Dance Exergames for Older Adults: A Systematic Review and Meta-Analysis With Narrative Synthesis

Abstract

Background

A systematic review and meta-analysis with narrative synthesis was conducted to evaluate the impact of dance exergaming on older adults’ health-related outcomes and its feasibility, usability, and safety.

Methods

PubMed, Scopus, CINAHL, Web of Science, The Cochrane Library, ProQuest Dissertations and Theses Global, and Google Scholar were searched from inception to December 7, 2023. Interventional studies using immersive or nonimmersive virtual reality platforms conducted on older adults ≥60 years old were eligible. Meta-analysis was conducted using the random effects model by pooling mean differences (MD) or standardized mean differences. Outcomes were narratively synthesized when meta-analysis was not possible.

Results

Forty-three articles from 37 studies were included (n = 1 139 participants at baseline). Postintervention, dynamic balance measured using Berg Balance Scale (pooled MD = 2.65, 95% CI: 1.73–3.57, p < .0001), Timed-Up-and-Go times (pooled MD = −1.04, 95% CI: −2.06 to −0.03, p = .04), choice stepping reaction time (pooled MD = −92.48, 95% CI: −167.30 to −17.67, p = .02), and movement time (pooled MD = −50.33, 95% CI: −83.34 to −17.33, p = .003) were significantly better in the experimental group compared to the control group. Adherence ranged from 76.5% to 100%, whereas attrition ranged from 9.1% to 31.9%. Most participants completed the intervention with no or minimal adverse effects.

Conclusions

Dance exergames are effective, feasible, usable, and safe for older adults. Further research is needed as the findings were limited by small sample sizes. Many studies could not be included in the meta-analysis as outcomes were too varied.

Research on interventions to maintain physical independence and cognitive function in older adults is important due to global population aging. A significant proportion of older adults are physically inactive (1–3), which contributes to declines in physical fitness and increased sedentary lifestyle (4). Sedentary behavior and physical inactivity are linked to higher mortality rates in older adults (5) and poorer quality of life (1,6,7). Studies indicate that age-related cognitive decline contributes to reduced physical function and disability in older individuals (8). On the other hand, systematic reviews and meta-analyses have found that physical activity is associated with improved cognitive function or slowing down the deterioration of cognitive impairment (9). Physical exercise is the sole intervention that has consistently demonstrated efficacy in mitigating functional decline among the aging population (8). Thus, it has been recommended for health promotion, disease prevention, and treatment for older adults against chronic diseases such as cardiovascular disease and stroke (10).

Research suggests that activities like exergames and dance, which involve multilimb coordination, attention, cognitive effort, and strategic decision-making, may have greater cognitive benefits compared to typical physical activities like running and walking (9). Exergaming is a popular exercise intervention for older adults, with well-documented benefits such as improved cognitive function and memory, depressive outcomes (11), balance (12), and reduced fear of falling (13). Exergaming is a technology-based physical activity that tracks body movement and provides immediate feedback on exercise performance (14,15). Individuals can play alone or with others for enjoyment. Exergaming can enhance physical activity levels among older adults as it is easily accessible and enjoyable (14,16) and could potentially foster social interaction when played with peers or family members. Additionally, exergaming may positively impact health-related quality of life (14). Exergames are a cost-effective and convenient intervention delivery method that can be played at home or in congregate environments with minimal modifications, potentially affecting physical and cognitive health on a community-wide scale (8). Common gaming systems include Dance Dance Revolution, Xbox Kinect, and Nintendo Wii (12).

Dancing uses several physical and cognitive skills that decline with age. This activity involves aerobic and cognitive components, as well as proprioception, sensorimotor body representation, spatial awareness (17) and the memorization and execution of numerous step sequences (18). Reminiscing on experiences from young adulthood and autobiographical memory can boost optimism and contentment, especially for older adults (17). Dancing also has a notable social aspect as it involves coordination with others (18). A recent meta-analysis concluded that dance benefits older adults with mild cognitive impairment as it significantly improves global cognition, physical function, memory, visuospatial function, and language abilities (19). Limited research has investigated the effects of dance and exergames on neurobiological mechanisms and inflammatory markers. Still, 2 studies reported a significant increase in brain-derived neurotrophic factors and lactate (9). In comparison, 2 other studies found reduced tumor necrosis factor levels compared to preexercise or control, similar to other forms of physical activity (9).

