Therefore, it is important not only to focus on specific technological or equipment categories but also to include digital interactive intervention techniques as much as possible. This will contribute to a better understanding and application of these intervention measures and facilitate a comprehensive exploration of the effects of digital interactive technology on mental health intervention for the elderly.

Hence, this systematic review and meta-analysis aims to encompass a wide range of digital interactive intervention techniques, rather than being limited to specific types of interventions or device classifications. Additionally, considering that older adults are more likely to have chronic illnesses or undergo long-term treatment [24], their physical condition may be one of factors to mental health and emotional issue [25]. Accordingly, this study will also conduct subgroup analyses based on the health status of older adults in the intervention groups. The objectives of this research were to compare the impact of different digital interactive intervention measures on mental health issues in older adults, and further explore the moderation effect of physical health status on the relationships between mental health issues and the effectiveness of interventions. Additionally, the effectiveness of these interventions in alleviating anxiety and depression symptoms will also be examined within different intervention groups.

The review adhered to the Cochrane Collaboration guidelines [26] and was conducted and reported accordingly. It was registered on the PROSPERO platform under the registration number CRD42023445765.

Search Strategy and Selection Criteria

The following databases were used and searched for relevant studies up until July 19, 2023: Web of Science, Medline, Academic Search Premier, CINAHL Complete, PsycINFO, Psych ARTICLE, and PubMed. The search terms included: (Older adult* OR elder* OR senior* OR aged 50 OR ageing OR aging OR geriatric*) AND (virtual real* OR vr OR video gam* OR computer gam* OR exergam* OR interactive gam* OR xbox OR kinect OR playstation OR nintendo OR wii) AND (depress* OR anxi* OR stress* OR distress*) AND (random* OR randomi?ed controlled trial* OR rct*).

Inclusion for the meta-analysis was based on studies that satisfied the following criteria: (1) RCT studies only; (2) participants with a mean age of above 50 years; (3) interventions implemented serious games, such as exergames, wearable devices, virtual reality games, or digital games; (4) comparison that received usual care or nonserious interventions in the control group; (5) outcomes measuring in emotional and mental health problems; (6) published in English and peer-reviewed journals. The exclusion criteria were as follows: (1) studies not in English; (2) thesis, dissertation, or conference and abstracts only; (3) not use any form of technology, and not for older adults; (4) studies that have implemented varying levels of dose or intensity for the serious game intervention specifically in the control group; (5) no quantitative comparison between study groups; (6) not related to emotional or mental problems.

Study Selection

After searching for all the studies in the totally 7 electronic databases, there are three step processes was implemented in the following study selection: (1) two researchers conducted an initial review by screening the titles and abstracts to identity the relevant articles; (2) the full text of the identified articles was reviews according to inclusive criteria; (3) the reference lists of the included studies were screened to identify any additional relevant publications. The third researcher intervened in the study selection process to address and resolve all discrepancies between the two researchers through discussions.

Data Extraction

Data extraction was conducted independently by two researchers for the included articles. The data and information comprised first author, published year and region. Study design included sample size and groups in the experiment. Participants’ characteristics included distribution of gender, health status, age (mean and SD). Details of the interventional group details included technology used, content, duration, frequency, time, as well as type of control group. Outcome characteristics comprised the measurements of emotional and mental health, the mean result and SD for both the intervention and control groups after the experiment. If the required data for analysis could not be found in the article or if the available data do not meet the format requirements for mean and SD, researchers requested data from the respective authors via email.

Data Analysis

To assess the effectiveness of digital interactive interventions on mental health, we employed the comprehensive Meta-Analysis 3.0. The meta-analysis involved calculating the standardized mean difference (SMD) along with a 95% confidence interval (CI) for the outcome measures to estimate the effect size. Heterogeneity among the studies was assessed using the I2 statistic [27, 28]. A low level of heterogeneity was considered when the I2 value was less than 40% [28]. To account for potential unexplained heterogeneity among the selected trials, a random-effects meta-analysis was employed to estimate all measures [28]. Publication bias was assessed using Egger’s regression test. Statistical significance was determined using a threshold of p values <0.05 [29].

In addition, we conducted subgroup analyses to further investigate the impact of different modes of interaction with digital technologies and participants’ health conditions on the effectiveness of the interventions. The intervention groups were categorized based on the mode of interaction, including immersive interaction, physical interaction, and mobile games. Furthermore, participants were also classified into subgroups based on the health issues.

Risk of Bias Assessment

The risk of bias in the included trials was independently assessed by two authors (Author 1* and Author 2*) using the revised Cochrane risk-of-bias tool. The assessment encompassed five domains: randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result [30]. Each domain was categorized as “low risk,” “some concerns,” or “high risk” based on the responses to the specific items within each domain [30].

Quality of Evidence Assessment

To evaluate the quality of evidence, we utilized the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines, which categorize evidence into four levels: high, moderate, low, and very low [31]. The overall assessment of evidence quality is determined by evaluating factors such as risk of bias, imprecision, inconsistency, indirectness, publication bias, effect size, dose-response relationship, and confounding factors.

Selected Studies

As shown the literature research and review process in the Figure 1. We initially identified 476 articles, out of which 130 were excluded due to duplications. From the remaining 346 articles, we conducted a screening based on titles and abstracts. Sixty studies appeared to be potentially relevant and were reviewed in full text. Twenty-eight articles met the predefined inclusion criteria. However, despite our attempts to obtain the necessary data from the authors, 8 out of the 12 studies did not provide sufficient information for meta-analysis. Therefore, we conducted the meta-analysis with a total of 20 studies [32‒51].

Fig. 1.

Flow of study selection and review.

Fig. 1.

Flow of study selection and review.

Close modal

Trial Characteristics for Meta-Analysis

The characteristics of the 20 included studies can be found in Table 1. A total of 1,309 older adults were involved in these studies. The mean age of the participants ranged from 50.5 to 85.3 (SD = 2.57–15.62), and the sample size of each study varied between 12 and 346. Among these 20 studies, all control groups received usual care and conventional lifestyle and exercise practices.

Table 1.

