An Integrated Program to Improve Cognitive and Physical Abilities in Older People

Abstract

Integrated programs combining two or more interventions, such as cognitive training and exercise, are attracting attention as a non-pharmacological treatment of dementia. Challenges in implementation, along with a lack of strategies to sustain engagement and motivation, have limited integrated programs in Korea. This study developed an integrated program using gamification strategies to improve cognition and physical strength in older people and evaluated its effectiveness. The study was conducted for 8 weeks in the form of stepping training using the Stroop effect on 24 adults aged 65 years or older. With this intervention, cognitive function significantly increased (p = 0.007); in particular, memory (p = 0.005) and language function (p = 0.042) showed significant improvement. Physical performance also significantly improved (p = 0.001), and the reward strategy had the highest satisfaction with 4.29 points in the user satisfaction survey. Thus, an integrated program is effective in improving cognition and physical performance in aging adults, and gamification has a positive effect on increasing persistence and motivation in older people. This study can be a useful reference in developing cognitive enhancement programs.

1. Introduction

The rapid aging of Korea’s population is drawing an increasing focus on geriatric diseases. Dementia, which is a typical disease of old age, is emerging as a serious social problem. In 2021, dementia patients accounted for 10% of the population aged 65 and over in Korea. Notably, older adult females have been reported to exhibit approximately a 35% higher risk of developing dementia compared to their male counterparts, with an associated mortality rate estimated to be twice as high [1].

Patients with dementia experience various changes, including declining cognitive function, daily physical performance, and emotional stability [2]. The cognitive decline leads to a decrease in physical strength and muscle power as well, which can lead to various medical accidents [3,4]. While dementia is difficult to treat, it can be prevented through early diagnosis and drug and non-drug treatment, and an integrated program combining two or more stimuli, such as cognitive training and physical activity, is a good non-pharmacological approach to treatment that can slow down the progress of dementia by activating intact brain cells [5]. Thus, integrated programs combining cognitive and physical training are an important factor in preventing dementia, although few such interventions are being undertaken in Korea due to difficulties in implementation. An analysis of the current status of cognitive rehabilitation programs implemented in dementia relief centers revealed that, despite the substantial demand among older adults for such programs, the availability of interventions that adequately reflect their needs and characteristics remains limited. This discrepancy has been associated with reduced program satisfaction and a decline in participant motivation. Furthermore, the findings indicate that older adults often struggle to maintain continued participation when their understanding of the program’s necessity is insufficient. Accordingly, enhancing the quality of cognitive rehabilitation programs by incorporating participant needs is crucial for promoting sustained program engagement and effectiveness [6].

Thus, to strengthen older people’s cognitive function, more than cognitive training is needed; it should be supplemented with regular physical activity; for this purpose, it is necessary to develop an integrated program encouraging participants to exercise consistently and autonomously, with a sense of engagement. This study proposes an integrated cognitive enhancement program combining gamification strategies to provide continuity and motivation for elderly patients and determines the effects of the program on the cognitive and daily physical performance of older people.

2. Literature Review

2.1. Cognitive and Physical Changes in Older Age

Cognitive decline occurs in older age as the aging brain shrinks in volume and loses brain cells [7], leading to memory loss, impaired comprehension, poor judgment, miscalculations, and decreased quality of life [8]. These symptoms intensify as dementia progresses. Dementia is the most common cognitive disorder experienced by older people and has been called the “disease of the 21st century.” For this reason, the quality of life of older people with dementia is significantly lower, and attention is increasingly focused on mild cognitive impairments, known as a pre-dementia stage [9,10].

Cognitive decline leads to a decline in physical performance, and older adults with cognitive decline tend to be physically inactive, increasing their risk factors for chronic diseases, including as pneumonia and infectious diseases, which lead to muscle weakness and stiff joints, increasing the risk of fractures [5]. They also experience worse balance and lower extremity muscle strength as a result of sarcopenia owing to decreased skeletal muscle mass [11]. Poor balance can lead to a narrower stride and slower walking speed, which increase the risk of falls [12], such that it is crucial to strengthen physical performance through regular exercise and physical activity.