Dance (19–24) and exergames (12–14,16,25–28) have been extensively studied as interventions for older adults in systematic reviews. However, there is limited research on dance exergaming. Dance exergaming entails playing an interactive video game in which the player engages in upper and lower body movements while dancing to music. Only 1 systematic review and meta-analysis on dance exergaming in older adults was conducted, including studies up to 2017. All 6 articles reviewed used StepMania (29). Given the growing body of research on dance exergaming interventions and the availability of new technology, there is a clear need for an updated review. They also recommended that future reviews include other study designs (29). Therefore, this systematic review aimed to synthesize the effects of dance exergaming on physical function, cognition, and psychological well-being in older adults and examine the feasibility, usability, and safety of dance exergames.

Method

This systematic review and meta-analysis were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (30). Its protocol was registered on PROSPERO (CRD42023395526).

Eligibility Criteria

Detailed eligibility criteria are presented in Table 1. Briefly, dance exergaming studies (both peer-reviewed and gray literature) involving older adults ≥60 years old (healthy or those with diseases) conducted in any setting were included. Dance exergames were interactive games involving players engaging in upper or lower body movements that may or may not match the rhythm. The game could be played on immersive or nonimmersive virtual reality platforms (31). To provide a comprehensive picture of the dance exergaming studies conducted, quasiexperimental (including single-group studies) or randomized controlled trials (RCT) published in English were eligible. Health-related outcomes such as physical and cognitive functions and psychological outcomes assessed using validated measures, feasibility, usability, and safety of dance exergames were outcomes of interest for this review. Only RCTs were included in the meta-analysis to ensure that it was based on evidence of the highest quality.

Search Strategy

Seven databases were searched (PubMed, Scopus, CINAHL, Web of Science, The Cochrane Library, ProQuest Dissertations and Theses Global, and Google Scholar) for articles published from inception until January 16, 2023, and the search was updated on December 7, 2023 (Supplementary Tables 1–6). Reference lists of relevant studies and reviews were also assessed. A 3-step search strategy was used. First, the terms “exergames,” “dance,” and “older adults” were searched in Pubmed to generate keywords and Medical Subject Headings. Second, the terms were used to search other databases. Lastly, gray literature and studies not found in databases were searched using Google Scholar and ProQuest for relevant articles. The initial search results were uploaded into Rayyan. After removing duplicates, S.Q.Y. and Y.J. independently identified potential studies using title and abstract and assessed full texts against eligibility criteria. Discrepancies were discussed until a consensus was reached in discussion with a third reviewer.

Data Extraction

A prepiloted data extraction form was developed to extract the following information: author, year, country, settings, study design, participant characteristics, exergame platform, intervention details, outcomes, and findings. S.Q.Y. extracted the data, and Y.J. checked it for accuracy by comparing the data extracted to the included article. Any discrepancies were discussed until a consensus was reached.

Risk of Bias Assessment

S.Q.Y. and Y.J. independently appraised the studies using the Mixed Methods Appraisal Tool (32). This tool includes 5 methodological quality criteria to evaluate a range of study designs, including randomized controlled trials, quantitative nonrandomized, and mixed method studies, with a response of “Yes,” “No,” and “Can’t tell” to each item. It starts with 2 screening questions: “Are there clear research questions?” and “Do the collected data allow to address the research questions.” Answering “No” or “Can’t tell” to either means that the study should not be evaluated using the tool. Any discrepancy was resolved by discussion. No study was excluded based on methodological quality.