Characteristics of the 20 papers in the systematic review

First author, publication yearSample size (n) and mean age (SD) (years)Health statusTrial duration and frequencyOutcome measuresQuestionnaireTreatment in control groups
Braulio Evangelista de Lima [39] (2021) N = 29, IG = 67.2 (4.4), CG = 68.0 (6.1) Without cognitive impairment and movement limitations 1 h, 3 times per week for 6 weeks Anxiety The Spielberger state-trait anxiety inventory (STAI) trait No exercise 
The Spielberger state-trait anxiety inventory (STAI) state 
Roberta L Rica et al. [40] (2020) N = 50, all >60 years Without cognitive impairment and movement limitations 1 h, 3 times per week for 3 months Depression Beck depression inventory Maintain their activities of daily living 
Guorong Chen et al. [41] (2021) N = 346, IG = 52.6 (11.4), CG = 50.5 (12.5) Diagnosed with colonic disease Watch a 6-min VR, when they accept treatment Anxiety Self-rated sleep quality Accept conventional education on bowel preparation before colonoscopy 
Mostafa Keshvari [42] (2021) N = 80, IG = 50.95 (4.120), CG = 52.08 (4.002) Diagnostic coronary artery angiography through radial artery Viewed a 5-min VR film before the start of the angiography Anxiety Short form of Spielberger state-trait anxiety inventory (STAI) Accept conventional angiography and complete the study questionnaires 
Joanna Szczepańska-Gieracha [43] (2021) N = 23, IG = 70.18 (4.87), CG = 71.25 (4.41) Average intensity of depression symptoms amounted to 12.26 in the geriatric depression scale (GDS-30) Support meeting: 1 h per time 1 week for 2 times Depression Geriatric depression scale (GDS-30) Received the standard treatment (40 min in general fitness training and 20 min of health-promoting education and psychoeducation twice a week) 
VR therapy: totally 8 sessions, 20 min per time, 2 times per weeks for 4 weeks Anxiety Hospital anxiety and depression scale-A (HADS) 
Depression and anxiety (total) Hospital anxiety and depression scale (HADS) 
Sam Yeol Wi [44] (2013) N = 40, IG = 76 (5.68), CG = 74.55 (4.45) Diagnosed as having degenerative osteoarthritis of the knees 30 min, 3 times per week for 4 weeks Depression Korean version of the short geriatric depression scale (SGDS-K) Undergo the standard treatment 
Sandra Jóźwik [45] (2021) N = 77, IG = 66 (9.73), CG = 63.96 (6.89) Undergoing phase II CR (cardiac rehabilitation) Standard CR: 40 min, 3 times per week for 8 sessions. and VR therapy: 8 sessions Depression Hospital anxiety and depression scale-D (HADS) Standard CR and Schultz Autogenic Training (Schultz Autogenic Training is a self-regulation and relaxation training method, it is widely used to cope with stress, anxiety, insomnia, and other issues related to mind-body balance) 
Anxiety Geriatric depression scale (GDS-30) 
Depression and anxiety (Total) Hospital anxiety and depression scale-A (HADS) 
Hospital anxiety and Depression scale (HADS) 
Ruby Yu [46] (2015) N = 32, year range 70–90 With mild-to-moderate dementia 30 min, 1–2 times per week for 8 sessions Depression Chinese version of the Cornell scale for depression in dementia (CSDD) Received conventional cognitive training activities 
Nathalie Swinnen et al. [37] (2021) N = 45, IG = 84.7 (5.6), CG = 85.3 (5.6) With major neurocognitive disorder (MNCD) residing in long-term care facilities 25 min, 3 times per week for 8 weeks (10 min walk to exercise room +15 min of exergaming) Depression Cornell scale for depression in dementia Seated listening to favorite music (control group), at a same volume, added to care as usual (care as usual consisted of pharmacotherapy and physiotherapy focusing on comfort care) 
Joaquin A. Anguera [47] (2017) N = 24, IG = 66.9 (6.8)CG = 69.4 (5.6) Suffering from major depression Problem solving therapy 8 weeks and cognitive intervention 20 min, 5 days per week for 4 weeks Depression Hospital anxiety and depression scale-D (HADS) Problem solving therapy for 8 weeks 
Phase one lasting 3 weeks is psychoeducational 
Phase two consists of independent practice of the PST skills 
Phase three consists of two relapse preventions sessions, using the problems solving model to develop plans to maintain depression and functional treatment gains 
Selda Karaveli Cakır [48] (2021) N = 60, IG = 56.33 (11.8), CG = 56.20 (15.62) Consisted of patients who underwent colonoscopy Watch a licensed virtual reality application, started 1 min before the colonoscopy process, which lasted 5–12 min on average: colonoscopy was performed on patients in both groups by the same gastroenterologist without the use of anesthesia Anxiety The state-trait anxiety inventory (STAI) Standard colonoscopy was performed 
Daniel Collado-Mateo [49] (2017) N = 83, IG = 52.52 (9.73), CG = 52.47 (8.75) Women with fibromyalgia 1 h, per sessions, 2 sessions per week for 8 weeks Depression Fibromyalgia impact questionnaire (FIQ) Continued their normative daily life 
Anxiety Fibromyalgia impact questionnaire (FIQ) 
Vishnunarayan G Prabhu [32] (2020) N = 12, Mean age = 66.1±7 Undergoing total knee arthroplasty 3-min baseline data collection and 5 min trained on biofeedback breathing or practice in the VR environment Anxiety State-trait anxiety inventory-6 (STAI-6) 3-min baseline data collection and 5 min other data collection (aim to consistent with the VR group) 
Lee Fuchs [33] (2022) N = 55, IG = 70 (7), CG = 70 (7) Undergoing primary total knee arthroplasty 15-min continuous passive motion (CPM) device physiotherapy with VR headset watch a movie Anxiety State-trait anxiety inventory-6 (STAI-6) 15-min continuous passive motion device (CPM) regular physiotherapy 
Błażej Cieślik [34] (2023) N = 60, IG = 68.77 (5.57), CG = 67.53 (5.51) With depressive symptoms 30-item Geriatric depression scale (GDS-30) score of <10 or a hospital anxiety and depression scale (HADS) score of <8 Gym: 40 min, 2 times per week for 4 weeks and VR Intervention: 20 min, 2 times per week for 4 weeks Depression Geriatric depression scale (GDS) Gym: 40 min, 2 times per week for 4 weeks 
Anxiety Hospital anxiety and depression scale-A (HADS) Relaxation: consisted of breathing exercises with muscle relaxation and guided imaginary: 20 min (10 min group relaxation + 10 min psychoeducation), 2 times per week for 4 weeks 
Depression and anxiety Hospital anxiety and depression scale (HADS) 
Beatrice Moret [35] (2022) N = 57, IG = 70.13 (3.73), CG = 71.11 (3.72) Without cognitive impairment and movement limitations 8 exercise session and 2 assessment sessions 45 min, 3–4 times per weeks for last 2–3 weeks Depression Beck depression inventory II (BDI-II) Continue the daily routine 
Nathalie Swinnen et al. [36] (2023) N = 18, IG = 81.9 (8.2), CG = 84.2 (5.9) With major neurocognitive disorder (MNCD) 3 session per week for 12 weeks Depression Cornell scale for depression in dementia (CSDD) Traditional exercise 15-min walk and 15-min standardized squatting and stepping exercise 
Each session consisted a walk to exercise room 15 min and 30 min of exergaming and a walk back to the ward 
Daniel Schoene et al. [38] (2015) N = 81, IG = 82 (7), CG = 81 (7) Without cognitive impairment and movement limitations 20 min, 3 times per week for 16 weeks Depression Patient health questionnaire (PHQ-9) People were given a brochure about evidence-based information on various health-related topics, such as fall prevention, staying active, exercising at home, healthy eating, eyesight care, choosing footwear and mobility and walking aids, and continue with their usual activities 
Kyeongjin Lee [50] (2023) N = 90, IG = 82 (7), CG = 81 (7) Without cognitive impairment and movement limitations Online education: 50 min, every week for 8 weeks, exergame program, 50 min, 3 times per week for 8 weeks Depression Depression was measured using the geriatric depression scale (GDS) Participants in the control group were not provided with any exercise instructions and no exercise program that could affect posttest results was implemented 
Zhou, He et al. [51] (2020) N = 73, IG = 62.7 (6.8), CG = 66.5 (10.0) End-stage renal disease 30 min, every week for 4 weeks, exergame program (including break time), Performed the hemodialysis treatment Depression Center for epidemiologic studies depression (CES-D) scale Receiving hemodialysis for three sessions per week 
During each hemodialysis session, a nursing staff instructed the participant in the CG to participate in a 30 min non-weight-bearing foot rotation intradialytic exercise program (including breaks) without any technology 
First author, publication yearSample size (n) and mean age (SD) (years)Health statusTrial duration and frequencyOutcome measuresQuestionnaireTreatment in control groups
Braulio Evangelista de Lima [39] (2021) N = 29, IG = 67.2 (4.4), CG = 68.0 (6.1) Without cognitive impairment and movement limitations 1 h, 3 times per week for 6 weeks Anxiety The Spielberger state-trait anxiety inventory (STAI) trait No exercise 
The Spielberger state-trait anxiety inventory (STAI) state 
Roberta L Rica et al. [40] (2020) N = 50, all >60 years Without cognitive impairment and movement limitations 1 h, 3 times per week for 3 months Depression Beck depression inventory Maintain their activities of daily living 
Guorong Chen et al. [41] (2021) N = 346, IG = 52.6 (11.4), CG = 50.5 (12.5) Diagnosed with colonic disease Watch a 6-min VR, when they accept treatment Anxiety Self-rated sleep quality Accept conventional education on bowel preparation before colonoscopy 
Mostafa Keshvari [42] (2021) N = 80, IG = 50.95 (4.120), CG = 52.08 (4.002) Diagnostic coronary artery angiography through radial artery Viewed a 5-min VR film before the start of the angiography Anxiety Short form of Spielberger state-trait anxiety inventory (STAI) Accept conventional angiography and complete the study questionnaires 
Joanna Szczepańska-Gieracha [43] (2021) N = 23, IG = 70.18 (4.87), CG = 71.25 (4.41) Average intensity of depression symptoms amounted to 12.26 in the geriatric depression scale (GDS-30) Support meeting: 1 h per time 1 week for 2 times Depression Geriatric depression scale (GDS-30) Received the standard treatment (40 min in general fitness training and 20 min of health-promoting education and psychoeducation twice a week) 
VR therapy: totally 8 sessions, 20 min per time, 2 times per weeks for 4 weeks Anxiety Hospital anxiety and depression scale-A (HADS) 
Depression and anxiety (total) Hospital anxiety and depression scale (HADS) 
Sam Yeol Wi [44] (2013) N = 40, IG = 76 (5.68), CG = 74.55 (4.45) Diagnosed as having degenerative osteoarthritis of the knees 30 min, 3 times per week for 4 weeks Depression Korean version of the short geriatric depression scale (SGDS-K) Undergo the standard treatment 
Sandra Jóźwik [45] (2021) N = 77, IG = 66 (9.73), CG = 63.96 (6.89) Undergoing phase II CR (cardiac rehabilitation) Standard CR: 40 min, 3 times per week for 8 sessions. and VR therapy: 8 sessions Depression Hospital anxiety and depression scale-D (HADS) Standard CR and Schultz Autogenic Training (Schultz Autogenic Training is a self-regulation and relaxation training method, it is widely used to cope with stress, anxiety, insomnia, and other issues related to mind-body balance) 
Anxiety Geriatric depression scale (GDS-30) 
Depression and anxiety (Total) Hospital anxiety and depression scale-A (HADS) 
Hospital anxiety and Depression scale (HADS) 
Ruby Yu [46] (2015) N = 32, year range 70–90 With mild-to-moderate dementia 30 min, 1–2 times per week for 8 sessions Depression Chinese version of the Cornell scale for depression in dementia (CSDD) Received conventional cognitive training activities 
Nathalie Swinnen et al. [37] (2021) N = 45, IG = 84.7 (5.6), CG = 85.3 (5.6) With major neurocognitive disorder (MNCD) residing in long-term care facilities 25 min, 3 times per week for 8 weeks (10 min walk to exercise room +15 min of exergaming) Depression Cornell scale for depression in dementia Seated listening to favorite music (control group), at a same volume, added to care as usual (care as usual consisted of pharmacotherapy and physiotherapy focusing on comfort care) 
Joaquin A. Anguera [47] (2017) N = 24, IG = 66.9 (6.8)CG = 69.4 (5.6) Suffering from major depression Problem solving therapy 8 weeks and cognitive intervention 20 min, 5 days per week for 4 weeks Depression Hospital anxiety and depression scale-D (HADS) Problem solving therapy for 8 weeks 
Phase one lasting 3 weeks is psychoeducational 
Phase two consists of independent practice of the PST skills 
Phase three consists of two relapse preventions sessions, using the problems solving model to develop plans to maintain depression and functional treatment gains 
Selda Karaveli Cakır [48] (2021) N = 60, IG = 56.33 (11.8), CG = 56.20 (15.62) Consisted of patients who underwent colonoscopy Watch a licensed virtual reality application, started 1 min before the colonoscopy process, which lasted 5–12 min on average: colonoscopy was performed on patients in both groups by the same gastroenterologist without the use of anesthesia Anxiety The state-trait anxiety inventory (STAI) Standard colonoscopy was performed 
Daniel Collado-Mateo [49] (2017) N = 83, IG = 52.52 (9.73), CG = 52.47 (8.75) Women with fibromyalgia 1 h, per sessions, 2 sessions per week for 8 weeks Depression Fibromyalgia impact questionnaire (FIQ) Continued their normative daily life 
Anxiety Fibromyalgia impact questionnaire (FIQ) 
Vishnunarayan G Prabhu [32] (2020) N = 12, Mean age = 66.1±7 Undergoing total knee arthroplasty 3-min baseline data collection and 5 min trained on biofeedback breathing or practice in the VR environment Anxiety State-trait anxiety inventory-6 (STAI-6) 3-min baseline data collection and 5 min other data collection (aim to consistent with the VR group) 
Lee Fuchs [33] (2022) N = 55, IG = 70 (7), CG = 70 (7) Undergoing primary total knee arthroplasty 15-min continuous passive motion (CPM) device physiotherapy with VR headset watch a movie Anxiety State-trait anxiety inventory-6 (STAI-6) 15-min continuous passive motion device (CPM) regular physiotherapy 
Błażej Cieślik [34] (2023) N = 60, IG = 68.77 (5.57), CG = 67.53 (5.51) With depressive symptoms 30-item Geriatric depression scale (GDS-30) score of <10 or a hospital anxiety and depression scale (HADS) score of <8 Gym: 40 min, 2 times per week for 4 weeks and VR Intervention: 20 min, 2 times per week for 4 weeks Depression Geriatric depression scale (GDS) Gym: 40 min, 2 times per week for 4 weeks 
Anxiety Hospital anxiety and depression scale-A (HADS) Relaxation: consisted of breathing exercises with muscle relaxation and guided imaginary: 20 min (10 min group relaxation + 10 min psychoeducation), 2 times per week for 4 weeks 
Depression and anxiety Hospital anxiety and depression scale (HADS) 
Beatrice Moret [35] (2022) N = 57, IG = 70.13 (3.73), CG = 71.11 (3.72) Without cognitive impairment and movement limitations 8 exercise session and 2 assessment sessions 45 min, 3–4 times per weeks for last 2–3 weeks Depression Beck depression inventory II (BDI-II) Continue the daily routine 
Nathalie Swinnen et al. [36] (2023) N = 18, IG = 81.9 (8.2), CG = 84.2 (5.9) With major neurocognitive disorder (MNCD) 3 session per week for 12 weeks Depression Cornell scale for depression in dementia (CSDD) Traditional exercise 15-min walk and 15-min standardized squatting and stepping exercise 
Each session consisted a walk to exercise room 15 min and 30 min of exergaming and a walk back to the ward 
Daniel Schoene et al. [38] (2015) N = 81, IG = 82 (7), CG = 81 (7) Without cognitive impairment and movement limitations 20 min, 3 times per week for 16 weeks Depression Patient health questionnaire (PHQ-9) People were given a brochure about evidence-based information on various health-related topics, such as fall prevention, staying active, exercising at home, healthy eating, eyesight care, choosing footwear and mobility and walking aids, and continue with their usual activities 
Kyeongjin Lee [50] (2023) N = 90, IG = 82 (7), CG = 81 (7) Without cognitive impairment and movement limitations Online education: 50 min, every week for 8 weeks, exergame program, 50 min, 3 times per week for 8 weeks Depression Depression was measured using the geriatric depression scale (GDS) Participants in the control group were not provided with any exercise instructions and no exercise program that could affect posttest results was implemented 
Zhou, He et al. [51] (2020) N = 73, IG = 62.7 (6.8), CG = 66.5 (10.0) End-stage renal disease 30 min, every week for 4 weeks, exergame program (including break time), Performed the hemodialysis treatment Depression Center for epidemiologic studies depression (CES-D) scale Receiving hemodialysis for three sessions per week 
During each hemodialysis session, a nursing staff instructed the participant in the CG to participate in a 30 min non-weight-bearing foot rotation intradialytic exercise program (including breaks) without any technology 