2.2. Integrated Program

Elderly people who have cognitive decline show declining memory over time, as well as reduced problem-solving skills and daily life performance [13]. These changes lead to decreased physical activity, increasing the risk factors for chronic diseases, weakening muscle strength, and stiffening joints, further increasing the risk of fractures [4,14].

Various methods have been suggested for improving late-life cognitive function, and the most frequently mentioned one is exercise [15]. Exercise is a good means of preventing cognitive decline through improving neurogenesis and brain plasticity [16]. In addition, regular exercise improves physical strength, which leads to positive changes in cognitive ability [17]; aerobic exercise such as walking, is more effective for cognitive function, including memory than anaerobic exercise [7].

Integrated programs are gaining attention as non-pharmacological approaches to prevent dementia and cognitive decline. An integrated program is one that combines two or more methods, such as cognitive therapy, exercise therapy, and art therapy, to achieve multiple effects [18]. Unlike programs adopting a single therapy, an integrated program can maximize a program’s effectiveness by stimulating the subjects’ interest and inducing active participation in terms of various interventions [19]. In fact, exercise programs incorporating dual tasks have been shown to positively impact cognitive function in older adults [20], and programs that involve performing cognitive tasks simultaneously with physical exercises have been found to improve the health-related quality of life in older adults [21].

In summary, the cognitive and physical abilities of older people are closely related, such that regular physical activity is essential to enhancing cognitive function. For this reason, as a preventive measure for healthy old age, this study creates an integrated program combining cognitive and exercise therapy and verifies its effectiveness.

2.3. Gamification Strategy

Gamification refers to the application of the mechanics and elements used in games to non-gaming applications [22]. The application of elements of gamification to common tasks can help improve the overall user experience [23], and gamification strategies to increase user engagement and involvement are gaining traction [24].

Reward, challenge, achievement, competition, relationship, access, and self-expression form part of the gamification strategies that have been used in previous studies to increase users’ interest and intention to continue, especially in the healthcare domain, where the use of such gamification strategies can increase users’ self-efficacy and sustainability [25]. In addition, older adults are more likely to be interested and motivated to do exercise when it is combined with gamification, and their interest tends to increase when an exercise program has a clearly defined topic, such as the prevention of dementia or falls or building strength [26].

The following interventions in older people had positive results: a twelve-week program incorporating a rhythmic stepping machine with games improved balance in older people [27], a motion-aware walking game that added a sense of challenge and competition improved physical function [28], a six-week interactive dance game with game elements of difficulty and music had a positive effect on balance ability and motivation [29], and a four-week stepping training program using challenge strategies improved walking ability and increased satisfaction [30].

While earlier studies apply gamification elements and strategies to the field of healthcare, it is often difficult to find examples of the effectiveness of gamification strategies, and there has been little research demonstrating the development and effectiveness of an integrated program using gamification in an offline environment rather than in a digital one. This study selects the main gamification strategies appropriate to the study from the seven gamification strategies that have been previously identified [25], namely reward, challenge, achievement, competition, relationship, access, and self-expression and investigates whether they have an impact on intention to continue using the program and motivation when in application to an integrated program.

2.4. Stroop Stepping Game

This study builds on the work of Chung et al. [30], extending it by incorporating the Stroop effect into the four-way stepping game. This effect refers to the phenomenon whereby when the meaning of a letter and its actual color do not match, people take longer to name the color of the letter and are more often incorrect in their naming. This effect is called Stroop interference; in particular, it is called Stroop congruence when the letters and colors match and the Stroop mismatch when they do not. The Stroop task, which is an application of the Stroop effect, is used to measure working memory and executive function in older people, and it is effective in cognitive enhancement [31]. In addition, gamified step training is effective in improving stepping and walking ability in older people and in improving balance and preventing falls in older people [27,32].

In this study, we defined a task combining these two elements as the Stroop Stepping Game (SSG). While previous studies only measured improvement of walking ability, this study further analyzed the improvement of cognitive and physical performance, including walking ability. The SSG involves viewing a shape and color combination task on a display and stepping in all directions on a footstool matching the shape or the color of the shape. While the typical Stroop task is a color-naming task requiring participants to name the color of a presented letter, this study used a shape and color combination instead of a letter and color combination to make the task more intuitive for older adults, who may be illiterate and/or colorblind. A prototype of the Stroop Stepping Game (SSG) is presented as shown in Figure 1.

