Our findings back up the hypothesis that FRED, an ad hoc-designed exergame, reduced the presence and severity of risk of frailty in a sample of sedentary elderly individuals to a significant extent, hence potentially altering their risk profile. The results we obtained, which are in keeping with previous evidence, suggest that elderly individuals with higher risk profiles may still benefit from preventive strategies and should not necessarily be excluded from any type of intervention that may help prevent disability.
The results are discussed in this section by contrasting them with those of other authors who have worked in similar, comparable areas of study. Cesari et al. [33
] conducted a study in which the physical activity programme they arranged included aerobics (walking), tests of strength, flexibility and balance training, all of which were performed in three phases over a 12-month period: adoption (weeks 1−8), transition period (weeks 9−24) and maintenance (week 25 to month 12). The results showed that regular physical activity may help reduce frailty, especially among individuals deemed to be at higher risk of disability.
Giné-Garriga et al. [34
] conducted a study that combined functional balance and lower-body strength-based exercises over a 12-week period, known as the functional circuit training program (FCT). This entailed balance training 1 day a week, followed by lower-body strength-based exercises of 15 minutes’ duration each on another day. The results obtained showed that the functional circuit training program (FCT) can be effective in improving self-reported aspects including fear of falling and the general state of health in a group of physically frail individuals.
Clegg et al. [35
] compared the effectiveness of the HOPE programme with usual care using a blind pilot randomised controlled trial (RCT), conducted over a 12-month period. This involved completing exercises of 15 minutes’ duration three times a day over 5 days of the week, with results showing that the trial provides initial evidence of the fact that a decline in mobility experienced by frail elderly individuals may be reduced via a 12-week exercise programme. Apart from mobility, independence in activities of daily living was also assessed via the Barthel Index, in which no significant differences between both groups was evidenced. As regards self-assessment of one’s state of health and quality of life via the EuroQol 5D-5L (EQ-5D-5L) questionnaire, the results showed a slight worsening. No data was provided about self-assessment of one’s state of health via the EuroQol-visual analogue scale (EQ-VAS).
Fairhall et al. [36
] made a comparison between study group and control group with frail elderly individuals by setting in motion a multi-factor intervention programme with online exercises over a 12-month period. The results showed that the prevalence of frailty was 14.7% less in the intervention group than in the control group after 12 months. There were no significant differences between groups in terms of scores regarding the usefulness of the EuroQol 5D-5L (EQ-5D-5L) questionnaire. There was not any data about self-assessment of one’s state of health via the EuroQol-visual analogue scale (EQ-VAS).
Milte et al. [37
] conducted a study over 2 weeks in order to explore the relative importance given to health and quality of life by elderly individuals who performed therapeutic gymnastics and undertook hydrotherapy sessions. Only results for the EuroQol 5D-5L (EQ-5D-5L) questionnaire were shown in this study, and no data was provided about the EuroQol-visual analogue scale (EQ-VAS).
Bieryla KA [38
] used the Xbox Kinect™ to improve balance in elderly individuals, The results showed an improvement in terms of the balance tests carried out. However, no improvements were evidenced in the Timed Up and Go (TUG) test, which the author did not expect given that use of the Kinect™ compels participants to move more than other game systems.
The above studies [34
] combine a range of physical activities which are of longer duration and performed at greater weekly frequency than the one carried out in our study using the FRED game. Although they manage to reduce frailty, they do so requiring far more time, and none of them contemplates exercise using an exergame. Only in the thee previous ones is reference made to the EuroQol 5D-5L (EQ-5D-5L) questionnaire, in which no significant differences are shown, whereas with the FRED game, the study group remained stable after 6 weeks while the control group slightly worsened. Unlike the other two authors referred to above, the EuroQol-visual analogue scale (EQ-VAS) was recorded in the study, in which the control group worsened whereas the study group significantly improved. Furthermore, the degree of independence for activities of daily living also evidenced an improvement after 6 weeks carrying out physical activity using the FRED game. Therefore, the degree of frailty is able to be reduced in less time using the FRED game, while the perception of one’s state of health and degree of independence in activities of daily living is much greater.