IG, intervention group; CG, control group.

In addition, among these 1,309 older adults, we classified them based on their health issues. A total of 200 older adults were classified into the neurocognitive disorders group [34, 36, 37, 43, 46, 47], which specifically included diseases such as depression, dementia, and other cognitive impairments. This group accounted for 15.28% of the total participants. 759 older adults were assigned to the Internal Medicine Group [41, 42, 44, 45, 48, 49, 51], which included conditions like colitis, heart disease, and coronary angiography, accounted for 57.98% of the total participants. 67 older adults underwent total knee replacement surgery and were thus placed in the surgical group [32, 33, 44], representing 5.12% of the total participants. Lastly, 283 older adults reported without health issues group [35, 38‒40, 50], comprising 21.62% of the total participants.

In the context of digital interactive technologies, we classified interactive technologies into three categories based on the devices used and the mode of interaction, namely immersive interaction group [32‒34, 41‒43, 45, 48], physical interaction group [35‒40, 44, 49‒51], and mobile game interaction group [46, 47] (see Table 2).

Table 2.

Summary of digital interactive interventions of the included studies

Classification of digital interaction: physical interaction
first author, publication yeartype of digital interactive devicescontentexhibit physical exercise
Braulio Evangelista de Lima [39] (2021) Xbox Kinect 
  • Game name “Your Shape Fitness evolved,” it simulates an environment with a variety of physical activities

  • The game activities selected for the physical activity sessions were: (1) Zen-Develop it (stretching, balance, and flexibility activities, similar to yoga); (2) pump it (to fill balls until they burst); (3) wall breaker (to break blocks, similar to boxing); (4) Kick it (soccer activity); (5) hurricane (to lift the balls off the floor and not let them fall); (6) stack in ip (balance activity)

 
  • Balance exercise

  • Coordination exercise

  • Posture control exercise

 
Sam Yeol Wi [44] (2013) Xbox 360 42-inch TVs with Kinetic sensors 
  • Virtual smash: a game that involves moving the hands and feet to smash virtual bricks appearing on the screen or moving the trunk to avoid bricks that fall down from above

  • Light race game: a game that involves stepping on blocks displayed on the floor of the screen using either one foot or both feet

 
  • Balance exercise

  • Coordination exercise

 
Nathalie Swinnen et al. [37] (2021) Exergame device “Dividat Senso” (Dividat, Schindellegi, Switzerland). It consisted of a step training platform (1.13m°¡ 1.13 m) which was sensitive to pressure changes (strain gauges measuring at 50 Hz), The platform was connected via a USB cable to a computer and a frontal television screen (LG, 94.5 cm × 53 cm, model 43LJ500V) 
  • The device provided real-time visual, auditory and somatosensory (vibrating platform) cues, and feedback in order to enrich the game experience

  • The sessions consisted of multiple games and the duration of each video game varied between 120 and 200 s

  • Participants interacted with the game interface by pushing one foot on one of the four different arrows. When the game required the player to perform a step to the left or right, the associated lower limb was used. For a step in the two other directions, the player used a lower limb of preference

 
  • Balance exercise

  • Coordination exercise

 
Daniel Collado-Mateo [49] 2017 Kinect (Microsoft) 
  • Training was based on an exergame, the Virtual Ex-FM, which has been specifically designed by the research group to improve the physical conditioning and the ability to perform activities of daily living of women with FM.