Synthesis Methods

Meta-analysis was performed using Review Manager Version 5.4.1. The random effects model was used for all analyses as it accounted for between-study heterogeneity. Effect sizes were pooled using standardized mean differences (SMD) and 95% confidence intervals (CI) when outcomes were measured differently among studies. Mean differences (MD) and 95% CI were pooled when outcomes were measured using the same tool, for example, Trail-Making Test A. Outcome data were extracted and/or calculated where possible using the Revman calculator function and published formulas (33,34), and only posttest values were used during meta-analysis. When a study had multiple outcomes eligible for inclusion in a meta-analysis for an outcome domain (eg, the effect of dance exergaming on balance was assessed using multiple tools), one tool was randomly selected for meta-analysis (35). This was done using an online randomizer (https://www.random.org/lists/), and the first tool in the list was chosen.

Cochran’s Q test and I² statistics were used to evaluate heterogeneity. Statistically significant heterogeneity was defined as p < .10. Heterogeneity was unimportant when I² = 0%–40%, moderate when I² = 30%–60%, substantial when I² = 50%–90%, and considerable when I² = 75%–100%. If significant heterogeneity was found, subgroup and sensitivity analysis were used to investigate sources of heterogeneity. Sensitivity analysis was done by excluding studies one by one. If the results remained consistent, they were robust. If results differed, they were treated with caution. If there were at least 10 studies in a meta-analysis, sources of heterogeneity were investigated using subgroup analysis (33). The predefined subgroups were the duration of intervention, sample size, settings, and type of exergame (multicomponent or single component). A statistically significant subgroup effect was defined as p < .1 (36). When there were at least 10 studies in a meta-analysis, publication bias was assessed using Jamovi version 2.3.21. Visual inspection of funnel plots, Begg’s and Egger’s linear regression tests were conducted to check for publication bias (33).

When meta-analysis was not possible (eg, inadequate data, nonuniform statistical analysis, or studies using different metrics to measure different aspects of a construct, making a direct comparison or statistical combination difficult), results were narratively synthesized. Single-group studies were narratively summarized as they were often exploratory in nature and had very small sample sizes. Quasiexperimental studies with 2 or more arms were excluded from meta-analysis to ensure that the results were based on evidence of the highest quality (ie, randomized controlled trials).

Results

Search Results

There were 321 records retrieved from search databases. After removing duplicates, 254 records were screened using title and abstract, and 48 articles were assessed based on full texts. A total of 43 articles based on 37 studies were included in the review (37–79) (Figure 1).

Most studies were conducted in laboratory settings (38,39,42,43,50,53,54,58,59,67,68,73,79), while some took place in participants’ homes (37,39,41,65,66) followed by long-term care (45,74,77,78) or assisted living facilities (44,60,69) and geriatric clinics (46–48). Others did not specify the setting of the intervention (40,51,52,55–57,61–64,70–72,75,76). There were 18 randomized controlled trials (37,45,47,48,54–56,60,61,64–66,70,71,74,77–79), 13 single-group studies (38,39,41,42,50,52,53,57–59,69,72,76), 2 two-arm (40,44,51,62,75), and 1 three-arm quasiexperimental studies (43). Studies were published in 15 countries, most commonly in Switzerland (37–39,44,45,47,48,60,64), Brazil (51,61,62,74,75,78), and the USA (50,59,69–71). A total of 1 139 participants at baseline were included in this review, with sample sizes ranging from 4 (41) to 90 (65) (mean = 30.8).

Most used nonimmersive virtual reality platforms except for 4 articles (42,67,68,72) that used a virtual reality headset. Twenty-two studies investigated multicomponent interventions (combining dance exergaming with other forms of exercise such as Tai Chi) (37–39,41,42,44,45,50,52,53,56–58,60,61,64,65,72,74,76,78,79), while 15 used solely dance exergames (40,43,47,48,51,54,55,59,62,66,69–71,75,77). Intervention duration ranged from a day to 24 weeks, most commonly 12 weeks (43,44,51,54,60–62,69,75,76,79), followed by 8-week (39,45,47,64,66,78) and 1-day interventions (42,50,57,58,72,74). Only 1 study, with a 1-year follow-up, investigated the long-term effects of dance exergaming (48,49). The characteristics of included articles are presented in Supplementary Tables 7 and 8.