In previous studies, four-way stepping games were primarily conducted using digital devices. Rhythmic step exercises, such as Dance Dance Revolution (DDR), have been shown to improve balance in older adults [33] and the four-way stepping test using a digital device is a way to measure changes in fall rates and improve fall efficacy [34]. However, most previous studies have focused on changes in either physical performance or cognitive function independently, with few examining the effects on both physical and cognitive functions simultaneously. Therefore, this study seeks to determine whether an exercise program that combines four-way step training with cognitive task, such as the Stroop effect, can lead to improvements in both cognition and performance. Previous studies using four-way step training or the Stroop effect have been characterized by the following key features (

Table 1. Characteristics and limitations of previous studies.

Study	Objective	Characteristics	Limitations
Lange et al. [35]	Preventing falls in older adults	➓ Interactive stepping game using digital devices ➓ Allows users to control their own difficulty level	➓ Prototype study not tested on older adults. ➓ Did not measure changes in physical ability and cognition.
Schoene et al. [34]	Measuring fall rates and risk of falls in older adults	➓ Use digital devices ➓ Use Stroop tasks (arrows + letters) ➓ Fall rates and fall risk assessment	➓ Conducted as a simple test rather than an exercise. ➓ Did not measure changes in physical ability and cognition.
Park et al. [36]	Improving balance and physical function in older adults	➓ Build and use digital stepping exercise machines ➓ Use fixed panel plates ➓ Choice music and training intensity ➓ Use gamification to motivate older adults	➓ Not suitable for older adults to carry around. ➓ Only measured physical changes in older adults.
Park et al. [27]	Measuring balance and motor reaction time in older adults	➓ Using a rhythmic balance machine that involves stepping on a ground ➓ Use fixed panel plates ➓ Choice music and training intensity	➓ Not suitable for older adults to carry around. ➓ Only measured physical changes and balance in older adults.
Chung et al. [30]	Improving physical fitness and walking ability in older adults	➓ Use props that are portable ➓ Use Stroop tasks (shapes + colors) ➓ Use gamification to motivate older adults	➓ Only measured changes in physical function and walking ability.

).

This study differs from previous studies in the following ways:

• This study is conducted as an offline program using experimental tools that are easy to make and cost-effective.
• It utilizes the Stroop task, which has been used to measure cognitive function, as one of the contents to check further whether cognitive function improves in addition to physical performance and physical ability.
• It considers the characteristics of older adults who may be illiterate and color-blind; the traditional Stroop task has been modified to use shape + color combinations instead of letter + color combinations.
• It gradually increases the position and spacing of prop-type step stools to see if this improves walking ability and stamina.
• It uses gamification strategies to increase motivation and persistence and quantitatively verify that the experiment had an impact on older adults’ satisfaction after the experiment.

3. Method

3.1. Paticipants

This study was conducted twice a week for 8 weeks in 2024 at the J-Silver Senior Welfare Center in Seongbuk-gu, Seoul, for a total of 16 sessions. After a one-week recruitment period, 24 participants aged 65 and over were recruited, regardless of gender. There were no exclusionary criteria such as education or living arrangements if they met the selection criteria. The selection criteria were as follows:

• Able to communicate independently;
• Able to walk independently;
• No diagnosed dementia (Cognitive Impairment Screening Test (CIST) score of 19 or higher);
• No vision or hearing impairment (glasses/hearing aids are acceptable).

The appropriate sample size for this study was determined using G*Power 3.1, and the total sample size was calculated to be 12 participants based on the within Subjective Design with repeated measures ANOVA test, with an effect size of f = 0.40, α = 0.05, and power = 0.80. Over the course of the program, 6 of the 24 subjects dropped out for personal reasons, leaving a total of 18 subjects who completed the program. The demographic and physical characteristics of the final study subjects are shown in

Table 2. Characteristics of participants (n = 18).