  • This program consists of 3 virtual environments developed to allow the patient to perform several motor training exercises. The first portion is a warm-up using a video in which an expert performs joint movements of the upper and lower limbs. Participants are encouraged to imitate these movements. The speed of these movements can be manually controlled at 0.5, 1, 1.5, and 2. The second part is an aerobic component performed by following dance steps marked by a professional kinesiologist and dance teacher. The third portion is postural control and coordination, which are trained through a game, in which participants have to reach an apple that appears and disappears near them. The body part used by the participant to reach for the apple is indicated by the application and can be manually controlled by the technician. Finally, walk training is developed using a circuit comprising a trail of footprints on a virtual floor. Participants must step on the virtual footprints and walk on the circuit. Amplitude and cadence are controlled by the technician. The interface allows the selection of different types of steps: a normative step, on tiptoe, heel walking, raised knees, and raised heels

 
  • Dancing exercise

  • Posture control exercise

  • Coordination exercise

  • Muscle strength exercise

 
Beatrice Moret [35] (2022) A TV screen 40″ liquid-crystal display (Samsung) An Xbox-360 console and a Kinect device 
  • Each participant, standing approximately 2 m away from the TV screen, performed the training individually under the supervision of a trained research assistant. The Kinect sensors provide participants with real-time audio-visual feedback

  • The first training session: Fruit Ninja exergame was selected for this first familiarization process, choosing three different activities: Zen, Classic, and Arcade. The games were repeated several times with increasing difficulty levels until the player feel confident in playing

  • Brain and body exercises: the exergame “Dr Kawashima selected as a combination of motor training. It demanding full-motion capabilities and provides each activity with three difficulty levels and the progression is determined by the player’s performance

 
  • Coordination exercise

  • Flexibility exercise

 
Nathalie Swinnen et al. [36] (2023) VITAAL exergame prototype 
  • The starting position was an upright stance and participants interacted with the game interface by performing a stepping movement of one foot in one of the four directions: up, down, left, and right. When the game required the player to perform a step to the left or right, the associated lower limb was used. For a step in the two other directions, the player chose the lower limb of preference. The minigames provided real-time visual and auditory cues and feedback to enrich the game experience

  • The exergaming details as following

  • Outdoor: player imitates movements of an avatar instructor

  • Library: player avoids books from falling through multidirectional stepping

  • Mommy chicken: player collects eggs while avoiding mommy chicken

  • Healthy snacks: player points out healthy food and avoids unhealthy food

  • Shopping list: player indicates whether the shown items correspond to the previously memorized shopping list

 
  • Balance exercise

  • Coordination exercise

  • Flexibility exercise

 
Daniel Schoene et al. [38] (2015) Step pad, similar to using a keyboard 
  • The interactive training system used stepping onto an electronic step pad to interact with a computer interface, and video game technology was used to deliver the training tasks on standard home television screens

  • The intervention comprised four games: Stepper, StepMania, Trail-Stepping and Tetris; Stepper: individuals viewed a graphical presentation of the mat arrows on the screen. The step direction was indicated by one arrow changing its color. Participants then stepped as quickly as possible onto the corresponding arrow of the mat and returned to the center; StepMania: during gameplay, arrows drifted up the screen and when they reached a target arrow position at the top of the screen, participant’s had to simultaneously step on the corresponding arrow of the step pad; Trail-Stepping: Participants were required to step on mat panels so as to connect numbers or numbers and letters in alternating order as fast as possible

  • Tetris: geometric shapes composed of four square blocks drifted down the screen at a constant speed. By stepping to the left or right, participants moved the shapes on the screen correspondingly

 
  • Balance exercise

  • Coordination exercise

  • Posture control exercise

  • Flexibility exercise

 
Roberta L Rica et al. [40] (2020) Xbox 360 Console (with Kinect Accessory Model LPF-00004/1414; Microsoft Corporation) 
  • Activities were designed using the following games: Kinect Sports Ultimate Collection; Your Shape Fitness Evolved; Dance Central; Nike + Kinect Training; Strength tasks, with the user instructed to carry out sustained squats or single extensions and light aerobic tasks, such as walking in place and dance steps

 
  • Balance exercise

  • Muscle strength exercise

  • Dancing exercise

 
Kyeongjin Lee [50] (2023) Ring Fit program, A massage ball 
  • Warm up: stretching using the Ring Fit program and a leg massage using a massage ball

  • Exercise: The adventure mode was selected. The participants performed yoga to increase balance, and leg and abdominal exercises to strengthen the lower extremity muscles. Ring Fit adventure involves exploring more than 20 different worlds and using real-life exercises to defeat the bodybuilder dragon and his minions. Jogging in place to cross grassy plains and climb stairs is expected to strengthen the lower extremities’ strength and improve the participants’ dynamic balance ability. Exercises to defeat the bodybuilder dragon and his subordinates consist of strength training of the arms, abdomen, and legs and yoga exercises to improve balance. Leg exercises include squats, knee lifts, thigh presses, wide squats, and side steps. Abdominal exercises include knee to chest, plank, leg raise, and seated ring raise. Arm exercises include overhead press, front press, bow pull, triceps kick back, and back press. Yoga exercises include warrior 1 pose (lunge pose), revolved crescent lunge pose, warrior 2 (wide stance pose), and warrior 3 pose (single-leg stance pose)

 
  • Balance exercise

  • Coordination exercise

  • Muscle strength exercise

 
Zhou, He et al. [51] (2020) Laptop, Wearable sensor 
  • Inertial sensors: participants wore inertial sensors on their feet to measure real-time three-dimensional foot rotation

  • Mapping foot rotation: foot rotations were mapped to control a laptop cursor, allowing participants to navigate and complete reaching tasks

  • Diverse exercise tasks: the exercise program included a variety of tasks, starting with simple foot rotations and progressing to more complex movements and cognitive challenges

  • Feedback system: participants received visual and audio feedback as rewards when successfully completing tasks

 
  • Non-weight-bearing exercise

 
Classification of digital interaction: physical interaction
first author, publication yeartype of digital interactive devicescontentexhibit physical exercise
Braulio Evangelista de Lima [39] (2021) Xbox Kinect 
  • Game name “Your Shape Fitness evolved,” it simulates an environment with a variety of physical activities

  • The game activities selected for the physical activity sessions were: (1) Zen-Develop it (stretching, balance, and flexibility activities, similar to yoga); (2) pump it (to fill balls until they burst); (3) wall breaker (to break blocks, similar to boxing); (4) Kick it (soccer activity); (5) hurricane (to lift the balls off the floor and not let them fall); (6) stack in ip (balance activity)

 
  • Balance exercise

  • Coordination exercise

  • Posture control exercise

 
Sam Yeol Wi [44] (2013) Xbox 360 42-inch TVs with Kinetic sensors 
  • Virtual smash: a game that involves moving the hands and feet to smash virtual bricks appearing on the screen or moving the trunk to avoid bricks that fall down from above

  • Light race game: a game that involves stepping on blocks displayed on the floor of the screen using either one foot or both feet

 
  • Balance exercise

  • Coordination exercise

 
Nathalie Swinnen et al. [37] (2021) Exergame device “Dividat Senso” (Dividat, Schindellegi, Switzerland). It consisted of a step training platform (1.13m°¡ 1.13 m) which was sensitive to pressure changes (strain gauges measuring at 50 Hz), The platform was connected via a USB cable to a computer and a frontal television screen (LG, 94.5 cm × 53 cm, model 43LJ500V) 
  • The device provided real-time visual, auditory and somatosensory (vibrating platform) cues, and feedback in order to enrich the game experience

  • The sessions consisted of multiple games and the duration of each video game varied between 120 and 200 s

  • Participants interacted with the game interface by pushing one foot on one of the four different arrows. When the game required the player to perform a step to the left or right, the associated lower limb was used. For a step in the two other directions, the player used a lower limb of preference

 
  • Balance exercise

  • Coordination exercise

 
Daniel Collado-Mateo [49] 2017 Kinect (Microsoft) 
  • Training was based on an exergame, the Virtual Ex-FM, which has been specifically designed by the research group to improve the physical conditioning and the ability to perform activities of daily living of women with FM.