Risk of Bias Assessment

The risk of bias assessment is presented in Table 2. Most randomized controlled trials were reported in reasonable detail, except for a few articles that did not specify how randomization was performed and whether there were baseline imbalances. Nonblinding of outcome assessors was common as they were also usually involved in the intervention implementation. Most quantitative nonrandomized studies were similarly well-reported, but many articles did not account for confounders in study design or analysis. At the same time, a few did not give detailed eligibility criteria. Mixed-method articles were poorly reported and conducted as none of the 3 integrated quantitative and qualitative findings to answer the research question(s). Hence, there was no interpretation of the integrated findings, nor were inconsistencies between qualitative and quantitative results addressed.

Synthesis Results

Some randomized controlled trials were summarized narratively because they did not reply to our email inquiries for additional data for meta-analysis (54,61,65,66,71), or because the outcomes were too dissimilar for meta-analysis. No subgroup analyses and tests of publication bias were conducted as all meta-analyses had less than 10 studies each. All findings summarized narratively are found in Supplementary Findings.

Effects of dance exergaming on physical functions (meta-analysis)

Static balance

Three studies evaluating the impact of dance exergaming on the extended balance test of the Short Physical Performance Battery were included in the meta-analysis (37,47,49) (n = 113). Surprisingly, the experimental group had a significantly lower score than the control group (pooled MD = −0.50, 95% CI: −0.91 to −0.09, p = .02). Heterogeneity was nonsignificant (p = .38, I² = 0%; Figure 2A).

Dynamic balance

Meta-analysis of 3 studies (55,56,70) (n = 80) found that the experimental group had a significant improvement in the dynamic balance component of Berg Balance Scale compared to the control group (pooled MD = 2.65, 95% CI: 1.73–3.57, p < .0001). Heterogeneity was nonsignificant (p = .96, I² = 0%; Figure 2A).

Timed-up-and-go test

Three studies were included in the meta-analysis (n = 92) (56,66,70) and the experimental group performed significantly faster compared to the control group (pooled MD = −1.04, 95% CI: −2.06 to −0.03, p = .04), with substantial heterogeneity (p = .04, I² = 68%; Figure 2A). When Lee et al. (56) were excluded during sensitivity analysis, heterogeneity (p = .40, I² = 0%) and the pooled effect size became nonsignificant (pooled MD = −0.55, 95% CI: −1.31 to 0.22, p = .16).

Five-times sit-to-stand

Two studies were included in the meta-analysis (n = 72) (56,66) and found no significant differences in the time taken between the experimental and control groups (pooled MD = −2.03, 95% CI: −6.81 to 2.76, p = .41), with considerable heterogeneity (p = .0002, I² = 93%; Figure 2A).

Short Physical Performance Battery

Four randomized controlled trials were included in the meta-analysis (n = 130) (45,47,49,64), which found no significant differences between experimental and control groups (pooled MD = 1.12, 95% CI: −0.26 to 2.49, p = .11), and heterogeneity was considerable (p < .0001, I² = 89%; Figure 2A). Heterogeneity remained significant while the effect size remained nonsignificant during sensitivity analysis.

Six-minute walk test

Two randomized controlled trials were included in the meta-analysis (n = 69) (49,71), which found no significant differences in the distance (m) walked between the experimental and control groups (pooled MD = 13.44, 95% CI: −29.98 to 56.85, p = .54). Heterogeneity was nonsignificant (p = .67, I² = 0%; Figure 2A).

