Nintendo Wii Virtual Reality Application In Older People With Alzheimer's Dementia
Phase: NA
Conditions: Age-Related Memory Disorders
Sponsor: Kırıkkale University

 
The Title of the study: 
Nintendo Wii Virtual Reality Application In Older People With Alzheimer's Dementia 
 
 
Date of the document: 
September 26, 2017: Permission was obtained from the Ministry of Family and Social 
Policies. 
December 12, 2017: The permission for the study was obtained from Karamanoğlu Mehmet 
Bey University Faculty of Health Sciences, Non-Invasive Clinical Research Ethics 
Committee. 
August 15, 2017: The literature was scanned. 
January 15 / April 30 2018: Data has been collected. 
May 15, 2018: Statistical Analysis was performed. 
January 18, 2020: Results were analyzed.  Primary Completion Date 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Author Information: 
Fatma Uğur PTa, Meral Sertel PT, Assoc. Prof b*  

 
a Hacettepe University, Faculty of Physical Therapy and Rehabilitation, Talatpaşa Street, 
Altındağ, Ankara, Turkey, TR06532. fatmakabakci1994@gmail.com 
b Kırıkkale University, Faculty of Health Sciences, Department of Physical Therapy and 
Rehabilitation, Kırıkkale, Turkey, TR71450. fzt_meralaksehir@hotmail.com  
 
ORCID Number: Meral Sertel - 0000-0002-7575-9762, Fatma Uğur - 0000-0002-0059-5636  
 
Corresponding Author: 
SERTEL, MERAL, PT, ASSOC. PROF.  
Department of Physiotherapy and Rehabilitation,  
Kırıkkale University Faculty of Health Sciences 
Tel: 90-318 357 37 38 
e-mail: fzt_meralaksehir@hotmail.com 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Nintendo Wii Virtual Reality Application In Older People With Alzheimer's Dementia 
Abstract  
Purpose: This study was planned to investigate the effects of the Nintendo Wii virtual reality 
application on muscle strength and fall risk in individuals with AD. 
Method: The study included a total of 32 volunteers between the ages of 65-80, with mild or 
moderate AD diagnosed. These individuals were divided into 2 groups as a training group and 
control group. The training group was trained with games from different categories such as 
balance and aerobic exercises with a Nintendo Wii virtual reality device 2 times a week for a 
period of 6 weeks, with 1 session lasting for 30 minutes. Mini-Mental State Test, Knee 
Extension Muscle Strength, Timed Up and Go Test, Tinetti Falls Efficacy Scale results of 
individuals were recorded in the evaluation. 
Results: The mean age of the control group was 73.13 ± 3.54 years, and the mean age of the 
training group was 73.75 ± 5.16 years. In the statistical analysis between groups, the Mini-
Mental State Test values were found to be statistically significant in favor of the training 
group (p=0.049). In the intra-group statistical analysis, there was a significant difference in all 
tests in the training group after the training, while no significant difference was found in the 
control group. 
Conclusions: It was found out that the virtual reality application in individuals with 
Alzheimer's dementia increased muscle strength and decreased the fall risk. As a result, 
supporting the physiotherapy and rehabilitation programs with technological developments 
and virtual reality applications will increase the success of the treatment. 
Keywords: Alzheimer's Dementia; Muscle strength; Fall; Virtual reality  
 
 
 
 
 
 
 
 
 

