As longevity increases, the population composition in most European countries is increasingly made up of older adults (1). While this is a success of health care and healthier lifestyles, the burden on health care services is already apparent, with even higher burdens to be expected in the decades to come¹. Consequently, measures that can contribute to sustained health, independence and quality of life in older age are needed. One of the most important single factors for healthy aging is physical activity and exercise, which can reduce the risk of all-cause mortality (2), frailty (3), the risk of several cardiovascular and metabolic diseases (4), and incident dementia (5), increase bone strength (6), and reduce falls (7). However, many older adults do not exercise and are not sufficiently physically active (8), and engaging in and keeping up an exercise routine can be difficult. Reasons for not exercising can include lack of interest, not believing that exercise could prolong your life, and feeling breathless and out of shape (9), while characteristics of exercise programs that promote adherence include individualization of exercise, education about the exercise program, the scientific rigor of the exercise selection, convenience, enjoyment, feedback and integration into daily life (10). Hence, the need for exercise programs that are fun, engaging and motivating, and that have lasting effects on physical activity.

Over the last decades, video games have been used increasingly for exercise purposes, in such cases termed as ‘exergaming’, which can be broadly defined as video games that “involves physical exercise and that integrates motion-tracking technology that enables interaction with the game and real-time feedback of user's performance” (11, 12). Benefits of exergames are that they can be tailored to the user's specific needs, with demands placed on different cognitive tasks or motor tasks according to relevant impairments (13, 14), but also that the gaming aspect is enjoyable, motivating and engaging (15). Importantly, the combination of cognitive and motor training (‘motor-cognitive training’) is hypothesized to facilitate additional neuroplastic effects for both domains (16). Studies over the last years suggest that exergaming can be more effective than conventional exercises for improving balance (17), cognitive functioning (18) and reducing falls (19) in older adults. A recent study showed that it should be noted there are also studies that show little or no difference to conventional exercises (14, 20). Exergames can be delivered over several different platforms, such as screens, surround-screen displays (21) or head-mounted displays (HMD). By using head-mounted virtual reality (VR) technology, all visual stimuli except what is shown in the display is removed. For this reason, this experience is generally considered the most immersive, and by extension, most engaging. There are few studies that compare outcomes of exergaming with HMDs to other platforms, but memory performance could potentially be better with HMDs (22).

Through a multidisciplinary collaboration funded by the EU-Active and Assisted Living program (23), a prototype of a novel VR-exercise game especially adapted for older adults has been developed. The goal of the collaboration is to develop an affordable VR solution which older adults can use by themselves at home to improve or maintain their levels of physical activity. Novel technological applications need to be specially adapted to the needs and abilities of the designated end users (24). However, as Song et al. (2025) points out: “Current VR Game designs often follow generic models, lacking personalized adjustment to address individual differences in physical abilities and cognitive levels”. Furthermore, research into VR and older adults often fail to sufficiently incorporate feedback from older adults during the design phase, resulting in systems that do not fully meet their needs (25, 26). Therefore, researchers are pointing to the need to gain better understanding about how older adults themselves experience using novel technology, such as VR, as tools to gain or support healthy ageing (24, 27, 28).

Therefore, the primary aim of this study is to investigate how older adults experience using a novel and technologically advanced VR-exercise game, and further whether playing the game would lead to more physical activity.

In this pilot study, we aimed to learn about the experiences of inactive older adults with an immersive VR exergame. Ten older adults were interviewed after the trial period and shared that they found the game interesting and visually pleasing, and that the overall experience had been fun. However, several also emphasized that the game was not very physically challenging, and that they saw it more as a game than as exercise.