The study conducted by Daniel Daniel et al. [39
] uses the exergame as a physical activity that can be performed to help try and limit frailty. In this case, the Nintendo®
and Wii™ consoles are used in conjunction with commonly-played games like bowling, tennis and boxing, which have been designed with the general public in mind, and these are then compared to seated exercise and control. Exercise sessions of 45 minutes’ duration were conducted three times a week over a 15-week period, and results pointed to the fact that all the differences indicated an improved physical functional state in the case of the seated exercise or Wii-fit groups, when compared to the control group. The FRED game differs from the above study because it managed to reduce the degree of frailty to a fifth of the time (3 weeks as opposed to 15), including sessions of less than half the duration (20 min as opposed to 45 min). In addition, the FRED game continued to reduce the degree of frailty over the 6-week period and consequently, it would seem to be more effective.
The study conducted by Van Diest et al. [40
] used the exergame to undertake unsupervised balance training at home, which involved the participant playing the role of a virtual ice skater for 30 minutes three times a week, over a six-week period. The pilot study ascertained on the one hand the fact that unsupervised home-based exergaming is a viable option in community-dwelling older adults, but also that participants do not necessarily gain the same benefit from such a programme, thus highlighting the need for more bespoke exergame training programmes. The conclusion drawn from this study clearly stresses the ad hoc nature of the FRED game when it comes to designing and preparing exercises, placing importance on the types of scenario to ensure they are creative and intuitive and capture the participant’s attention and interest. The specific movements that were carefully chosen for each scenario, respecting biomechanics, neuromotor functions and participation both of upper and lower extremities and the trunk, were able to facilitate independence in terms of basic activities of daily living (ADLs) such as transferring, dressing, eating, toileting and walking.
As regards physiological constants such as heart rate, systolic blood pressure, diastolic blood pressure and blood oxygen saturation, there are no studies in the literature reviewed that have measured these constants in elderly individuals in order to ascertain whether the physical exercise involved lies within certain safety parameters and whether it is in turn cardiac healthy.
Scheer et al. [41
] evaluated the effects of competing against a computer or human opponent in young adults on a person’s heart rate, ventilation, oxygen consumption and amount of energy expended using Nintendo Wii™, Sony Move and Microsoft Kinect™ games. The results obtained in the case of oxygen consumption were then used to compare Nintendo Wii, Sony Move and Microsoft Kinect™ games by taking into account moderate health guidelines suggested to encourage physical activity.
In their study, O’Donovan et al. [42
] compared the amount of energy expended when playing in both individual and multi-player mode using Xbox Kinect™ and Wii™ consoles. They concluded that the amount of energy expended together with the person’s heart rate increased when playing with the Xbox Kinect™ console in multi-player mode.
There is a recent publication by Barry el al. [43
], in which they describe the study conducted to compare the effects of exergaming with traditional gymnastics-based exercises in which patterns of movement, intensity and physiological demand were similar for postural control. All participants (young adults) completed three exercise sessions of 30 minutes’ duration a week over a 4-week period. Heart rate was compared between groups and no differences were found. Ratings for perceived exertion (RPE) or the Borg scale were significantly lower in the Kinect ™ group. The Kinect ™ group perceived less physical exertion than the group which carried out traditional gymnastics-based exercises. There were also significant differences in terms of acceptance of the technology between groups and in considering it to be a positive exercise experience, with higher scores in the case of the Kinect exercise group. They concluded that exergaming with Kinect ™ may attain moderate levels of physical exercise intensity with positive feelings about the reduction in perceived exertion in comparison to traditional types of exercise.
In this sense, we obtained using similar results in terms of the fact that a moderate level of physical activity intensity may be obtained, accompanied by a low rating of perceived exertion. This was also accepted positively and proved a motivating force in improving the individual’s physical condition.
Karahan et al. [44
] conducted a study to compare the effects between exergames using the Xbox Kinect™ device and exercise at home involving balance training, functional mobility and lity of life among individuals over 65 years of age. Each participant played for 30 minutes 5 days per week over a 6-week period (30 sessions in total) in the company of an experienced nurse, who was able to carry out cardiopulmonary monitoring in order to ensure there were no events and, thus, ensure the safety of the exercise being undertaken. The extent to which participants enjoyed it was in turn assessed using a 5-point Likert scale (0−5). Results were positive and both groups improved in terms of balance, functional mobility and quality of life, although the authors pointed out that the group which did the exercise using the Xbox Kinect™ device obtained better results.