Choice stepping reaction time

The Choice Stepping Reaction Time test used a step pad. The screen shows a graphical representation of arrows on the mat. When one arrow changed color, participants moved as swiftly as possible in the same direction as indicated and returned to the center. Reaction time (RT) is measured from the occurrence of the stimulus to the initiation of movement (lifting off of the foot), whereas movement time is measured from the initiation of movement to the foot stepping down (66). Meta-analysis of 2 studies (n = 113) (65,66) found that the experimental group performed significantly faster than the control group in terms of RT (pooled MD = −92.48, 95% CI: −167.30 to −17.67, p = .02), and heterogeneity was nonsignificant (p = .11, I² = 60%). Meta-analysis of 2 studies for movement time (n = 113) (65,66) was also significantly faster in the experimental group (pooled MD = −50.33, 95% CI: −83.34 to −17.33, p = .003), and heterogeneity was also nonsignificant (p = .17, I² = 48%; Figure 2A).

Functional independence

Meta-analysis of 2 studies (n = 34) (55,77) found no significant differences between experimental and control groups for functional independence (pooled SMD = 0.24, 95% CI: −1.54 to 2.01, p = .79; Figure 2B). Heterogeneity was considerable (I² = 83%, p = .01).

Summary of findings for physical function measures

Through meta-analysis, we found that the experimental group had significantly better dynamic balance, timed-up-and-go time, choice stepping reaction, and movement time than the control group. However, for other outcomes such as 5-times-sit-to-stand, Short Physical Performance Battery, aerobic capacity, and endurance, functional independence, there were no significant differences compared to the control group, and/or there were mixed findings in the narrative synthesis (Supplementary Findings). In contrast, according to the meta-analysis, the control group performed significantly better on static balance than the experimental group, and studies included in narrative synthesis had mixed findings.

Effects of dance exergaming on cognitive functions (meta-analysis)

Trail-Making Test A

Meta-analysis of 5 studies (37,45,47,48,65) (n = 211) found no significant differences between the experimental and control group on the time taken (pooled MD = −3.45, 95% CI: −7.16 to 0.26, p = .07). Heterogeneity was nonsignificant (p = .57, I² = 0%; Figure 3A).

Trail-Making Test B

Meta-analysis of 5 studies (37,45,47,48,65) (n = 211) found no significant differences between the experimental and control groups on the time taken (pooled MD = −13.25, 95% CI: −32.37 to 5.87, p = .17). Heterogeneity was substantial (p = .01, I² = 69%; Figure 3A). When de Bruin et al. (45) were removed during sensitivity analysis, heterogeneity became nonsignificant (I² = 41%, p = .16), but the effect size remained unchanged (−4.65, 95% CI: −18.26 to 8.97, p = .50).

Digit forward span

Meta-analysis of 2 studies (37,48) (n = 80) found no significant differences between the experimental and control groups for digit forward span (pooled MD = −0.33, 95% CI: −0.72 to 0.06, p = .10). Heterogeneity was nonsignificant (p = .33, I² = 0%; Figure 3A).

Stroop tasks (time taken)

Meta-analysis of 2 studies (37,47) (n = 64) found no significant differences between the experimental and control groups for Stroop tasks (pooled SMD = −0.15, 95% CI: −0.65 to 0.34, p = .54). Heterogeneity was nonsignificant (p = .64, I² = 0%; Figure 3A).

Summary of findings for cognitive outcomes

Meta-analyses found no significant differences between experimental and control groups for Trail-Making Tests A and B, digit forward span, and Stroop tasks. In the narrative synthesis, there were also mixed findings on memory-related outcomes, and cognitive screening tests.

Effects of dance exergaming on psychological well-being (meta-analysis)

Fear of falling

Seven studies were included in the meta-analysis (45,47,49,60,65,66,70) (n = 263). Lower scores indicate a lower fear of falling. Random effects meta-analysis found no significant differences between the experimental and control groups (pooled SMD = −0.16, 95% CI: −0.49 to 0.17, p = .33), and heterogeneity was nonsignificant (p = .12, I² = 40%; Figure 3B).