The participants found the game to be novel, fun and interesting. Motivation is crucial for adherence to exercise, and de Groot and Fagerström describes how participants in a fall prevention program were motivated by expectations of improved balance, physical function and health (40). Although such motivations concerned factors that could be seen as highly relevant to themselves, they could still be seen as extrinsic, meaning that the activity of exercise was perhaps not motivating in itself. A key feature of exergames is that the gaming aspect is intrinsically motivating, and that players engage in them longer (41). This was showed by Meldrum and co-authors in a RCT comparing virtual reality exercises with conventional exercises in people with vestibular disorders, where there were no significant differences in functional outcomes between groups, but the VR-exercise group exercised more than the protocol specified and also reported higher enjoyment (42). The participants in our study described the game with words like “pleasant”, “enjoyable”, “fun” and as a “positive experience”. They also pointed out the competitive aspect, where performance is rewarded with scores and points, as motivating (43). Some participants said that to them, exercising should include social interaction, and that playing alone was not motivating. This is in line with the findings of Kaos and co-authors, who found that exergame adherence was higher when playing in a multiplayer setting, than in a single player setting. The authors point out group belonging as crucial to game designs (44). Also, some participants expressed that the games could have been more challenging, both game-wise but also physically. A common sentiment among the participants was that the game was not physically demanding. This is reflected in how the average Borg scale value was around 10, and the average maximal heart rate was marginally higher than 100 BPM, for all three levels (Table 3). Consequently, the game failed to induce any substantial exercise effects. This is in contrast to the systematic review of Peng and co-authors, who found that active video games facilitated light-to-moderate energy expenditure during playing (45). It should be noted that maintaining the player's safety was an important priority for the design of the game in this study, which in turn made it challenging to adequately individualize the difficulty setting for each player. In hindsight, having a software feature which could have dynamically adapted the difficulty level of the movements based on a player's performance during the game would probably be more beneficial than the fixed difficulty setting created in the design process. As such, the game may be better suited for frailer older adults with more pronounced deconditioning and mobility issues, which was also suggested by the participants. Alternatively, the game could also be seen as a way to break up lengthy periods of sitting or sedentary behavior, which can be detrimental to health (46).

With regards to game design, the participants expressed that they would have liked the game to be more challenging, and with more opportunities for progression, which is important in game design; when games become too easy, it is easy to lose motivation (43). The participants suggested using more balloons, at different levels, and perhaps also using props, such as rackets, to reach the objects. The environment in itself was perceived as discomforting by some of the participants, such as a feeling of “being pulled outwards” when standing in an exposed spot. Simeonov and co-authors found that height exposure was perceived as equally stressful in real and virtual environments (47), but Bovim and co-authors found that while gait became unsteady and cautious while walking onto a virtual glass bridge over a high drop, gait normalized relatively quickly, suggesting that people can adapt well to height exposure (48).

One of the aims of the study was to explore whether playing the game would facilitate more physical activity also outside of the game setting, the rationale being that inactive people would find playing the game motivating and thereby being more physically active, and that this would transfer to other physical activities. Most participants expressed that playing the game did not make them more physically active in general and in their daily lives. This can also be seen in the count of daily steps, which was more or less the same before the intervention, during the intervention and after the intervention (Table 6). We have found no studies investigating how playing an exergame may transfer to being more physically active outside of the gaming context, but it can possibly be assumed that feeling fit and as an “exerciser” would be associated with more exercise and physical exertion in daily life, not unlike how Rodrigues and co-authors show in a study of young and middle-aged adults, that past positive exercise experiences are associated with future exercise (49). In the present study, the exercise intervention lasted only two weeks, and was perceived as low intensity, and it is unlikely that it would have any lasting impact on the physical activity behavior of the participants.

This study is limited by a low number of participants. Furthermore, although they were recruited on the basis of being physically inactive, their physical functioning was good, as shown in Table 2. A recurring comment in the interviews was that the game was too easy and that the participants did not feel that they exerted themselves, and the target group for inclusion should likely have been individuals with lower physical capacity and more ADL dependence.

A strength of the study is that we got deeper knowledge about the experiences with the game through the interviews, which will be very important for further game development. The game was developed in close collaboration with older adults, and their input was taken into consideration, from using balloons as the targets to hit, to specifically composed music. This study is a continuation of the process of developing the game optimally for potential target groups.

In this study we included ten relatively healthy but inactive older adults, where all piloted a VR game with six sessions over two weeks. The main finding of the study is that while older adults enjoyed the experience of playing a virtual reality exergame, the game was not physically demanding enough for the participants, and also that the game presented too few challenges. Game development should focus on tasks that keep players interested and engaged over longer times, without jeopardizing safety.