Efficacy of the Use of Exergames in Promoting the Mental Health of the Elderly: Protocol of a Systematic Review

Round 1

Reviewer 1 Report

Dear authors,

Thank you for the opportunity to review your protocol(s). I find this is a generally interesting emerging topic and the time seems right for further review.

Before progressing, however, there are a few things I would consider worth addressing. Section-by-section feedback is provided below. 

Introduction

Firstly, I feel that you need to justify the reasoning behind your review. What gap or issue within our current knowledge does it address? And how does it expand or complement other existing reviews on exergames and the elderly (example links provided below)? These questions should be explicitly answered in the text of the protocol and the eventual final published review.

Relatedly, why have you chosen to focus on the specific elements (cognitive stimulation, emotional management, socialisation) within your RQs? How do you define those terms and their importance? 

Methodology

The criteria within the methodology need to be more fleshed out. I have two immediate questions reviewing the inclusion criteria.

You should justify why 60 years old is the selected cut off age. 

How do you define mental health, and what kind of interventions can be included based on that definition? I realise you provide more detail below, but I think it is important to specify the definition/understanding of this key term. 

Also, I note that some similar/redundant terms reccur in your search strings. For instance, why have both 'elderly' and 'frail elderly'? Would the term 'elderly' alone not capture results for both? Likewise, would the term 'game' not also capture related terms such as 'simulation game', 'video game' and so on? I suspect you could trim down the search string without reducing the  results or rigour. If, in testing this, you had a different experience, then I'd be curious to know! 

Discussion

You refer to 'previous studies' (L216) but do not provide references. Please do so. 

Other reviews (sample)

https://journals.sagepub.com/doi/pdf/10.1177/0898264314551171

https://www.sciencedirect.com/science/article/abs/pii/S0003687016302265

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4180490/ 

Author Response

Dear reviewer,

We try to answer all the questions you asked. We are sure that all the comments were important to contribute to the improvement of the quality of this manuscript and to the reflection in the group of authors.

At your disposal for any further clarification,
Best regards,

The authors.

Answers:

Comment 1: 

Firstly, I feel that you need to justify the reasoning behind your review. What gap or issue within our current knowledge does it address? And how does it expand or complement other existing reviews on exergames and the elderly (example links provided below)? These questions should be explicitly answered in the text of the protocol and the eventual final published review.

Autor response:

Added:

This sytematic review adds to the existing literature on exergames and the elderly by focusing on the potential cognitive benefits of exergames specifically for older adults with mild cognitive impairment (MCI). While previous reviews have examined the effects of exergames on physical health outcomes in older adults, few have specifically explored their potential cognitive benefits for those with MCI. Our review also goes beyond previous research by synthesizing evidence from both randomized controlled trials and observational studies, providing a comprehensive overview of the current state of knowledge on this topic. Ultimately, our review aims to help address the gap in our understanding of how exergames may be used to improve cognitive function in older adults with MCI, and to highlight the potential benefits of integrating exergames into interventions designed to promote healthy cognitive aging.

Comment 2:

Relatedly, why have you chosen to focus on the specific elements (cognitive stimulation, emotional management, socialisation) within your RQs? How do you define those terms and their importance? 

Autor response:

We chose to focus on the specific elements of cognitive stimulation, emotional management, and socialization within our research questions because these are critical components of successful aging and have been shown to be positively impacted by exergames.

Cognitive stimulation is essential for maintaining cognitive function and preventing cognitive decline in older adults. Exergames have been found to enhance cognitive function by promoting neuroplasticity and increasing brain activity. Emotional management is also crucial for successful aging, as older adults may experience social isolation, loneliness, and depression. Exergames can serve as a tool for emotional management by providing opportunities for social interaction, enjoyment, and positive mood induction.

Finally, socialization is a vital aspect of successful aging, and exergames can be used to facilitate social interaction and engagement among older adults. By incorporating socialization into our research questions, we hope to explore the potential of exergames as a tool for promoting 

social interaction and reducing social isolation in older adults.

Overall, we believe that cognitive stimulation, emotional management, and socialization are critical components of successful aging, and our focus on these elements within our research questions is justified by the potential of exergames to positively impact each of these areas.