 
Study Procedure and Protocol 
The study included a total of 32 volunteers between the ages of 65-80, who stayed in 
Karaman Ahmet Mete Nursing Home, Elderly Care and Rehabilitation Center, with mild or 
moderate Alzheimer's dementia diagnosed by a neurologist. There were 90 older people in 
Karaman Ahmet Mete Nursing Home, Elderly Care and Rehabilitation Center. Power analysis 
was performed to determine the size of the sample to be included in the study. As a result of 
the power analysis, assuming that the effect size to be obtained between the two groups will 
be large (d = 0.9), when at least 32 individuals (at least 16 individuals per group) were 
included in the study, it was calculated that 80% power could be obtained at 95% confidence 
level (with 0.05 error margin). As a result of the power analysis, it was calculated that at least 
16 individuals could be included in each group (at least 32 individuals in total). 20% risk rate 
was determined for the individuals who could leave the study, 3 individuals were added to 
each group, and the study was organized with 19 individuals in each group. However, these 
people were excluded from the study as 4 people were not meeting inclusion criteria, 2 people 
were declined to participate, and therefore the study was completed with 32 individuals 
(Figure 1). The study included volunteers between the ages of 65-80 with mild or moderate 
AD diagnosis, who did not have any difficulty or problems in communicating, who did not 
have any neurological diseases that disrupt balance and coordination such as a 
cerebrovascular event, Parkinson's disease, Multiple Sclerosis, and neurological disorder, who 
obtained a score of 18 - 24 points in the Mini-Mental State Test (MMST) were included in the 
study. Patients diagnosed with rapidly progressing dementia (infection, vascular, hematologic 
diseases), those who could not be contacted during the follow-up period or who did not 
participate in the training session, those who experienced cardiac and cerebrovascular events, 
endocrine disorders, fluid-electrolyte imbalance and infection, those with malignancy and 
those who received chemotherapy and radiotherapy that causes malignancy, delirium or 
depression and malignant sensory loss (those with the Semmes-Weinstein monofilament 
thickness of 4.56 and above), and those with a lower or upper extremity amputation at any 
level were excluded from the study.  
Among the 38 individuals with AD diagnosis, 1 individual was not included in the study after 
the first evaluation due to the MMST score lower than 18, 3 individuals were not included in 
the study due to the hearing and communication problems, and 2 individuals were not 
included because they did not want to start the study. The first evaluation of the patients was 

performed before randomization. 32 individuals suitable for the criteria were included in the 
study (Figure 1). Randomization was performed by the sealed-envelope method. According to 
this method, 4 females and 12 males were determined to be in the control group, while 5 
females and 11 males were determined to be in the training group.  
The evaluation was completed before the intervention. The same evaluation was conducted 
after 6 weeks. The physiotherapist with more than 5 years of experience conducted all the 
evaluations. Exercise training was given by a another 2-year experienced physiotherapist.The 
training group was trained with games from different categories such as balance and aerobic 
exercises with a Nintendo Wii virtual reality device 2 times a week for a period of 6 weeks, 
with 1 session lasting for 30 minutes, and each patient was trained with the same games. In 
the control group, no application was performed during this period, and routine medical 
treatments were continued. The training group was evaluated before and after the training, 
while the control group was re-evaluated at the end of the 6th week after the first evaluation. 
After the study was completed, the volunteers from the control group were also given 
training.  
In order to determine the sociodemographic characteristics of individuals, the case report form 
included questions about name and surname, age, height, weight, body mass index, dominant 
side, smoking, alcohol use, previous occupation, marital status, educational status, income 
level, number of children, social security, special healthcare needs, number of falls in the last 
year, vision problems, personal history, family history, medicines used, surgeries undergone, 
and use of a walking stick. 
Their cognitive status was evaluated by the MMST. According to the MMST, 24-30 points 
were considered as normal cognitive levels, 18-23 points were considered as mild cognitive 
disorders, and 0-17 points were considered as severe cognitive disorders. 
Muscle strength was evaluated by the knee extension strength. The knee extension strength 
was measured by a hand-held muscle strength dynamometer (Baseline Evaluation System, 
New York). The knee extension strength measurement was preferred in this study because it 
is a measurement that gives information about general lower extremity muscle strength. The 
knee extension strength was evaluated in the sitting position with the hip and knee joint at 90  
flexion. The patient was asked to arrange his/her leg, the force was applied over the ankle, and 
the patient was asked to resist this force and keep his/her position. This measurement was 
repeated 3 times bilaterally, and the arithmetic mean of the values was taken. This 