In this sense, our results differ because it resulted in a major difference in terms of physical condition after just three sessions a week and for less duration, as the risk of frailty evidenced in the study group was significantly reduced whereas it considerably worsened in the control group. Similarly, it did so in terms of independence in activities of daily living, with the study group obtaining better results in the Barthel Index than the control group, which obtained a worse result after 6 weeks. As regards compliance with safety with a view to preventing any event from taking place that might put the participants at risk, physiological constants were measured in the FRED game such as heart rate, rating for perceived exertion, systolic blood pressure, diastolic blood pressure and blood oxygen saturation. These measurements were taken before commencing, immediately afterwards and 5 minutes after having completed in order to make an assessment taking into account the safety parameters established and published by European guides, resulting in a cardiac healthy and safe exercise because safety compliance of the physical exercise exceeded 87% and even improved as the days went by. Moreover, in no case was the activity abandoned due to physical discomfort.
A recent publication by Meneghini et al. [45
] involves a qualitative study about the perception of elderly people with regard to participation in exergaming-based exercise. Fourteen individuals (55−77 years of age) carried out 12 weeks of exercise (50 min, 3 days/week) using Xbox 360 Kinect™ Sports. Participants reported psychological benefits (self-esteem, concentration, mood, reasoning, memory and wellbeing), physical benefits (agility and physical conditions) and social interaction (exchange of experiences, friendship and competitiveness). As regards group experiences, innovation, the game itself and visual stimulation were cited as features of the games, and the perception of benefits from participation in exergames fostered the pursuit of exercise and increases motivation among participants. In this sense, in the case of the FRED game, it managed to reduce the frailty risk that benefit from physical exercise entails by half the time (weeks) and in sessions of less than half the duration. It also managed to improve the degree of independence in activities of daily living and in the perception of participants’ state of health. The study group awarded the game very high scores, meaning that the game was accepted and rated very positively in terms of its usability. The game was also adhered to and complied with by the study group, as all and every one of the participants completed the same number of sessions and responded 100% to the daily questions to ascertain whether they liked the game and whether they found it motivating for the purpose of improving their physical condition. All the benefits obtained and described previously are due to the added appeal offered by the FRED game over other types of existing game. This appeal of being an ad hoc designed game in which the idea is for the user to be the protagonist achieves greater involvement in, adherence to and compliance with physical exercise.
The ad hoc developed FRED game helped to reduce the degree of frailty by improving the functional capacity of frail elderly individuals, thus enabling them to remain independent as long as possible.
Frail elderly individuals improved the perception of their state of health and quality of life while in turn their mood was improved, they became motivated towards participation and integration and, hence, were able to prevent the sense of isolation which they would otherwise easily tend towards.
The FRED game helped to maintain and improve independence in activities of daily living in frail elderly individuals.
The FRED game showed that it is able to motivate frail elderly individuals in doing exercise, because it involved a game that they liked and which proved motivating for the purpose of improving their physical condition. The feature of having been designed ad hoc proved very appealing among frail elderly individuals, who felt themselves to be the protagonists and thus achieved better involvement in, adherence to and compliance with physical exercise. The activity proposed with the FRED game did not entail any risk to the frail elderly individuals who took part in it, given that they worked within safe and cardiac healthy parameters.
The study undertaken confirms the fact that the FRED game proves to be a valid technological solution for reducing frailty risk.
Based on the study conducted, the exergame may be considered to be an effective, safe and entertaining alternative with which an improvement is made not only in terms of the physical and functional capacity of the individual, but also an improvement in psychological and social aspects which, in short, make the individual evidence a greater degree of independence over a longer time, i.e. “bring more life to the years”.
The possibility of carrying out a study in the near future is under consideration, in which prevention of the onset of frailty could be studied.
The biggest limitation in the study was the sample size. On the other hand, the participation of a greater number of day centers would help to enlarge the sample, but they only accepted 2 centers. For these reasons, the authors would like to carry out future research on a larger scale.