Added: The existence of evidence suggests that cognitive stimulation, emotional management, and socialization are three key areas that can potentially benefit older adults' health and wellbeing through exergame use. This systematic review focuses on these elements because they have been identified as important factors in promoting successful aging and maintaining independence in older adults. By examining the effects of exergames on these specific areas, we hope to gain a more comprehensive understanding of the potential benefits of exergames for older adults.

Comment 3:

You should justify why 60 years old is the selected cut off age.

Autor response:

The cut off age of 60 years old was selected based on the World Health Organization's definition of "older adult," which is commonly used in gerontology research. Additionally, previous studies have also used this age range to define the older adult population, as it is generally considered the age at which individuals start to experience age-related declines in physical and cognitive function. By focusing on this age group, we hope to provide a more targeted and relevant review of exergames for the older adult population.

Added:

A cut-off age of 60 years old was selected, which is consistent with the World Health Organization's definition of "older adult" and is commonly used in gerontology research. This age range is also supported by previous studies as the age at which individuals begin to experience age-related declines in physical and cognitive function. By focusing on this age group, our review aims to provide a targeted and relevant analysis of exergames for older adults.

Comment 4:

How do you define mental health, and what kind of interventions can be included based on that definition? I realise you provide more detail below, but I think it is important to specify the definition/understanding of this key term.

Autor response:

Types of intervention(s)

This review will include studies that implement  the use of exergames for mental health promotion. Mental health is defined as a state of well-being in which an individual can cope with the normal stresses of life, work productively, and contribute to their community. Exergames have the potential to promote mental health by providing cognitive stimulation, emotional management, and socialization, which are key elements of mental well-being. In terms of interventions, we will include studies that use exergames as the primary intervention for promoting mental health in older adults.

Comment 5:

Discussion section: lines 9-11 the sentence (…) as holders of specialized knowledge. and (…) Please correct the dot in the middle of the sentence.

Autor response:

Regarding your concern about the inclusion of both "elderly" and "frail elderly" as search terms in our database, we believe that it is important to include both terms in order to ensure that all relevant results are captured.

While it may seem redundant to include both terms, doing so can actually help to provide clarity and precision in our search results, allowing us to more easily identify and analyze the specific subset of elderly individuals who are most relevant to our study. While all frail elderly people are elderly, not all elderly people are frail, and including both terms in our search can help to ensure that we capture all relevant results for our study, including those related to the specific population of frail elderly individuals.

Comment 6: You refer to 'previous studies' (L216) but do not provide references. Please do so. 

Autor response:

References added.

Reviewer 2 Report

I would like to recognize the authors to write the protocol for the study of t the effectiveness of exergames in promoting the mental health and socialization of the elderly. The study has practical implications. This topic is lack of innovation.

I carefully read your manuscript, and I have some doubts or suggestions, which, I hope, will improve the quality of your article.

Introduction:

- In the third paragraph, some findings were listed to show the effect of exergames on cognitive function, not entirely mental health. Is there some article on the effectiveness of exergames in promoting all domain of mental health and socialization of the elderly, more studies can be added to expand this section.

Methods:

- It is recommended to follow the PRISMA-P checklist to write the method section of the study.

- It is recommended that all outcomes for which data will be sought be listed and defined, including the prioritization of primary and additional outcomes, and justified.

- Guidelines for inclusion, exclusion of literature should not be repeated.

Discussion:

- The discussion part is not sufficient, and does not reflect the innovation of the research.

Author Response

Dear reviewer,

We try to answer all the questions you asked. We are sure that all the comments were important to contribute to the improvement of the quality of this manuscript and to the reflection in the group of authors.

At your disposal for any further clarification,
Best regards,

The authors

Answers:

Comment 1:

In the third paragraph, some findings were listed to show the effect of exergames on cognitive function, not entirely mental health. Is there some article on the effectiveness of exergames in promoting all domain of mental health and socialization of the elderly, more studies can be added to expand this section.

Autor response: Studies added, as suggested.

Comment 2:

It is recommended to follow the PRISMA-P checklist to write the method section of the study.

Autor response: In the protocol development, we took into consideration the PRISMA checklist.