Variables		Numbers
Gender	Male	3
	Female	15
Education Level	No formal education	0
	Middle school or higher	7
	High school or higher	8
	University or higher	3
Cognitive level	Normal	17
	Cognitive impairment	1
Total		18

and

Table 3. Physical characteristics of participants (n = 18).

Variables	M ± SD
Age (years)	73.7 ± 4.3
Height (cm)	156 ± 5.6
Weight (kg)	55.4 ± 8.9
BMI (kg/m2)	22 ± 3.4

.

The participants were informed of the purpose and effectiveness of the program in a one-time orientation, and they voluntarily agreed to participate in the study after understanding the purpose and objectives of the study. An overview of the program is given in

Table 4. Program overview.

Section	Contents
Title	Color Step for Cognitive Enhancement
Personnel	24 people
Period	2 September 2024, to 31 October 2024
Session	21 sessions (1 OT, 1 pilot game, 3 measurements, 16 main programs)
Duration	About 50 min per session
Expected outcomes	Strengthening cognitive abilities and daily physical strength

.

Before they began the program, the Cognitive Impairment Screening Test (CIST) was administered to all participants to classify them into normal and cognitively impaired groups, and the program was conducted as a single group.

3.2. Measurement

The selected measures were used to assess changes in cognition, physical performance, and satisfaction. The detailed measurement timeline is shown in

Table 5. Measurement timeline.

Section		Pre	Post 1	Post 2
Cognitive	CIST	O	−	O
Physical Performance	TUG	O	O	O
	FTSTS	O	O	O
	10 MWT	O	O	O
Satisfaction Survey		−	O	O

.

3.2.1. Measurement of Cognitive Function

To investigate cognitive changes in the participants before and after the program, the Cognitive Impairment Screening Test (CIST), which is commonly used to diagnose dementia in Korea, was administered before and after the program. Following the completion of the relevant training course and after familiarizing themselves with the test manual, the examiners conducted the test with the participants one-on-one. The test took about 10–15 min per person.

The CIST evaluates six areas: orientation, attention, visuospatial function, executive function, memory, and language function, with a total score of 30 points. Scores of 24 or higher are considered normal, between 20 and 23 denotes mild cognitive impairment, and 19 or lower indicates dementia. Scores are differentiated in relation to age and education, where higher scores generally present improved cognitive function. However, because the testers are not medical professionals, they cannot diagnose dementia, so only the changes in scores over the course of the program were compared for academic purposes.

3.2.2. Measurement of Physical Performance

To determine changes in physical abilities and performance before and after the program, we conducted three physical performance tests: before the program, during it (post 1), and after it (post 2). We assessed participants’ physical performance using three methods that are commonly used to assess overall physical performance in older adults: Timed Up and Go Test (TUG), Five Times Sit To Stand Test (FTSTS), and 10 Meter Walk Test (10 MWT) (Figure 2).

The TUG test provides a comprehensive measure of balance, walking ability, and lower extremity strength in older adults. In this test, the participant sits in a chair and, at the examiner’s signal “Go!” walks at a normal pace toward a marker that is placed 3 meters in front of the participant and then returns to the return point and sits back in the chair again. After the subject one practice run before the test, the examiner measures the subject’s performance on three iterations of the test and records the average performance time.

The FTSTS test is often used to comprehensively assess lower extremity strength and dynamic balance in older adults. In this test, the participant sits in a chair without armrests, arms crossed with hands on shoulders and is timed in getting up and sitting down as quickly as possible five times, beginning on the examiner’s “Go!” signal. After one practice run is provided before the test, the examiner measures the subject’s performance time once.

The 10 MWT is often used to assess static balance and walking ability in older adults. In this test, the participant waits behind a marked line, walking at a normal speed along the 10 m line at the examiner’s “Go!” signal. After giving the subject one practice run before the test, the examiner measures the subject’s walking time three times and records the average value.

3.2.3. Measurement of Satisfaction Survey

To assess the satisfaction of the participants with the program, two surveys were conducted: during (post 1) and after (post 2) the assessment. Responses to the questionnaire were pre-designed based on a 5-point Likert scale and consisted of 22 questions covering usefulness, satisfaction, persistence, and motivation (

Table 6. Survey questions.