Depression screening tests

Five studies were included in the meta-analysis (47,49,55,65,77) (n = 197), and no significant differences were found in the effects of dance exergaming on depression levels (pooled SMD = −0.39, 95% CI: −0.96 to 0.18, p = .18; Figure 3B). Heterogeneity was considerable (p = .01, I² = 69%) (Figure 3B). Heterogeneity became nonsignificant (p = .09, I² = 54%) when Eggenberger et al. (47), an outlier, was removed during sensitivity analysis, and the effect size became significant (SMD = −0.59, 95% CI: −1.12 to −0.07, p = .03).

Feasibility, usability, and safety

Feasibility was measured using adherence to the training regimen (attendance) and attrition rates (Supplementary Table 8). Fifteen articles reported on adherence (38,39,44,45,47,48,51,59,60,62–66,71), which ranged from 76.5% (137.7 minutes) (45) to 100% (231–279 minutes) (64). Attrition was reported in 21 articles (38,39,43,44,46–48,51,54,56,60,62,65–67,71,75–79), and ranged from 9.1% (56) to 31.9% (65).

Usability was assessed in 15 articles (38,39,41,42,47,48,50,53,57,58,66–68,72,76) (Supplementary Table 8). Most articles used the System Usability scale, Game Experience Questionnaire, User Experience Questionnaire (38,39,41,42,53,58), and Physical Activity Enjoyment scale (47,48). Most participants found dance exergaming to be enjoyable and usable. A minority did not enjoy it (58,66). Other articles used self-developed Likert scale questions on participants’ perceptions of the usability of the exergame, such as training enjoyment (50,57,66,72). Immersion in the virtual reality platform was measured in 4 studies (57,67,72). One study also assessed simulator sickness (68) and found that dance exergames were more likely to induce motion sickness symptoms than strength endurance exergames.

Adverse events were assessed in 12 articles (37–39,41,45,59,62–66,76) (Supplementary Table 8). Most articles reported no adverse events such as falls. There were minor adverse effects, such as dizziness during body rotations and slight body pain. One participant had high blood pressure during dancing, which was not disclosed to the researchers before the intervention (41), while another with postpolio syndrome reported severe leg pain requiring hospitalization the day after the intervention (66). Most articles had stringent eligibility criteria (Supplementary Table 7), which likely ensured that participants could complete the intervention safely. It was also mentioned in many articles that research/healthcare staff were present during the intervention to ensure their safety, and a few described that the older adults wore safety harnesses, gait belts, or held onto ropes to prevent falls (37–39,41,44,48,49,54,56–58,60–62,69,70,74,76).

Discussion

This systematic review and meta-analysis evaluated the effects of dance exergaming on physical, cognitive functions, and psychological well-being. The meta-analyses found that dance exergaming significantly improved dynamic balance measured using Berg Balance Scale, timed-up-and-go times, choice stepping RT, and movement time. For other outcomes assessed in this review, there were no significant differences with the control group, mixed results were found in the narrative syntheses, and/or that the findings were based on weak evidence (eg, small sample size, single-group studies). The diversity of outcomes, tools, and study designs limited the number of studies included in the meta-analyses. Dance exergames were found to be effective and safe for most older persons in this review.

Mixed findings on dance exergaming’s effect on static balance outcomes were found in the meta-analysis and narrative synthesis. The meta-analysis found that the control group performed better than the experimental group, but caution is needed due to different controls used, and complexity of intervention implemented among the 3 studies (39,47,49). The ability to maintain an upright posture and retain the line of gravity within the boundaries of the base of support (ie, quiet standing) is defined as static balance (80). A previous meta-analysis on the effects of exergaming on healthy older adults also found no significant effects on static balance (12). The narrative synthesis additionally showed mixed findings across studies of varying study designs. Hence, further research is needed on this outcome.

The meta-analysis and narrative synthesis showed that dance exergaming resulted in a significant improvement in dynamic balance. This is likely due to the fact that dancing involves constant changes in body postures, thereby training the older adults’ dynamic balance, which is defined as the ability to retain equilibrium while shifting weight and frequently changing the base of support (80). Similar to a previous meta-analysis, exergaming was effective in improving the dynamic balance of older adults as measured using timed-up-and-go (12).