measurement was performed twice as the first and last evaluation, and the results were 
recorded in kg-force [24]. 
The fall was evaluated with the Tinetti Falls Efficacy Scale (TFES), and this scale is a 10-item 
scale. These items include bathing, reaching out to shelves, walking inside the house, 
preparing food, going to bed and getting out of bed, answering the door, sitting on the chair 
and getting up from the chair, getting dressed and undressed, personal care, going to the toilet 
and leaving the toilet. The question of “How much do you feel confident while doing the 
above activities?” was asked to state a point between 1 and 10. 1 means very high confidence, 
and 10 means no confidence. A score between 0 and 100 is obtained in total. If the total score 
is more than 70 points, there is fear of falling. 
The Timed Up and Go Test (TUG) is a test that assesses the fall risk, mobility and physical 
performance in older people. A chair and a stopwatch are required to perform the test. The 
test is carried out with the patient's usual shoes, and the patient is told that he/she can use 
walking aids if needed. This test was performed by giving the command to the individual to 
get up from the chair without arm support while sitting on the chair, to walk in a 
predetermined 3-meter area and return, and to sit again on the chair without arm support 
(Image 3.1). The result was recorded in seconds (sec). If the older people completes this test 
in a longer time than 12 seconds, there is a fall risk. 
Each part of Nintendo Wii was introduced to the individuals in the training group in the first 
session and games were played with the support of a physiotherapist. How to play the selected 
games and their objectives were explained and taught to each individual by the 
physiotherapist in practice. The patient was supported with verbal and physical feedback 
when it was noticed that the patient made wrong movements during the games played in later 
sessions. Games that require serious strength, balance, and coordination such as Bird’s eye 
Bull’s eye, Obstacle Course, Balance Bubble, etc. were considered as a difficult activity for 
the patient and were not used in this study. 
The difficulty of the games was set to the simplest level for each patient. Their difficulty level 
was increased as the patients became successful. The difficulty of the games was increased 
according to the classification determined by the Nintendo Wii device. The duration of each 
game was different, and the games were played until the end of their times. All games were 
played by the patients under the same conditions, in the same environment, at the same 
temperature and at the same time in each session. 

The permission for the study was obtained from Karamanoğlu Mehmet Bey University 
Faculty of Health Sciences, Non-Invasive Clinical Research Ethics Committee. Voluntary 
consent forms were signed by both individuals with AD and caregivers of these individuals. 
 
CONSORT 2010 Flow Diagram 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessed for eligibility (n= 38 ) 
Excluded  (n= 6  ) 
   Not meeting inclusion criteria (n= 4 ) 
   Declined to participate (n= 2 ) 
   Other reasons (n=0  ) 
Analysed  (n= 16 ) 
 Excluded from analysis (give reasons) (n=0 ) 
Lost to follow-up (give reasons) (n= 0 ) 
Discontinued intervention (give reasons) (n=0 ) 
Allocated to intervention (n= 16 ) 
 Received allocated intervention (n= 16 ) 
 Did not receive allocated intervention (give 
reasons) (n= 0 ) 
Lost to follow-up (give reasons) (n=0  ) 
Discontinued intervention (give reasons) (n=0 ) 
Allocated to intervention (n= 16 ) 
 Received allocated intervention (n= 16 ) 
 Did not receive allocated intervention (give 
reasons) (n=0  ) 
Analysed  (n= 16 ) 
 Excluded from analysis (give reasons) (n=0 ) 
Allocation 
Analysis 
Follow-Up 
Randomized (n=32  ) 
Enrollment 

Statistical Analysis Plan  
The data were analyzed using the SPSS 24.0 packaged software. Continuous variables were 
presented as mean ± standard deviation, median (minimum and maximum values), while 
categorical variables as number and percentage. The suitability of the data for normal 
distribution was examined by the Shapiro-Wilk test. The significance test of the difference 
between the two means was used in comparing the independent group differences when the 
parametric test assumptions were provided, and the Mann-Whitney U test was used in 
comparing the independent group differences when the parametric test assumptions were not 
provided. The significance test of the difference between the two pairs was used in comparing 
the dependent group differences when the parametric test assumptions were provided, and the 
Wilcoxon two-pPaired sample test was used when the parametric test assumptions were not 
provided. Differences between categorical variables were analyzed by chi-square analysis. In 
all analyses, p<0.05 was accepted as statistically significant. 
Results 
The mean age of the individuals was 73.13 ± 3.54 years, and the mean age of the training 
group was 73.75 ± 5.16 years. No statistically significant difference was found between the 
groups in terms of age, gender, height, weight, body mass index, occupation, marital status, 
education level, income level, number of children, and social security (p>0.05). 
Upon examining the MMST values, the difference between the 2 groups was not statistically 
significant (p>0.05). In the post-training measurements, the values of the training group were 
significantly higher compared to the control group (p<0.05). When the changes in the groups 
before and after the training were examined, no statistically significant change was observed 
in the control group, whereas the values of the training group were significantly higher after 
the treatment (p<0.05) . 
When the right and left knee extension muscle strength values of individuals with AD were 
examined, the difference between the 2 groups was not statistically significant before and 
after the training (p>0.05). When the changes of the groups before and after the training were 
examined, there was no significant change in the control group, whereas the values of the 
training group were significantly higher after the training (p<0.05). 
When the TFES values were examined, no difference was found between the 2 groups before 
and after the training (p>0.05). When the changes of the groups before and after the training 
were examined, there was no significant change in the control group (p>0.05), whereas the 
values of the training group were significantly lower after the training (p<0.05). 