Sections	Response Items
Utility	➓ I feel that my memory and cognitive abilities have improved through the program.
	➓ I feel that my physical strength and lower limb strength have improved through the program.
	➓ Continuing to use the program will help improve my cognitive abilities.
	➓ Continuing to use the program will help improve my physical strength.
Satisfaction	➓ The program is safe and has a low risk of injury.
	➓ The pace of the program is reasonable.
	➓ The difficulty level of the program is reasonable.
	➓ The length of the program is reasonable.
	➓ Learning and participating in the program is easy to understand.
	➓ I was able to clearly see the shape and color of the shapes in the program.
	➓ The program is fun.
	➓ I would like to recommend the program to others.
	➓ The facilitator accurately explained the purpose and effects of the program.
	➓ The facilitator conducted the program by carefully reflecting the cognitive/physical characteristics of each individual subject.
	➓ The facilitator reflected the opinions of the subjects well (difficulty level, physical strength level, presence of music, etc.)
	➓ The program that reflected the opinions of the subjects was satisfactory.
Persistence and Motivation	➓ I plan to continue using the program.
	➓ Through the program, I became interested in cognitive improvement and lower limb strength exercises.
	➓ Knowing about the effectiveness of the program increases motivation to continue with the program.
	➓ [Challenge] The game method of increasing difficulty (levels) increases motivation to continue the program.
	➓ [Competition] The game method of cooperating and competing with the next team creates a competitive spirit and increases motivation to continue the program.
	➓ [Reward] Using rewards (attendance/game stickers) to increase game participation increases motivation to continue with the program.

).

3.3. Experimental Design

This study investigated the impact of an integrated program on older adults’ perceptions of cognition and physical performance, along with the impact of gamification strategies on program satisfaction. The research hypotheses and models are shown in

Table 7. Research model.

Independent Variables	Dependent Variables	Measurement Details
Integrated Program	Cognitive Function (CIST)	Orientation
		Attention
		Visuospatial Function
		Executive Function
		Memory
		Language Function
	Physical Performance	TUG (Timed Up and Go)
		FTSTS (Five Times Sit to Stand)
		10 MWT (10-Meter Walk Test)
	Satisfaction Survey	Utility
		Satisfaction
		Persistence and Motivation
Gamification Strategy		Challenge
		Competition
		Reward

.

H1. 

Integrative programs will affect cognition in older adults.

H2. 

Integrative programs will affect older adults’ physical performance.

H3. 

Gamification strategies will affect older adults’ persistence and motivation.

3.3.1. Experimental Setup

This study was conducted as a program in an unobstructed auditorium in a welfare center. Two displays were set up at the eye level of the subjects, and a footrest was attached 1.5 m from the tablet. The footrests were made of 1 mm thick line drawing paper with a few steps to prevent injury due to falls, and each footrest was 20 × 20 cm in size. The scaffolds were set up before the experiment to match the subjects’ average stride lengths (Figure 3).

The Stroop task was presented to the subjects on a digital screen, a display standby from L (model: 27ART10AKPL/32-inch) that can be moved around the auditorium.

3.3.2. Experimental Procedure

The 24 older adults were divided into two groups, each with one facilitator. The program was held in a small auditorium at a welfare center, and the participants waited in designated seats with their partners (Figure 4).

For approximately 50 min, the subjects played the SSG, combining cognitive training and exercises with their partner in a relay format. The games incorporated two matching and two mismatching games, including three rounds of easy, moderate, and hard difficulty per game. The number of shapes increased by one each round, and for the Stroop mismatch game, the number of shapes increased by 1/3 (1 mismatch out of 3), 1/2 (2 mismatches out of 4), and 4/5 (4 mismatches out of 5). To prevent monotony, the facilitator encouraged the subjects by providing immediate feedback on their performance and playing their preferred Korean traditional-pop songs. Before and after the program, warm-up and cool-down exercises were performed for 3 min, and if the participants needed to take a break during the program, they were invited to sit on chairs provided in the auditorium. A social worker was present throughout the length of the program to ensure safety. The detailed program structure per session is shown in

Table 8. Program overview.