  • This program consists of 3 virtual environments developed to allow the patient to perform several motor training exercises. The first portion is a warm-up using a video in which an expert performs joint movements of the upper and lower limbs. Participants are encouraged to imitate these movements. The speed of these movements can be manually controlled at 0.5, 1, 1.5, and 2. The second part is an aerobic component performed by following dance steps marked by a professional kinesiologist and dance teacher. The third portion is postural control and coordination, which are trained through a game, in which participants have to reach an apple that appears and disappears near them. The body part used by the participant to reach for the apple is indicated by the application and can be manually controlled by the technician. Finally, walk training is developed using a circuit comprising a trail of footprints on a virtual floor. Participants must step on the virtual footprints and walk on the circuit. Amplitude and cadence are controlled by the technician. The interface allows the selection of different types of steps: a normative step, on tiptoe, heel walking, raised knees, and raised heels

 
  • Dancing exercise

  • Posture control exercise

  • Coordination exercise

  • Muscle strength exercise

 
Beatrice Moret [35] (2022) A TV screen 40″ liquid-crystal display (Samsung) An Xbox-360 console and a Kinect device 
  • Each participant, standing approximately 2 m away from the TV screen, performed the training individually under the supervision of a trained research assistant. The Kinect sensors provide participants with real-time audio-visual feedback

  • The first training session: Fruit Ninja exergame was selected for this first familiarization process, choosing three different activities: Zen, Classic, and Arcade. The games were repeated several times with increasing difficulty levels until the player feel confident in playing

  • Brain and body exercises: the exergame “Dr Kawashima selected as a combination of motor training. It demanding full-motion capabilities and provides each activity with three difficulty levels and the progression is determined by the player’s performance

 
  • Coordination exercise

  • Flexibility exercise

 
Nathalie Swinnen et al. [36] (2023) VITAAL exergame prototype 
  • The starting position was an upright stance and participants interacted with the game interface by performing a stepping movement of one foot in one of the four directions: up, down, left, and right. When the game required the player to perform a step to the left or right, the associated lower limb was used. For a step in the two other directions, the player chose the lower limb of preference. The minigames provided real-time visual and auditory cues and feedback to enrich the game experience

  • The exergaming details as following

  • Outdoor: player imitates movements of an avatar instructor

  • Library: player avoids books from falling through multidirectional stepping

  • Mommy chicken: player collects eggs while avoiding mommy chicken

  • Healthy snacks: player points out healthy food and avoids unhealthy food

  • Shopping list: player indicates whether the shown items correspond to the previously memorized shopping list

 
  • Balance exercise

  • Coordination exercise

  • Flexibility exercise

 
Daniel Schoene et al. [38] (2015) Step pad, similar to using a keyboard 
  • The interactive training system used stepping onto an electronic step pad to interact with a computer interface, and video game technology was used to deliver the training tasks on standard home television screens

  • The intervention comprised four games: Stepper, StepMania, Trail-Stepping and Tetris; Stepper: individuals viewed a graphical presentation of the mat arrows on the screen. The step direction was indicated by one arrow changing its color. Participants then stepped as quickly as possible onto the corresponding arrow of the mat and returned to the center; StepMania: during gameplay, arrows drifted up the screen and when they reached a target arrow position at the top of the screen, participant’s had to simultaneously step on the corresponding arrow of the step pad; Trail-Stepping: Participants were required to step on mat panels so as to connect numbers or numbers and letters in alternating order as fast as possible

  • Tetris: geometric shapes composed of four square blocks drifted down the screen at a constant speed. By stepping to the left or right, participants moved the shapes on the screen correspondingly

 
  • Balance exercise

  • Coordination exercise

  • Posture control exercise

  • Flexibility exercise

 
Roberta L Rica et al. [40] (2020) Xbox 360 Console (with Kinect Accessory Model LPF-00004/1414; Microsoft Corporation) 
  • Activities were designed using the following games: Kinect Sports Ultimate Collection; Your Shape Fitness Evolved; Dance Central; Nike + Kinect Training; Strength tasks, with the user instructed to carry out sustained squats or single extensions and light aerobic tasks, such as walking in place and dance steps

 
  • Balance exercise

  • Muscle strength exercise

  • Dancing exercise

 
Kyeongjin Lee [50] (2023) Ring Fit program, A massage ball 
  • Warm up: stretching using the Ring Fit program and a leg massage using a massage ball

  • Exercise: The adventure mode was selected. The participants performed yoga to increase balance, and leg and abdominal exercises to strengthen the lower extremity muscles. Ring Fit adventure involves exploring more than 20 different worlds and using real-life exercises to defeat the bodybuilder dragon and his minions. Jogging in place to cross grassy plains and climb stairs is expected to strengthen the lower extremities’ strength and improve the participants’ dynamic balance ability. Exercises to defeat the bodybuilder dragon and his subordinates consist of strength training of the arms, abdomen, and legs and yoga exercises to improve balance. Leg exercises include squats, knee lifts, thigh presses, wide squats, and side steps. Abdominal exercises include knee to chest, plank, leg raise, and seated ring raise. Arm exercises include overhead press, front press, bow pull, triceps kick back, and back press. Yoga exercises include warrior 1 pose (lunge pose), revolved crescent lunge pose, warrior 2 (wide stance pose), and warrior 3 pose (single-leg stance pose)

 
  • Balance exercise

  • Coordination exercise

  • Muscle strength exercise

 
Zhou, He et al. [51] (2020) Laptop, Wearable sensor 
  • Inertial sensors: participants wore inertial sensors on their feet to measure real-time three-dimensional foot rotation

  • Mapping foot rotation: foot rotations were mapped to control a laptop cursor, allowing participants to navigate and complete reaching tasks

  • Diverse exercise tasks: the exercise program included a variety of tasks, starting with simple foot rotations and progressing to more complex movements and cognitive challenges

  • Feedback system: participants received visual and audio feedback as rewards when successfully completing tasks

 
  • Non-weight-bearing exercise

 
Classification of digital interaction: immersive interaction
first author, publication yeartype of digital interactive devicescontent
Mostafa Keshvari [42] (2021) VR video headset playing VR video and Huawei mobile phone play the music 
  • Before the start of the angiography, the subjects viewed a 5-min natural scene that was filmed at various natural locations and landscapes such as the beach, mountains, waterfalls, rivers with pleasant sounds by a VR camera

  • The sounds included soft music, birdsong, and waterfall sounds

 
Guorong Chen et al. [41] (2021) A VR head-mounted, 3-dimensional display 
  • VR videos provided 4 parts of information to educate patients, including instructions on bowel preparation, a to-do list before the procedure, a brief introduction to specific procedures of colonoscopy, and a to-do list after a therapeutic procedure (e.g., polypectomy)

 
Joanna Szczepańska-Gieracha [43] (2021) VRTierOne (Stolgraf®, Stanowice, Poland) device, The hardware consists of VR HTC VIVE goggles (2017) and two controllers (manipulators) plugged into a PC. 
  • Patients use of the controller interaction with the virtual world and color the mandala with appropriate colors. Every task that the patient completes is rewarded by beautiful flowers appearing in the garden. If any of the tasks prove too difficult, the computer instantly adjusts their level to the patient’s cognitive and kinesthetic abilities

  • At the end of the therapy, the visual effect of a beautiful, colorful garden is complemented with lively music and the sounds of nature (birds singing, water flowing, wind blowing)

 
Sandra Jóźwik [45] (2021) VR TierOne device set: VR goggles (HTC VIVE PRO), Computer dedicated to processing 3D graphic 
  • An important element of each session is the coloring of therapeutic mandalas (a new mandala every session)

  • The patient’s engagement and efforts put into this task are rewarded as the garden, initially neglected and gray, regains its colors, energy, and beauty

  • VR TierOne engages all the patient’s senses (sight, hearing, kinesthesia), deepening the process of immersion in the virtual world

 
Selda Karaveli Cakır [48] (2021) An Android mobile phone placed in Cardboard Super Flex Goggles Watch a licensed virtual reality application, “A walk on the beach” 
Vishnunarayan G Prabhu [32] (2020) Virtual reality devices, Biopac® AcqKnowledge® with VizMove. A Biopac® MP160 system along with BioNomadix® BN-RSPEC, BN-ECG, BN-PPGED wireless transmitter-receiver pair were used to collect the user’s respiration rate in breaths per minute (BPM), and electrocardiogram (ECG) in volts 
  • The patient was asked to lay down on the bed, which was inclined at 120° and watch a virtual reality video