Comment 3: 

It is recommended that all outcomes for which data will be sought be listed and defined, including the prioritization of primary and additional outcomes, and justified.

Autor response: 

This review will consider studies that measure the following outcomes using valid and reliable instruments. The primary outcomes of interest are as follows:

• Cognitive ability: the capacity to learn, reason, and understand information, as well as to solve problems and make decisions.
• Emotional creativity: the ability to generate and express novel and appropriate emotions in response to different situations, as well as to regulate and manage one's own emotional experiences and responses.
• Memory: the ability to acquire, store, and retrieve information over time.
• Attention: the ability to focus and sustain one's cognitive resources on a specific task or stimulus, while inhibiting distractions and irrelevant information.
• Reaction time: the speed at which an individual can respond to a stimulus, typically measured by the time between the presentation of a stimulus and the initiation of a response.

In addition, we are also interested in the following outcomes:

• Emotional well-being: the subjective experience of positive emotions, life satisfaction, and purpose in life, as well as the absence of negative emotions and psychological distress.
• Self-esteem: the evaluative and affective component of one's self-concept, including feelings of self-worth, competence, and adequacy.
• Psychosocial capacity: the ability to engage in social interactions and relationships, as well as to cope with stress, adapt to changing environments, and maintain a sense of meaning and purpose in life.
• Sleep quality: the subjective and objective characteristics of sleep, including the duration, efficiency, and continuity of sleep, as well as the presence of sleep disturbances and disorders.

These outcomes were selected based on their relevance to the research question and their potential to provide insight into the relationship between the use of exergames for mental health promotion.

Comment 3: 

Guidelines for inclusion, exclusion of literature should not be repeated.

Autor response:

The necessary adjustments have been made.

Comment 4:

The discussion part is not sufficient, and does not reflect the innovation of the research.

Autor response: Adjustments made to reflect the innovation of the review.

Reviewer 3 Report

Dear authors,

the topic of the paper is very interesting; however, even if the protocol of the review is explained, the paper completely lacks to describe which are the paper selected, these papers are not cited in the bibliography and it is not explained how they contribute to the definition of the topics. Lastly, no discussion is proposed. Moreover, Table 1 is too extended with regard to the rest of the paper.

Author Response

Dear reviewer,

We try to answer all the questions you asked. We are sure that all the comments were important to contribute to the improvement of the quality of this manuscript and to the reflection in the group of authors.

At your disposal for any further clarification,
Best regards,

The authors

Answers:

Comment 1: 

the topic of the paper is very interesting; however, even if the protocol of the review is explained, the paper completely lacks to describe which are the paper selected, these papers are not cited in the bibliography and it is not explained how they contribute to the definition of the topics. Lastly, no discussion is proposed. Moreover, Table 1 is too extended with regard to the rest of the paper.

Autor response: Since this is a protocol, it only presents the criteria to effectively carry out the systematic review later on. There is, however, a clear description of the process we will follow to conduct the systematic review.

Reviewer 4 Report

Thank you for the opportunity to review the protocol. The paper is interesting but needs some corrections, explanations, and additions. The main contribution of the authors is clearly presented. I have a few recommendations for the authors to address before publication.

My comments are as follows:

General comments:

1.       All references should be corrected according to MDPI Chicago Style. References are missing spaces, commas, etc.  

Abstract:

Introduction

1.      Line 78-79: The authors mention other types of video games above, could the authors explain why the study focused only on Wii games??

2.      Line 79-81: In Protocol 2, do the authors also focus only on Wii games or also on other games? Could the authors explain this?

3.      Could authors specify what is new in this research please?

Methods 

Inclusion Criteria

1.      Were all elderly people included in the study, regardless of comorbidities, etc.?

2.      Does the study contain any exclusion criteria?

Search Strategy:

1.      Could the authors clarify the following questions:

- Was screening tool/form created for this project?

- What was an agreement between the Screeners’ decisions on both stages of the screen?

2.      Was the search string further expanded by running searches with Medical Subject Heading (MeSH Terms)? If so, it should be mentioned in the manuscript.