Sections	Contents	Times (min)
Warm up	Head rotation, shoulder rotation, waist rotation, knee rotation, and ankle rotation	3
SSG (congruent)		20
Break time		5
SSG (not congruent)		20
Cool-down	Head rotation, shoulder rotation, waist rotation, knee rotation, and ankle rotation	3
Total		About 50

.

Over the course of 16 trials, the subjects stepped on the footstool that matched the color of the shape in trials 1–8 and the footstool that matched the shape in trials 9–16. To improve concentration, the game was played in groups of two or four, in a simultaneous relay format and quickly, with the location and spacing of the footsteps changing every four rounds to prevent monotony as skill levels increased (

Table 9. Organized by program session.

Sections	1–4	5–8	9–12	13–16
Mission	Step on the footboard that matches the color		Step on the footboard that matches the shape
Rules	[#1–4] 1. Two participants play at one time. 2. The activity is done in relay format. 3. A sticker is awarded if the team finishes more quickly than the other team.
	[#5–16] 1. Four participants play at one time. 2. The activity is done in relay format. 3. A sticker is awarded if one team finishes more quickly than the other. 4. A sticker is awarded if your team breaks its previous record.
Footboard position
Footboard spacing	40 cm	45 cm	50 cm	55 cm

).

In this study, we selected gamification tactics to motivate and engage the program participants (Figure 5). Rewards, challenges, and competition were chosen as gamification tactics, and these were used in the following ways:

• Reward

To motivate and sustain the subjects, rewards were provided for attendance and team game performance. The rewards were provided in relation to the number of foot-shaped stickers so that they could be attached to the team’s individual attendance sheet and to the game map. After the program, gift rewards were given to individuals and teams who had received a certain number of stickers.

2.

Challenge

To provide a sense of challenge, the teams were provided with the opportunity to challenge themselves to reach the next level of difficulty. The participants were shown the records of their previous round before beginning the program to allow them to feel a sense of challenge so that they could voluntarily update their execution times.

3.

Competition

Establishing a competitive framework in relation to collaboration with others could impact the individual’s achievements and, further, their relationships with others [23]. Therefore, this study designed a program in such a way that two teams compete, thereby creating a competitive environment grounded in collaboration, with the goal of fostering natural relationships among participants and ensuring the program’s sustainability.

4. Statistics

This study used IBM’s SPSS Statistics 29.0 to analyze the effects of an integrated program on older adults’ cognitive and physical performance and the effects of gamification strategies on program satisfaction. Repeated-measures analysis of variance (RM ANOVA) and a paired samples t-test were used to test for differences between before and after the 8-week program, with p ≤ 0.05 as the criterion of significance.

4.1. Cognitive Function

A paired t-test was conducted to determine whether the integrated program influenced subjects’ cognitive performance. The results presented a statistically significant increase in the total score of the CIST test (p = 0.007), with significant increases in memory (t = 3.249, p = 0.005) and language function (t = 32.204, p = 0.042). The results for visuospatial function were not statistically significant, but a slight improvement was seen between before (1.55 ± 0.68) and after (1.88 ± 0.32) intervention. These findings align with Hong’s [37] study, which demonstrated that integrative programs significantly improved cognitive function in older adults. Generally, integrated programs are recognized for their effectiveness in improving cognitive function and memory. However, studies by Kong [38] and Kim [39] confirmed that integrated programs specifically designed for cognitive training led to significant improvements across all domains of cognitive function, rather than being limited to memory enhancement. Accordingly, the results of this study corroborate these prior findings, underscoring that integrative programs contribute to the enhancement of overall cognitive function in older adults, extending beyond memory alone (

Table 10. Results of the CIST (n = 18).

Sections	M ± SD		t (Post-Pre)	p	d	n2
	Pre	Post
Orientation	4.75 ± 0.44	4.72 ± 0.57	−0.437	0.668	−0.103	0.011
Attention	2.84 ± 0.48	2.83 ± 0.38	0.000	1.000	0.000	0.000
Visuospatial function	1.55 ± 0.68	1.88 ± 0.32	2.062	0.055	0.486	0.200
Executive function	5.15 ± 0.98	5.05 ± 0.8	−0.766	0.454	−0.180	0.033
Memory	8.29 ± 1.68	9.38 ± 0.77	3.249	0.005	0.766	0.383
Language function	3.6 ± 0.5	3.77 ± 0.42	2.204	0.042	0.519	0.222
Total	26.3 ± 2.73	27.66 ± 1.78	3.079	0.007	0.726	0.358

).

