Game-Based versus Training-Based Virtual Reality for Cognitive Rehabilitation in Mild Cognitive Impairment and Dementia: A Systematization of Design Paradigms, Outcomes, and Evaluation Rigor

Abstract

Therapeutic exercises can help slow cognitive decline in dementia, but conventional programs are often tedious and difficult to sustain. Virtual reality (VR) offers an alternative through game-based approaches designed to improve engagement and training-based approaches focused on structured functional recovery. Prior reviews report inconsistent findings about these paradigms, while it remains unclear whether the labels represent systems that are technologically distinct. Following PRISMA 2020 guidelines, we systematize 34 studies published between 2015 and 2026, including 16 controlled efficacy trials and 18 design and feasibility studies involving mild cognitive impairment, dementia and Alzheimer's disease. We develop a taxonomy covering design paradigm, immersion, feedback modality, difficulty adaptation and hardware. Our analysis shows substantial overlap between game-based and training-based systems, suggesting that these labels do not clearly distinguish their technological characteristics. We also introduce VR-RES, a seven-dimensional framework for evaluating study quality. Its application highlights recurring limitations in the evidence base, particularly limited follow-up, poor reproducibility and insufficient analysis of demographic factors such as age, sex and education. Based on these findings, we provide recommendations for future VR cognitive rehabilitation research, emphasizing specific design features, rigorous evaluation and improved reporting practices.