No significant differences were found in 5-times-sit-to-stand, Short Physical Performance Battery, and 6-minute walk test between the experimental and control groups. However, dance exergaming may have beneficial effects on older adults’ aerobic capacity. A previous meta-analysis found that dancing increased peak oxygen consumption compared to nonexercise controls (81), and no differences were found with other forms of exercise (81,82). Another interesting outcome explored in this review is the positive impact of dance exergaming on heart rate variability (Supplementary Findings), similar to other exercise interventions, indicating improved cardiac autonomic control and cardiovascular health (83). Dance exergaming may have thus cardiovascular benefits for older adults. Normal aging impairs cardiac autonomic control, resulting in reduced parasympathetic modulation of the cardiovascular system (reduced heart rate variability). Reduced cardiac autonomic control is linked to negative health outcomes like coronary heart disease, increased mortality, future functional decline, and sarcopenia. These conditions increase the risk for cardiovascular diseases, decreased physical fitness, and reduced quality of life in older adults. Dance exergaming may help improve cardiovascular fitness and provide associated benefits for older adults (83).

No significant differences were found between the experimental and control groups for Trail-Making Tests A and B. The findings on memory-related outcomes, Stroop tasks, and cognitive screening tests were mixed. Other cognitive functions were also assessed in the included studies. Research on dance exergaming and older adults’ cognition is limited due to diverse study designs, cognitive domains examined, and tools used. Consequently, no definitive conclusion can be drawn from this meta-analysis and narrative synthesis. However, the included studies did indicate some positive effects of dance exergaming on cognition in older adults. These mixed findings are supported by previous reviews, which concluded that dancing resulted in positive cognitive changes, although mixed results were seen as well (17,84). Eleven out of 23 studies found improved executive function, 2 out of 5 studies found improved general cognition, and 5 out of 10 studies found improved short- and long-term memory in older adults compared to controls or other intervention groups (17). The mixed effects of dance may be due to differences in participants’ baseline physical activity levels and training intensity across studies (17). Dancing increases brain-derived neurotrophic factors in older adults, which can improve neuroplasticity and cognitive functions by protecting against neuronal death in the hippocampus (84). Improvement in cognitive functions is also facilitated by older adults’ constant learning of new dance choreographies and the intensity of the exercise, which affects the level of brain-derived neurotrophic factors expressed (84).

Similar to the previous dance exergaming meta-analysis, no significant differences between experimental and control groups on fear of falling were reported (29) despite having a larger sample size. This is likely because fear of falling is a multifactorial issue. While dancing has improved the dynamic balance of older adults (a modifiable risk factor), other psychological and practical aspects were not directly addressed, such as using cognitive behavioral therapy techniques to help older adults recognize, evaluate, and transform their distorted beliefs (85,86), and equipping them with falls prevention and management skills (86,87).

In the meta-analysis on depressive symptoms, when the outlier was removed during sensitivity analysis (47), there was a significant improvement in depression scores in the intervention group compared to the control group. In Lee et al. (55) and Rica et al. (61) (Supplementary Findings), where participants had depressive symptoms at baseline, the experimental group showed a significant reduction in depressive symptoms measured using Beck Depression Inventory compared to the control group, indicating that dance exergaming may help those with depressive symptoms. A systematic review similarly found that exergaming benefited older adults in studies where depressive symptoms were an inclusion criterion, while mixed findings were seen in other studies without it (88). Unlike the previous review on dance exergaming for older adults (29), the findings of this review suggest that dance exergaming may be effective in reducing depressive symptoms.

Only 2 studies examined quality of life and health, with conflicting results on whether dance exergaming improved quality of life (Supplementary Findings) (61,69). A systematic review and meta-analysis of dance interventions for older adults with mild cognitive impairment found no significant differences between the intervention and control groups on its effects on quality of life (19).