3.      When the database search was performed? Could authors please specify this and include in the manuscript?

Data extraction

1.      Did you use a data extraction form based on ICF framework during the data extraction process?

Discussion

1.      The Discussion should also provide practical guidelines for the reader.

2.      It is still not clear if the study will include only Wii games or also others.

Conclusions

1.      While the practical applications are almost obvious, perhaps they should be mentioned.

Reference

1.       Please correct the references according to MDPI Chicago Style.

Author Response

Dear reviewer,

We try to answer all the questions you asked. We are sure that all the comments were important to contribute to the improvement of the quality of this manuscript and to the reflection in the group of authors.

At your disposal for any further clarification,
Best regards,

The authors

Answers:

Comment 1: 

All references should be corrected according to MDPI Chicago Style. References are missing spaces, commas, etc.  

Autor response: The necessary adjustments have been made.

Comment 2: 

 Line 78-79: The authors mention other types of video games above, could the authors explain why the study focused only on Wii games??

Autor response: The background that refers to another protocol in which the focus was on Wii was used for the specific purpose of evaluating the effectiveness of the Wii, as we intend to develop an RCT using the Wii Switch and would like to find out if there are already studies that have used this game and, on the other hand, identify the types of games and assessment instruments used. In the present study, this criterion does not exist because the aim is to verify the effectiveness of exergames in promoting cognitive stimulation, emotional management, and socialization.

Comment 3: 

Line 79-81: In Protocol 2, do the authors also focus only on Wii games or also on other games? Could the authors explain this?

Autor response: In protocol 2, all types of exergames will be included, as the aim is to evaluate the effectiveness of exergames in cognitive stimulation, emotional management, and socialization, aspects that were not considered in protocol 1. Regarding physical fitness, there is already a study that summarizes the effectiveness of exergames in promoting it. However, there is no study yet that demonstrates the effectiveness of the Wii in terms of physical fitness.

Comment 4: 

Inclusion Criteria

1. Were all elderly people included in the study, regardless of comorbidities, etc.?
2. Does the study contain any exclusion criteria?

Autor response:

1 - Yes, older adults will be included regardless of comorbidities, and these comorbidities will be subsequently identified in the data extraction table.

2 - No, there are exclusion criteria. All articles that do not meet the inclusion criteria will be excluded. However, we made changes to the item that addresses the inclusion criteria to bring greater clarity to the text.

Comment 4: 

Search Strategy:

1. Could the authors clarify the following questions:

- Was screening tool/form created for this project?

- What was an agreement between the Screeners’ decisions on both stages of the screen?

2. Was the search string further expanded by running searches with Medical Subject Heading (MeSH Terms)? If so, it should be mentioned in the manuscript.
3. When the database search was performed? Could authors please specify this and include in the manuscript?

Autor response: 

1 - Yes, the screening tool was created specifically for this project to address the outlined objectives.

2 - A pilot analysis of 2% of the articles was already conducted by two reviewers, and there was a 94% agreement.

3 - Regarding the search date in the databases and the MeSH terms, this information is included in Table 1.

Comment 5: 

Data extraction

1. Did you use a data extraction form based on ICF framework during the data extraction process?

Autor response: nce this review follows the JBI methodology, the various stages followed the same methodology.

Comment 6: 

Discussion

1. The Discussion should also provide practical guidelines for the reader.
2. It is still not clear if the study will include only Wii games or also others.

Autor response: Although it is a protocol, the discussion was reformulated to bring more clarity and better understanding for the reader.

Comment 6: 

Conclusions

1. While the practical applications are almost obvious, perhaps they should be mentioned.

Autor response: The information has been added.

Reviewer 5 Report

This manuscript presents a systematic review and protocol related with efficacy of the use of exergames in promoting the mental 

health of the elderly . This review  is generally well written, but it is unclear what this review adds to what is already known and have been published earlier. No clear research question seems to be formulated, the conclusions are unclear and other major concerns with this manuscript.

My specific comments are stated below. Overall, several important issues need to be addressed and some are of methodological character which requires a considerable revision of the paper. 

1. The introduction section did not provide a clear rationale for carrying out the study (for example, why is your research question important? What gap in the literature is the study addressing?