  • The front view of a virtual beach environment that includes hues of blue and green, and sunlight

  • The side view includes blue sky with sunrise and natural resonant wave movement

  • The VR environment included the sound of sea waves crashing, seagulls cawing, and the wind blowing to replicate the audio experienced on a beach

 
Lee Fuchs [33] (2022) Samsung Gear VR: head-mounted display that allows projection of a three-dimensional image, CPM: continuous passive motion device 
  • VR intervention included a movie that was picked by the patient from several options, either a nature film or a music film

 
Błażej Cieślik [34] (2023) VR TierOne device, Hardware: VR HTC VIVE goggles and two HTC VIVE controllers 
  • At the beginning of the session, the patient was placed in front of a garden door. After a few minutes, the door to the garden opened, and the patient moved inside and was encouraged to observe the elements of the garden

  • The garden, initially neglected, grew livelier, and more colorful with each session. In the middle of the session, a black and white mandala appeared in front of the participant. The patient’s task was to color it using the controllers

  • The music used was composed by the collaboration of a music therapist and a music composer. It is relaxing and becomes more joyful as the therapy progresses

 
Classification of digital interaction: immersive interaction
first author, publication yeartype of digital interactive devicescontent
Mostafa Keshvari [42] (2021) VR video headset playing VR video and Huawei mobile phone play the music 
  • Before the start of the angiography, the subjects viewed a 5-min natural scene that was filmed at various natural locations and landscapes such as the beach, mountains, waterfalls, rivers with pleasant sounds by a VR camera

  • The sounds included soft music, birdsong, and waterfall sounds

 
Guorong Chen et al. [41] (2021) A VR head-mounted, 3-dimensional display 
  • VR videos provided 4 parts of information to educate patients, including instructions on bowel preparation, a to-do list before the procedure, a brief introduction to specific procedures of colonoscopy, and a to-do list after a therapeutic procedure (e.g., polypectomy)

 
Joanna Szczepańska-Gieracha [43] (2021) VRTierOne (Stolgraf®, Stanowice, Poland) device, The hardware consists of VR HTC VIVE goggles (2017) and two controllers (manipulators) plugged into a PC. 
  • Patients use of the controller interaction with the virtual world and color the mandala with appropriate colors. Every task that the patient completes is rewarded by beautiful flowers appearing in the garden. If any of the tasks prove too difficult, the computer instantly adjusts their level to the patient’s cognitive and kinesthetic abilities

  • At the end of the therapy, the visual effect of a beautiful, colorful garden is complemented with lively music and the sounds of nature (birds singing, water flowing, wind blowing)

 
Sandra Jóźwik [45] (2021) VR TierOne device set: VR goggles (HTC VIVE PRO), Computer dedicated to processing 3D graphic 
  • An important element of each session is the coloring of therapeutic mandalas (a new mandala every session)

  • The patient’s engagement and efforts put into this task are rewarded as the garden, initially neglected and gray, regains its colors, energy, and beauty

  • VR TierOne engages all the patient’s senses (sight, hearing, kinesthesia), deepening the process of immersion in the virtual world

 
Selda Karaveli Cakır [48] (2021) An Android mobile phone placed in Cardboard Super Flex Goggles Watch a licensed virtual reality application, “A walk on the beach” 
Vishnunarayan G Prabhu [32] (2020) Virtual reality devices, Biopac® AcqKnowledge® with VizMove. A Biopac® MP160 system along with BioNomadix® BN-RSPEC, BN-ECG, BN-PPGED wireless transmitter-receiver pair were used to collect the user’s respiration rate in breaths per minute (BPM), and electrocardiogram (ECG) in volts 
  • The patient was asked to lay down on the bed, which was inclined at 120° and watch a virtual reality video

  • The front view of a virtual beach environment that includes hues of blue and green, and sunlight

  • The side view includes blue sky with sunrise and natural resonant wave movement

  • The VR environment included the sound of sea waves crashing, seagulls cawing, and the wind blowing to replicate the audio experienced on a beach

 
Lee Fuchs [33] (2022) Samsung Gear VR: head-mounted display that allows projection of a three-dimensional image, CPM: continuous passive motion device 
  • VR intervention included a movie that was picked by the patient from several options, either a nature film or a music film

 
Błażej Cieślik [34] (2023) VR TierOne device, Hardware: VR HTC VIVE goggles and two HTC VIVE controllers 
  • At the beginning of the session, the patient was placed in front of a garden door. After a few minutes, the door to the garden opened, and the patient moved inside and was encouraged to observe the elements of the garden

  • The garden, initially neglected, grew livelier, and more colorful with each session. In the middle of the session, a black and white mandala appeared in front of the participant. The patient’s task was to color it using the controllers

  • The music used was composed by the collaboration of a music therapist and a music composer. It is relaxing and becomes more joyful as the therapy progresses

 
Classification of digital interaction: mobile game interaction
first author, Publication yeartype of digital interactive devicescontent
Ruby Yu [46] (2015) Sur 40, iPad, optical touch computer screen 
  • Four touch-screen video games, including: (1) Bingo; (2) connect the dot ultimate (lite); (3) find difference; (4) mosquito splash that mainly tap working memory and attention control were used

 
Joaquin A. Anguera [47] (2017) A mobile, iPad 
  • Video game used in by Anguera et al. called NeuroRacer

  • This game involves guiding a character through an immersive environment while responding to select targets, with the design format being ideally entertaining to children

 
Classification of digital interaction: mobile game interaction
first author, Publication yeartype of digital interactive devicescontent
Ruby Yu [46] (2015) Sur 40, iPad, optical touch computer screen 
  • Four touch-screen video games, including: (1) Bingo; (2) connect the dot ultimate (lite); (3) find difference; (4) mosquito splash that mainly tap working memory and attention control were used

 
Joaquin A. Anguera [47] (2017) A mobile, iPad 
  • Video game used in by Anguera et al. called NeuroRacer

  • This game involves guiding a character through an immersive environment while responding to select targets, with the design format being ideally entertaining to children

 

Specifically, the immersive interaction primarily relies on 3D immersive virtual reality devices, such as head-mounted displays and full-body tracking system. These devices create a sense of complete immersion in a virtual environment by simulating visual, auditory, and tactile experiences. The physical interaction involves devices that require active physical engagement from users, such as motion-sensing controllers and dance mats. Users’ body movements and positions are detected by these devices, translating them into in-game actions. For example, users can swing the controller to simulate striking or throwing actions, or use dance mats to control character movement through steps. The mobile game interaction utilizes touch-screen devices, such as iPads and smartphones. Users interact with games primarily through gestures like swiping, tapping, or pinching on the screen.

Meta-Analysis of the Effects on Outcomes

The meta-analysis on improvement of mental health among the selected 20 studies examined three outcome measures, depression, anxiety, depression, and anxiety.

Depression

Depression was assessed 14 trails [34‒38, 40, 43‒47, 49‒51], with total 348 participants in the digital interactive intervention groups and 370 participants in the control groups. The meta-analysis illustrated a significant difference between the digital interactive intervention and control group (I2 = 67.092%, p < 0.001; SMD = −0.656, 95% CI = −0.932 to −0.380, p < 0.001) (Fig. 2a). The results indicated that depression was significantly lower in the intervention group compared to the control group.

Fig. 2.

Meta-analysis of the effects of (a) depression; (b) anxiety; (c) depression and anxiety. c Reported the result of integrated depression and anxiety. The data were obtained from the hospital anxiety and depression scale (HADS) questionnaire, which encompasses three distinct outcomes. In addition to the depression and anxiety mentioned in this section, the other two outcomes are anxiety and depression individually.

Fig. 2.

Meta-analysis of the effects of (a) depression; (b) anxiety; (c) depression and anxiety. c Reported the result of integrated depression and anxiety. The data were obtained from the hospital anxiety and depression scale (HADS) questionnaire, which encompasses three distinct outcomes. In addition to the depression and anxiety mentioned in this section, the other two outcomes are anxiety and depression individually.

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Anxiety

Anxiety was assessed 10 trails [32‒34, 39, 41‒43, 45, 48, 49], with total 405 participants in the digital interactive intervention groups and 420 participants in the control groups. The results indicated that anxiety was significantly lower in the intervention group compared to the control group SMD = −0.381 s, 95% CI = −0.517 to −0.245, p < 0.001. Low heterogeneity was observed (I2 = 19.360%, p = 0.259).

Depression and Anxiety

Depression was assessed 3 trails [34, 43, 45], with total 69 participants in the digital interactive intervention groups and 91 participants in the control groups. The digital interactive intervention was associated with significantly lower of depression compared to the control group (SMD = −0.709 s, 95% CI = −1.195 to −0.222, p = 0.004). High heterogeneity was observed (I2 = 49.692%, p = 0.137).