4.2. Physical Performance

RM ANOVA was conducted to determine whether the integrated program influenced subjects’ performance. The results showed that TUG, FTSTS, and 10 MWT all showed significant increases compared to the pre-program (p = 0.001). This aligns with Lee’s [40] findings that integrated programs positively affect both cognition and daily physical performance in older adults. Stride length and gait speed also increased significantly, which was consistent with Chung et al.’s [30] findings that a fall prevention program using a four-way stepping game improved walking ability and lower extremity muscle strength. The results showed that the integrated program influenced physical performance and walking ability in older adults (

Table 11. ANOVA of TUG, FTSTS and 10 MWT (n = 18).

Source	Type III SS	DF	MS	f	p	d	n2
TUG (s)	28	2	13.998	29.107	0.001	1.308	0.631
Error	16.35	34	0.481
FTSTS (s)	125.6	2	62.780	45.775	0.001	1.639	0.729
Error	46.63	34	0.481
10 MWT (s)	1.25	2	0.627	12.894	0.001	0.087	0.431
Error	1.65	34	0.049
Step length (cm)	186	2	93.205	12.563	0.001	0.086	0.411
Error	252.24	34	7.419
Speed (m/s)	0.09	2	0.046	11.840	0.001	0.833	0.425
Error	0.13	34	0.004

).

In addition, while step length and speed increased gradually over time, the results for TUG, FTSTS, and 10 MWT showed a significant decrease at the mid-test and only a slight increase at the post-test, which may be the result of the subjects becoming less nervous as they gained proficiency with the program. However, ultimately, we found a significant increase in the post-test scores related to the pre-test (Figure 6a–e).

4.3. Satisfaction Survey

A paired t-test was conducted to determine whether the integrated program and the gamification strategy that were applied in the program had an impact on the participants’ satisfaction. In all, 17 subjects participated in the satisfaction assessment survey. The results showed no statistically significant differences in the change in total score, but there was a significant increase in the score for utility (t = 60.662, p = 0.001). By seeing the changes in their presentation and performance in real time, the subjects may have recognized the cognitive and physical changes in themselves and appreciated the usefulness of the program (

Table 12. Results of satisfaction survey (n = 17).

Sections	M ± SD		t (Post-Pre)	p	d	n2
	Pre	Post
Utility	3.89 ± 0.22	4.07 ± 0.22	60.662	0.001	0.818	0.956
Satisfaction	4.19 ± 0.18	4.15 ± 0.17	−0.557	0.589	−0.231	0.019
Persistence motivation	4.13 ± 0.11	4.12 ± 0.15	−0.328	0.968	−0.077	0.007
Total score	4.12 ± 0.2	4.13 ± 0.17	0.332	0.743	0.054	0.007

).

The gamification strategy was rated highly by the subjects, with an average score of 4, confirming a high degree of satisfaction. The reward strategy showed a slight increase in the post-assessment (4.29 ± 0.58) relative to the pre-assessment (4.17 ± 0.72). This outcome may be because the participants preferred to have the intermediate results and observe physical performance changes every four sessions together with a simple snack (

Table 13. Results of scores for gamification strategies (n = 17).

Sections	M ± SD		t (Post-Pre)	p	d	n2
	Pre	Post
Challenge	4.23 ± 0.75	4.17 ± 0.52	−0.436	0.668	−0.093	0.012
Competition	4.23 ± 0.66	4.23 ± 0.56	0.000	1.000	0.000	0.000
Reward	4.17 ± 0.72	4.29 ± 0.58	0.808	0.431	0.184	0.039
Total	4.21 ± 0.33	4.23 ± 0.55	0.370	0.747	0.044	0.008

).

5. Discussion

This study developed an integrated program aimed at motivating older adults to voluntarily engage in physical activities through gamification strategies while assessing changes in cognition and physical performance. The results revealed significant improvements in the cognitive and physical performance test results, confirming that the integrated program was effective in improving the cognitive and physical performance of older adults.