When the TUG test values were examined, there was no difference between the 2 groups 
before and after the training (p>0.05). When the changes of the groups before and after the 
training were examined, there was no significant change in the control group (p>0.05), 
whereas the values of the training group were significantly lower after the training (p<0.05). 
Conclusion 
Along with cognitive functions, losses in motor functions such as muscle strength, balance, 
coordination, and walking occur in individuals with AD. A good physiotherapy and 
rehabilitation program is required to prevent and treat these problems. The virtual reality 
environment is a computer-generated three-dimensional simulation of a real-world situation in 
which the user can sense and control this simulation environment sensorially by means of 
special devices. In conclusion, the support of physiotherapy and rehabilitation programs with 
technological developments and virtual reality applications will increase the success of 
treatment especially for muscle strength, walking speed, reduction of fall risk and cognitive 
functions. This training may work as well, and that the results indicate that it may reduce the 
risk of falls. 
 
Who to Contact  
If you have any questions you may ask them now or later, even after the study has started. If 
you wish to ask questions later, you may contact any of the following: [Dr Meral SERTEL 
and PT Fatma UĞUR)  
 
Ethic Commitee 
A pilot and randomized controlled trial was conducted. Ethical approval for this study was 
received from Karamanoglu Mehmet Bey University, Faculty of Health Sciences, Non-
Interventional Clinical Research Ethics Committee on December 27, 2017(Decision Number: 
02-2017/08). In addition, this study was based on a thesis project, and permission was 
obtained from the Ministry of Family and Social Policies on September 26, 2017 (73595336-
605.01-E.99172). Voluntary forms were signed by both AD members and those who were 
responsible for their care. 
 
PART II: Certificate of Consent This section should be written in the first person and have a 
statement similar to the one in bold below. If the participant is illiterate but gives oral consent, 
a witness must sign. A researcher or the person going over the informed consent must sign 
each consent. The certificate of consent should avoid statements that have "I understand…." 

phrases. The understanding  should perhaps be better tested through targeted questions during 
the reading of the information sheet (some examples of questions are given above), or through 
the questions being asked at the end of the reading of the information sheet, if the potential 
participant is reading the information sheet him/herself. I have read the foregoing information, 
or it has been read to me. I have had the opportunity to ask questions about it and any 
questions that I have asked have been answered to my satisfaction. I consent voluntarily to 
participate as a participant in this research.  
Print Name of Participant__________________  
Signature of Participant ___________________  
Date ___________________________ Day/month/year 
 If illiterate Aliterate witness must sign (if possible, this person should be selected by the 
participant and should have no connection to the research team). Participants who are illiterate 
should include their thumb-print as well. Page 5 of 10 I have witnessed the accurate reading 
of the consent form to the potential participant, and the individual has had the opportunity to 
ask questions. I confirm that the individual has given consent freely.  
Print name of witness_____________________ AND  
Participant Signature of witness ______________________  
Date ________________________ Day/month/year  
Statement by the researcher/person taking consent I have accurately read out the information 
sheet to the potential participant, and to the best of my ability made sure that the participant 
understands that the following will be done: 
 1.  
2. 
 3. 
 I confirm that the participant was given an opportunity to ask questions about the study, and 
all the questions asked by the participant have been answered correctly and to the best of my 
ability. I confirm that the individual has not been coerced into giving consent, and the consent 
has been given freely and voluntarily.  
A copy of this ICF has been provided to the participant.  
Print Name of Researcher/person taking the consent________________________  
Signature of Researcher /person taking the consent__________________________  
Date ___________________________ Day/month/year