Subgroup Analysis

Interventions Based on Interactive Technologies

In the subgroup analysis, we examined the effectiveness of different types of digital interactive technology interventions for depression and anxiety symptoms separately. The results revealed that physical interaction and immersive interactions significantly reduced depression among older adults, while the effectiveness of mobile game interaction was not significantly.

The effectiveness of Physical Interactive interventions on depression was assessed in 9 trials [35‒38, 40, 44, 49‒51] (Fig. 3a). The meta-analysis results indicated a significant reduction in depression (I2 = 76.720%, p < 0.001; SMD = −0.711, 95% CI = −1.102 to −0.319, p < 0.001). Similarly, the effectiveness of immersive interactive interventions on depression was evaluated in 3 trials [34, 43, 45]. The meta-analysis results demonstrated a significant reduction in depression (I2 = 9.638%, p = 0.331; SMD = −0.699 s, 95% CI = −1.026 to −0.373, p < 0.001) (Fig. 3b). The effectiveness of mobile game interventions on depression was examined with 2 trials [46, 47], the effect of the intervention on depression did not reach statistical significance (I2 = 0.000%, p = 0.421; SMD = −0.217 s, 95% CI = −0.755 to −0.320, p = 0.428) (Fig. 3c). This suggests that there was no significant difference in depression levels between the intervention and control groups.

Fig. 3.

Meta-analysis of the effects of depression interventions of (a) physical interaction; (b) immersive interaction; (c) mobile game.

Fig. 3.

Meta-analysis of the effects of depression interventions of (a) physical interaction; (b) immersive interaction; (c) mobile game.

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For anxiety symptoms, the analysis only included interventions using physical interactive intervention and immersive interaction. The results indicated that both of these interventions were effective in reducing anxiety. A total of 8 trials [32‒34, 41‒43, 45, 48] were conducted in the Immersive interactive intervention groups. The results showed a moderate level of heterogeneity (I2 = 35.696%, p = 0.144), and the meta-analysis indicated a significant reduction in anxiety (SMD = −0.343 s, 95% CI = −0.493 to −0.194, p < 0.001) (Fig. 4a). Additionally, there were 2 trials [39, 49] conducted in the physical interactive intervention groups. The results showed no heterogeneity (I2 = 0.000%, p = 0.985) and a significant decrease in anxiety (SMD = −0.573 s, 95% CI = −0.910 to −0.236, p = 0.001) (Fig. 4b).

Fig. 4.

Meta-analysis of the effects of anxiety interventions of (a) immersive interaction; (b) physical interaction.

Fig. 4.

Meta-analysis of the effects of anxiety interventions of (a) immersive interaction; (b) physical interaction.

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Interventions Based on Health Conditions

In the subgroup of older adults without health issues, a total of 4 trials [35, 38, 40, 50] investigated the effects of digital interactive technologies on depression, while 1 trail explored its effects on anxiety. The results demonstrated the effectiveness of digital interactive technology in reducing depression among older adults without health issues (I2 = 88.617%, p < 0.001, SMD = −0.981, 95% CI = −1.809 to −0.153, p = 0.020) (Fig. 5).

Fig. 5.

Meta-analysis the effects of digital interaction on depression intervention without health issues.

Fig. 5.

Meta-analysis the effects of digital interaction on depression intervention without health issues.

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There were 5 trails [41, 42, 45, 48, 49] included to examine the impact of digital interactive technology on anxiety intervention in internal medicine patients. Among these trails, 4 trails [44, 45, 49, 51] also investigated its effects on depression in internal medicine patients. The findings indicated that digital interactive technology effectively reduced anxiety among internal medicine patients (I2 = 22.300%, p = 0.272, SMD = −0.325, 95% CI = −0.481 to −0.169, p < 0.001) (Fig. 6a) and also showed its efficacy in relieving depression in internal medicine patients (I2 = 0.000%, p = 0.705, SMD = −0.388, 95% CI = −0.630 to −0.145, p = 0.002) (Fig. 6b).

Fig. 6.

Meta-analysis of the effect of digital interaction on (a) anxiety in internal medicine patients; (b) depression in internal medicine patients.

Fig. 6.

Meta-analysis of the effect of digital interaction on (a) anxiety in internal medicine patients; (b) depression in internal medicine patients.

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Regarding the patients with neurocognitive disorders, 6 trails [34, 36, 37, 43, 46, 47] were examined the effect of digital interactive technology on depression symptoms, with two also exploring its impact on anxiety intervention. The data revealed that digital interactive technology was effective in intervening both depression (I2 = 32.388%, p = 0.193, SMD = −0.702, 95% CI = −0.991 to −0.413, p < 0.001) (Fig. 7a) and anxiety (I2 = 0.000%, p = 0.503, SMD = −0.790, 95% CI = −1.237 to −0.342, p = 0.001) (Fig. 7b) among patients with neurocognitive disorders.

Fig. 7.

Meta-analysis of the effect of digital interaction on (a) depression in neurocognitive disorders; (b) anxiety in neurocognitive disorders.

Fig. 7.

Meta-analysis of the effect of digital interaction on (a) depression in neurocognitive disorders; (b) anxiety in neurocognitive disorders.

Close modal

Lastly, a subgroup analysis of older adults with surgical problems, included 2 trials, both focused on total keen replacement surgery, to examine the intervention of digital interaction technology on anxiety [32, 33]. The analysis results indicated that digital interactive technology did not demonstrate effectiveness in reducing anxiety specifically for surgical procedures (I2 = 55.340%, p = 0.135, SMD = −0.453, 95% CI = −1.399 to −0.493, p = 0.348) (Fig. 8).

Fig. 8.

Meta-analysis of the effect of digital interaction on anxiety in surgical group.

Fig. 8.

Meta-analysis of the effect of digital interaction on anxiety in surgical group.

Close modal

Risk of Bias

Among the 20 included trials, 12 trials had a low risk of bias, 2 had a high risk and 6 trials had some concerns (see Table 3).

Table 3.

Assessment results of the risk of bias

Table 3.

Assessment results of the risk of bias

Close modal

The Quality of Evidence

The GRADE revealed that the quality of evidence for digital intervention for anxiety was rated high, intervention on depression, depression, and anxiety were rated moderate. The physical interaction intervention was assessed as moderated for depression and high for anxiety. The immersive interaction intervention was rated high for both depression and anxiety. In addition, the mobile game interaction on depression was rated as moderate. Regarding specific health groups, the quality of evidence was moderate for depression in the group without health issues and anxiety in the surgical group. For all other health groups, the quality of evidence was rated as high (see Table 4).

Table 4.

Results of the GRADE assessment for quality of evidence

No. of trials for outcomesNo. of participantsQuality of evidence
intervention groupcontrol group
Depression (n = 14) 348 370 ⊕⊕⊕◯a moderate 
Anxiety (n = 10) 405 420 ⊕⊕⊕⊕ high 
Depression and anxiety (n = 3) 69 91 ⊕⊕⊕◯a moderate 
Different types of technological interventions for depression 
 Physical interaction (n = 8) 251 253 ⊕⊕⊕◯a moderate 
 Immersive interaction (n = 3) 69 91 ⊕⊕⊕⊕ high 
 Mobile game interaction (n = 2) 28 26 ⊕⊕⊕◯b moderate 
Different types of technological intervention for anxiety 
 Immersive interaction (n = 8) 348 365 ⊕⊕⊕⊕ high 
 Physical interaction (n = 2) 57 55 ⊕⊕⊕⊕ high 
Interventions for depression based on health conditions 
 Without health issues (n = 4) 122 123 ⊕⊕⊕◯a moderate 
 Internal medicine (n = 3) 127 146 ⊕⊕⊕⊕ high 
 Neurocognitive disorders (n = 6) 99 101 ⊕⊕⊕⊕ high 
Interventions for anxiety based on health conditions 
 Internal medicine patients (n = 5) 313 333 ⊕⊕⊕⊕ high 
 Neurocognitive disorders (n = 2) 41 42 ⊕⊕⊕⊕ high 
 Surgical group (n = 2) 36 31 ⊕⊕⊕◯a moderate 
No. of trials for outcomesNo. of participantsQuality of evidence
intervention groupcontrol group
Depression (n = 14) 348 370 ⊕⊕⊕◯a moderate 
Anxiety (n = 10) 405 420 ⊕⊕⊕⊕ high 
Depression and anxiety (n = 3) 69 91 ⊕⊕⊕◯a moderate 
Different types of technological interventions for depression 
 Physical interaction (n = 8) 251 253 ⊕⊕⊕◯a moderate 
 Immersive interaction (n = 3) 69 91 ⊕⊕⊕⊕ high 
 Mobile game interaction (n = 2) 28 26 ⊕⊕⊕◯b moderate 
Different types of technological intervention for anxiety 
 Immersive interaction (n = 8) 348 365 ⊕⊕⊕⊕ high 
 Physical interaction (n = 2) 57 55 ⊕⊕⊕⊕ high 
Interventions for depression based on health conditions 
 Without health issues (n = 4) 122 123 ⊕⊕⊕◯a moderate 
 Internal medicine (n = 3) 127 146 ⊕⊕⊕⊕ high 
 Neurocognitive disorders (n = 6) 99 101 ⊕⊕⊕⊕ high 
Interventions for anxiety based on health conditions 
 Internal medicine patients (n = 5) 313 333 ⊕⊕⊕⊕ high 
 Neurocognitive disorders (n = 2) 41 42 ⊕⊕⊕⊕ high 
 Surgical group (n = 2) 36 31 ⊕⊕⊕◯a moderate 

aDowngraded by one level for inconsistency (I2 value is larger than 40%).

bDowngraded by one level for imprecision (fewer than 60 participants).