The Cognitive Impairment Screening Test (CIST) results demonstrated significant enhancements in memory and language abilities, aligning with previous research suggesting that integrated programs positively impact cognitive function in older adults. Additionally, this study incorporated a Stroop game combining shapes and colors, referencing the work of Kim [10]. The Stroop effect is widely utilized to assess cognitive function, and gamified Stroop tasks have been shown to enhance cognition [41]. While Stroop tasks have traditionally been used in cognitive assessments, relatively few studies have explored their gamification and application to older adults. This study, therefore, provides valuable evidence that gamified Stroop tasks can positively influence cognitive performance in this population.

Assessments of physical performance indicated significant improvements in Timed Up and Go (TUG), Five Times Sit To Stand (FTSTS), and 10-Meter Walk Test (10 MWT) performance times, as well as increases in step length and walking speed. Jeong et al. [21] previously reported that exercise and cognitive intervention programs positively influence body composition, cognitive function, and health-related quality of life. Consistently, this study also demonstrated improvements in cognitive function and physical performance, reinforcing prior findings. However, body composition assessments over the twelve-week program revealed no significant changes. As suggested by Lee [40], long-term implementation of such programs, combined with lifestyle modification education, may have a positive impact on body composition.

The satisfaction survey results indicated high levels of participant satisfaction with the program and gamification strategies, with ratings of 4 or higher and a significant increase in perceived usefulness. Overall, participants responded positively to the program and gamification elements, particularly favoring the reward system. However, despite an increase in perceived usefulness, overall satisfaction scores showed a slight decline, potentially due to the repetitive nature of the fixed game method requiring foot movements in all directions. This monotony may have reduced participant interest and long-term adherence, limiting the program’s effectiveness. Therefore, to sustain voluntary engagement in older adults, it is essential to introduce content variation and incorporate appropriate challenge-based mission elements. Additionally, participants exhibited a preference for rewards over challenges in gamification strategies. To further enhance motivation, future program designs should integrate a broader range of challenge and competition elements alongside rewards.

Many participants suggested incorporating additional content, such as stepping to music and using props, to facilitate at-home exercise. These findings suggest that the gamification strategy effectively addressed the lack of user motivation in the healthcare domain, as noted by Park [25]. Moreover, during the twelve-week program intervention, 18 older adults voluntarily completed the program, representing 75% of the initial 24 participants. Given a primary goal of gamification is to enhance user engagement and encourage voluntary participation [24], this study provides evidence that the gamification strategy positively influenced user engagement and satisfaction.

This study has several limitations. First, it was conducted over a relatively short duration (two months) and involved a small sample size. While the CIST results indicated significant improvements in memory and language function, increasing the sample size and extending the study period would enhance the reliability of findings and enable the evaluation of changes in additional cognitive domains over time.

Due to the specific characteristics of the welfare center where the experiment was conducted, participants were recruited with an uneven gender ratio, as there was a significantly higher number of female seniors. In general, female older adults are 25% more likely to develop dementia and twice as likely to experience falls compared to their male counterparts [1,42]. Therefore, future studies may yield more reliable results if the program is conducted separately for male and female participants.

Furthermore, some participants reported mild boredom due to being randomly assigned to teams, highlighting the need to segment participants based on both cognitive and age-related factors. To ensure sustained engagement, future iterations of the program should be designed to accommodate different age groups, enabling older adults to continue exercising regardless of location.

Finally, although this study measured improvements in cognitive and physical performance using validated assessment tools, the results were not confirmed by medical practitioners. Consequently, the medical efficacy of the intervention remains uncertain. Future research should seek to enhance the reliability and effectiveness of the program through medical validation while also diversifying content to sustain participant interest and engagement.

6. Conclusions

This study is significant in its application of gamification strategies, which are not commonly used in the healthcare field, to an integrated program to increase motivation to verify cognitive and physical changes. This is expected to be a preliminary study that could be referenced when creating an integrated program using gamification strategies in healthcare. It is expected that an integrated program to mitigate cognitive decline in older people can be developed on the foundation of this study.