Feasibility in terms of adherence was good (76.5%–100%), similar to a previous review on exergame interventions (26). This was attributed to factors like the appeal and enjoyment of the exergames (26,89–91). Dance exergames had slightly higher adherence than conventional exergames for older adults (54%–100%) (13,92). Feasibility in terms of attrition rates (9.1% to 31.9%) was also similar to the literature on exercise interventions, which reported attrition rates of 7% to 58% (93). Exergames were also similarly found to have no or rare adverse effects, suggesting that it is a generally safe intervention (26). This could be because most exergames are supervised and studies have included safety elements as found in our review, similar to previous systematic reviews (91,92,94,95). Home-based unsupervised exergames for older adults have been conducted with limited or no adverse events, but all participants had at least one supervised session to ensure safety, and it is unclear if participants played in the presence of their families, which could prevent adverse events such as falls (96). Supervision may also contribute to good adherence rates. A trial on home-based exergaming found that older adults used their exergame training devices less frequently during the unsupervised phase, which occurred after the supervised phase, suggesting that video gaming elements alone are insufficient in encouraging self-directed exercise in the home environment. Future research may consider including social elements and sustainable clinician involvement (97).

Usability assessments found that some older adults gave low/neutral scores, indicating a need for improved designs of the exergames. Qualitative findings on older adults’ experiences with dance exergames show that navigating the game environment and controls was difficult (38,39,41,53,98). Some older adults found the dance routines easy (38,50,98), while others requested that the dance routines be slower and simpler (42).

Strengths and Limitations

This review is currently the most comprehensive systematic review and meta-analysis of dance exergaming among older adults. We additionally assessed numerous physical and cognitive outcomes, feasibility, usability, and adverse events that were not evaluated in the previous systematic review (29), providing valuable evidence on the effectiveness and utility of dance exergames.

Subgroup analysis was not possible due to limited studies in meta-analyses. The review thus could not determine the effects of intervention duration, sample sizes, different intervention settings, or the complexity of intervention on older adults’ outcomes. In addition, many of the participants were high functioning both physically and cognitively, which may explain why some measures did not find significant differences in those who participated in dance exergaming compared to the controls. We only included English articles, so articles in other languages may have been missed.

Implications for Future Research

Researchers often design complex interventions with small sample sizes that combine dance exergames with other physical exercises. This makes it difficult to determine the specific effect of dance exergames alone, as noted in a previous systematic review (29). The use of various outcome measures made it challenging to analyze the effects of dance exergaming through meta-analysis. More research on dance exergames is needed before using them in multicomponent interventions. Future studies should use standardized outcome measures to draw more robust conclusions on dance exergaming in future meta-analyses. Only one study had long-term follow-up. More studies are needed to determine if dance exergaming benefits last over time.

Additionally, many studies in this review were exploratory with small sample sizes. Hence, more randomized controlled trials with larger sample sizes should be conducted. Most included studies were also done in labs or participants’ homes. Future research should study the impact of dance exergames in community settings, such as senior activity centers, on promoting physical activity on a larger scale among older adults.

More research is needed to improve the design of dance exergames for older adults, as some usability assessments showed low/neutral ratings for enjoyment (Table 2). The previous review found that high attrition rates in exergame studies may be due to participants’ lack of engagement and study design, which reduced enjoyment and fun. Consequently, this could reduce motivation to complete or adhere to the intervention (29).

Conclusion

Dance exergaming improved older adults’ dynamic balance, timed-up-and-go times, choice stepping reaction, and movement time. It was found to be feasible, usable, and safe. There were mixed or nonsignificant findings for other physical and cognitive outcomes and effects on psychological well-being. Future studies should use standardized tools to evaluate physical and cognitive function, conduct larger randomized controlled trials, explore the long-term effects of dance exergames, and improve the design of dance exergames.

Funding

This review was undertaken as part of a study funded by the National University Healthcare System Family Medicine/Primary Care/Health Services Research Seed Grant (Sep 2021) (NUHSRO/2021/115/RO5+6/FMPCHSRG-Sep21/01). The funder had no role in the design and conduct of the review, approval of the manuscript, and decision to submit the manuscript for publication.

Conflict of Interest

None.

References