This paper presents a systematic review and meta-analysis that investigates the effectiveness of different types of digital interactive technologies in the intervention of depression and anxiety among older adults. The analysis comprehensive literature searches and encompasses includes 19 randomized controlled trials (RCT) for synthesis. To ensure reliable scientific evidence, the study required the control group to only received usual care and conventional lifestyle and exercise practices. This approach aimed to minimize the influence of other interventions on the research outcomes. Specifically, usual care refers to the implementation of standardized and conventional treatments or examination procedures for individuals diagnosed with specific health conditions, such as colon diseases [41, 48], coronary artery diseases [42], or total knee arthroplasty [32, 33]. The exercise practices encompassed activities such as walking, muscle relaxation, and step exercises [34, 36, 37]. Furthermore, the older adults in the control group maintained their usual daily routines and habits, which referred to as conventional lifestyle [35, 38, 40, 49]. Among the 20 included studies, 6 studies focused on the intervention effects of digital interactive technologies on anxiety, 10 studies explored the intervention effects on depression, and the remaining 4 studies examined the combined intervention effects on depression and anxiety.

Regarding depression interventions, 8 studies utilized physical interaction as the intervention measure, while the other 2 studies employed mobile games as the intervention method. The meta-analysis results demonstrated a statistically significant effect of physical interaction in reducing depression (p < 0.001). The digital physical interactive interventions included mild aerobic activities such as walking or gait interaction [36‒38, 40, 44, 49], as well as activities that incorporated stretching and balance, such as yoga or posture control [39, 49, 50]. To enhance engagement and interactivity, gamified technologies were integrated into these digital interactive interventions. Examples of such games include “Your Shape Fitness Evolved,” “Fruit Ninja,” and “Light Race Game.” The positive effectiveness of these interventions confirmed the efficacy of mild aerobic training and flexibility training in improving depressive symptoms [52]. By engaging in physical interaction, older adults can obtain physical and cognitive stimulation, thereby improving their depression [53, 54]. These findings are consistent with previous research emphasizing the physical activities and exercise positive impact of these interventions on mental health outcomes [20, 55].

In addition, the analysis results did not reveal a significant difference in the effects on depression between the two studies that included the mobile game intervention group studies (I2 = 0.000%, p = 0.421). The effect of mobile game interaction in alleviating depression is not significant (p = 0.428). It is worth noting that all participants in these mobile game studies were diagnosed with clinical depression, providing insights into the intervention effects of mobile games on this specific health issues. Although the results of the meta-analysis did not show significant effects of mobile games in intervention depression, this does not imply that mobile devices totally lack potential for interventions in depression. Compared to physical interaction and immersive interventions that require more time and space, mobile devices offer higher flexibility and convenience [56, 57]. Older adults can engage in mental health interventions using mobile devices at their own time and location, without the need for specific settings or equipment. This is important for mental health problems that require long-term participation in ongoing interventions [58]. Therefore, further research could focus on optimizing the design and content of mobile game interventions to enhance their therapeutic effects in treating depression.

Among the seven studies investigating the effects of anxiety interventions, immersive interactive technologies were commonly employed as interventions for anxiety in medical settings, specifically during preoperative examinations or surgical procedures. Previous relevant research has discussed the potential application of virtual reality immersive technology in helping older adults overcome anxiety during medical procedures [59]. Virtual reality has shown significant effectiveness by providing a realistic virtual experience and creating a safe and controllable environment for older adults to gradually adapt to and cope with the anxiety of medical procedures [60, 61]. These research findings align with our data analysis results, which demonstrated the effectiveness of immersive interactive technology in interventions for internal medicine treatments, indicating a positive impact on reducing anxiety.

However, it should be noted that the effectiveness of immersive interactive technology was not observed in surgical procedures (SMD = −0.453, 95% CI = −1.399 to −0.493, p = 0.348). This difference may be attributed to the unique characteristics of surgical procedures, which often involve invasive treatments, surgical incisions, tissue damage, and the use of anesthesia. Patients undergoing surgery may experience heightened physiological and psychological stress, necessitating more detailed and personalized intervention approaches [62]. Furthermore, both groups of studies involved surgical procedures focused on total knee replacement surgeries. This specific type of surgery may have distinct contexts and requirements, potentially requiring more targeted intervention measures to address surgery-related anxiety. To comprehensively evaluate the intervention effects of virtual reality technology in surgical procedures, future research could further explore other types of surgeries and compare different types of surgeries to assess the effectiveness in a more comprehensive manner. Additionally, individual differences and intervention timing can also influence the effectiveness of surgical intervention. Each patient may exhibit unique psychological and emotional responses based on individual characteristics. The choice of intervention timing can be adjusted according to different stages of the surgery. Virtual reality technology can be utilized for relaxation and anxiety reduction before surgery to alleviate patient discomfort.

Limitations

There are still limitations in this study. First, the number of RCTs on digital interactive interventions is limited, which restricts to conduct subgroup analyses and may result in high heterogeneity of the results. Although we employed a random-effects model to analyze the data, considering the potential heterogeneity among studies, caution is still needed when interpreting the findings. Second, the duration and frequency of interventions are critical factors affecting intervention effectiveness. However, due to the inclusion of studies conducted in different intervention settings, such as clinical, surgical, or community settings, and with varied intervention protocols, there is heterogeneity in intervention methods and time spans. We were unable to conduct detailed subgroup analyses on the duration and frequency of interventions. To gain a better understanding of intervention effects, future research should focus on specific subgroups with consistent intervention settings and sample characteristics. Additionally, the subgroup analysis of mobile game interactions had a limited sample size, which restricts a comprehensive analysis of this specific intervention method. Future studies should aim to increase the sample size for mobile game interactions to thoroughly evaluate their effectiveness in managing depression and anxiety symptoms in older adults.

This study revealed the potential effectiveness of digital interactive technology in the intervention of depression and anxiety among older adults. Specifically, the results indicate that immersive interactive technology has a significant effect in reducing anxiety symptoms during medical procedures in older adults, while the effectiveness of immersive interactive technology was not observed during surgical procedures. No significant effect of mobile game interaction was found in reducing depression. Future research should focus on optimizing the design and content of mobile game interventions to enhance their effectiveness in treating depression and gain a deeper understanding of their effects on specific populations and mental health conditions, and also explore effectiveness of virtual reality interventions in surgical procedures. In this process, individual differences and the timing of interventions should also be taken into consideration. Overall, digital interactive technology shows potential in the intervention of depression and anxiety among older adults, but further research is needed to optimize its efficacy and understand its effects in specific environments and populations.

An ethics statement is not applicable because this study is based exclusively on published studies that received informed consent from their respective participants. It was registered on the PROSPERO platform under the registration number CRD42023445765.

The authors have no conflicts of interest to declare.

This work was supported by the Hong Kong Polytechnic University (Project No. P0040352 and No. P0046465), the Youth Innovation Talents in Universities of Guangdong Province (Grant No. 2023WQNCX062), the Startup Fund of Southern University of Science and Technology (Grant No. Y01966117 and Y01966223), and the Health and Medical Research Fund (20211201).

Xinyu Shi: data extraction, formal analysis, and writing – original draft. Jiaxin Zhang: conceptualization, methodology, investigation, data curation, formal analysis, supervision, and writing – review and editing. Hailiang Wang: conceptualization, methodology, and investigation – review. Yan Luximon: conceptualization, methodology, and investigation – supervision and review. All authors contributed and approved the final manuscript for publication.

Additional Information

Xinyu Shi and Jiaxin Zhang contributed equally to this work.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

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