I suggest in this section should be improved, with more information related with this condition exergames in promoting the mental health of the elderly.

 2. Methods: Was the study registrered at PROSPERO? Please to include the date of registered .

3.  Methods - literature search and selection: Please outline the exact search string or provide an appendix with the search strategy with specific search outcomes for each search and combinations. 

4. Methods - literature search and selection: Did you restrict study selection on any language? 

5. Results. Please add this section and performed a systematic review, according to international standards,  provide specific numerical data. Please add the calculate related with risk of bias was evaluated of this investigation.

 6. Within your discussion,  compare outline your results, discuss their novelty and their application to practice.

 7. Conclusion. These conclusions need to be softened, modified a in order to reflect only the study findings.

Author Response

Dear reviewer,

We try to answer all the questions you asked. We are sure that all the comments were important to contribute to the improvement of the quality of this manuscript and to the reflection in the group of authors.

At your disposal for any further clarification,
Best regards,

The authors

Answers:

Comment 1: 

 The introduction section did not provide a clear rationale for carrying out the study (for example, why is your research question important? What gap in the literature is the study addressing?

Autor response:

Additional information has been added.

Comment 2: Methods: Was the study registrered at PROSPERO? Please to include the date of registered .

Autor response: This study was registered on OSF on October 21, 2022.

Comment 3: 

Methods - literature search and selection: Please outline the exact search string or provide an appendix with the search strategy with specific search outcomes for each search and combinations. 

Autor response: The search strategy for each specific database is listed in Table 1, which includes the name of the database, search date, results, and search strategy.

Comment 4: 

Methods - literature search and selection: Did you restrict study selection on any language? 

Autor response: Yes, only articles written in English, Portuguese, Spanish, and French will be considered, as stated in the inclusion criteria.

Comment 5: 

Results. Please add this section and performed a systematic review, according to international standards, provide specific numerical data. Please add the calculate related with risk of bias was evaluated of this investigation.

Autor response: As a protocol, it only presents the criteria for effectively carrying out the review at a later stage. However, there is a clear description of the process that we will follow to conduct the systematic review.

Comment 6: 

Within your discussion, compare outline your results, discuss their novelty and their application to practice.

Autor response: Our paper describes a protocol, and therefore, we do not have concrete results to compare or discuss at this stage. Our main focus is to outline the potential contributions and novelty of our protocol, as well as its practical application. We understand that the lack of empirical data may limit the depth of our discussion, but we plan to address this limitation in the future by conducting a systematic review, which will provide more comprehensive results. Therefore, our paper serves as a proposal for further research, rather than a report of actual findings. Thank you for considering our work in this context.

Comment 7: 

Conclusion. These conclusions need to be softened, modified a in order to reflect only the study findings.

Autor response: Our paper describes a protocol, and therefore, we do not have concrete results to compare or discuss at this stage. Our main focus is to outline the potential contributions and novelty of our protocol, as well as its practical application. We understand that the lack of empirical data may limit the depth of our discussion, but we plan to address this limitation in the future by conducting a systematic review, which will provide more comprehensive results. Therefore, our paper serves as a proposal for further research, rather than a report of actual findings. Thank you for considering our work in this context.

Round 2

Reviewer 1 Report

Thank you for the revisions and your overall receptiveness to comments. I am happy with the changes made.

One note though: in your new text, you make claims (e.g. about how 60 years old has been identified by the WHO as 'older adults' or the definition of mental health) that do not have any references. These definitions and associated claims should be referenced! 

Author Response

Notes to reviewers attached

Author Response File: Author Response.docx

Reviewer 3 Report

I appreciate the efforts of the authors, but several issues are not solved: it is not clear how many papers were identified, why, how; discussions, the most relevant section for a review paper, are not sufficiently discussed, The table about the search criteria is still too much wide compared to the rest of the paper

Author Response

Notes to reviewers attached

Author Response File: Author Response.docx

Reviewer 5 Report

 My opinion about the article remains the same of the previous revisions of manuscript. Most of the issues that I advanced to you not was repaired. A new study would be needed to make these things suitable. The clarifications provided do not solve the problem.

Author Response

Notes to reviewers attached

Author Response File: Author Response.docx