The Effect of Immersion Technology on the Quality of Life in Older Adults: A Systematic Review

ABSTRACT

Objectives

In physical reality, mobility limitations often hinder the ability of older individuals to fully interact with the world. Aging increases the likelihood of a decline in social activities. New technologies, including immersion technologies, are increasingly gaining attention as society grapples with the challenges of an aging population. The metaverse offers a compelling opportunity to reimagine the perspective of empowering older individuals.

Methods

A systematic review was conducted on the PubMed, IEEE, Scopus, and Web of Science databases in December 2024 using a search strategy composed of the keywords “elderly,” “metaverse,” “augmented reality” and “virtual reality,” along with their synonyms in the titles of the articles. Descriptive, qualitative, review, and non‐English studies were excluded. The quality assessment of the articles and their bias evaluation were performed based on the JBI index and PRISMA guidelines.

Results

The search yielded 1153 articles, 37 of which met the study entry conditions. Thirty studies utilized virtual reality technology for the rehabilitation of elderly people. Most studies aimed to improve symptoms of Alzheimer's disease, physical activity, and cognitive impairment. Seven studies focused on the design and use of immersive technologies to improve Parkinson's symptoms and motor impairments resulting from strokes. Four studies focused on designing environments and games that could help elderly people engage in physical activity and exercise using immersive technologies. The quality of life of elderly people improved in line with the use of these technologies, and symptom weakness improved.

Conclusions

The metaverse can serve as a comprehensive and supportive platform for elderly people. The development of various digital applications or applications covering health, banking, financial affairs, shopping, and social media for performing daily activities from home via an online mode can assist elderly people. The metaverse offers innovative solutions to inspire and support elderly people in staying active. VR and AR technologies provide a dynamic platform for participation in exercise programs, recreational activities, and personalized health programs for elderly people.

Immersive technologies, especially virtual reality (VR), significantly improve the quality of life for older adults by enhancing physical health, cognitive function, and psychological well‐being. These technologies can be adapted to meet individual needs, making them an effective tool for addressing the challenges of aging.

1. Introduction

The increasing age of the global population is a significant concern, progressing at a remarkably rapid pace and creating various challenges for older individuals and their families. According to the United Nations, the global population aged 65 and older is expected to rise from 727 million in 2020 to over 1.5 billion by 2050, constituting more than 16% of the world's inhabitants. This demographic shift is particularly pronounced in countries such as Japan, South Korea, Germany, and Italy, where the elderly will account for over 30% of the total population. Additionally, the World Health Organization (WHO) predicts that by 2050, one in six individuals worldwide will be elderly, underscoring the urgent need for innovative strategies to enhance their quality of life.

Elderly individuals often experience limited social interaction and mobility, which fosters a profound sense of loneliness, placing them at an increased risk of depression and other health conditions [1, 2]. Enabling them to live independently and socially engaged is crucial. Non‐communicable and chronic conditions such as cognitive decline, Alzheimer's disease, hearing loss, visual impairment, heart disease, and osteoporosis significantly impact their daily lives [3]. The inability to participate in social activities, whether due to mobility restrictions or the temporary absence of family members, can lead to prolonged social isolation [4, 5]. This long‐term isolation may intensify feelings of loneliness, consequently triggering depression, anxiety, irritability, and ultimately, an increased risk of cognitive decline [6]. Notably, depression in the elderly cannot be effectively managed through medication alone but requires rehabilitation‐based interventions [7, 8, 9].

Virtual social interaction through mobile phones and tablets has been proposed as a potential solution to overcome physical and temporal limitations, utilizing voice and video communication. However, studies suggest that screen‐based interactions fail to eliminate the sense of separation [10, 11, 12]. The Metaverse, an expansive virtual ecosystem, seamlessly integrates physical and digital worlds by combining Artificial Intelligence (AI), the Internet, and extended realities such as Mixed Reality (MR), Augmented Reality (AR), and Virtual Reality (VR). Fueled by rapid advancements in 5G technology, a range of innovative platforms—such as holographic VR and Metaverse Social, which merge online and offline social networks—offer promising opportunities to enhance the well‐being of the elderly [13, 14].

Unlike traditional online and offline social networks, the Metaverse social ecosystem provides a virtual environment tailored to address the psychological and emotional needs of the elderly. For example, it enables older adults to maintain social connections, even during home isolation, by engaging in regular and meaningful social activities that strengthen their sense of participation. Additionally, quantitative assessments of their psychological state can be conducted before and after interventions, ensuring accurate monitoring of their well‐being [15, 16]. Within VR‐based platforms, social interactions extend beyond text, voice, photos, or videos, allowing users to visit parks, play games, and engage in shared activities using digital avatars—regardless of time or location [17, 18].

The growing demand for intelligent healthcare solutions among the elderly has accelerated the adoption of Metaverse‐driven medical applications, offering comprehensive self‐care and health management capabilities [19, 20]. Nevertheless, integrating advanced technologies presents challenges for elderly individuals with impaired vision, diminished motor function, and cognitive disorders. However, technological advancements have progressively mitigated these limitations by enhancing performance, tracking capabilities, and mobility, thereby reducing caregiver burdens and facilitating aging‐in‐place solutions [21].

Furthermore, the Metaverse presents significant potential in fitness and rehabilitation, with studies confirming the effectiveness of virtual exercise programs and immersive gaming experiences that can be customized to match recommended activity levels [22]. The concept of “Dementia Villages,” first introduced in the Netherlands and Germany, revolutionized collective care approaches by prioritizing the psychological and emotional needs of individuals with dementia. These villages leveraged reminiscence therapy, demonstrating notable cognitive and emotional benefits [23, 24, 25, 26, 27]. Expanding upon this model, virtual environments can now be designed as “Virtual Playgrounds,” where dementia patients can immerse themselves in familiar past experiences, fostering a sense of comfort and emotional stability [28].

Recognizing the positive impact of immersive technologies on elderly populations, this study aims to examine their role in rehabilitation and overall quality of life, identifying emerging trends and evaluating the effectiveness of these innovative solutions [29]. This research explores how immersive technologies influence multiple facets of elderly well‐being, including cognitive enhancement, social connectivity, and physical rehabilitation. Additionally, it investigates how the Metaverse and associated technologies contribute to reducing loneliness and promoting mental health among older adults.

Although numerous studies have highlighted the benefits of Virtual Reality (VR) for the elderly, a significant research gap remains regarding the advantages and challenges associated with Metaverse‐based interventions and other immersive technologies aimed at enhancing elderly well‐being. This study seeks to bridge this gap by conducting a systematic review of existing literature, providing a comprehensive evaluation of the effectiveness of these technologies across various aspects of elderly life, while also outlining directions for future research.

Given the increasing trend of aging populations worldwide and the urgent need for innovative healthcare solutions, it is essential to explore and implement immersive technologies tailored to the needs of this demographic. This study serves as a valuable resource for healthcare policymakers and medical professionals, equipping them with evidence‐based insights to optimize the use of the Metaverse and related digital technologies in enhancing the mental, cognitive, and physical well‐being of the elderly.

2. Methods

This study adhered to the 2020 PRISMA guidelines for systematic reviews and meta‐analyses, as proposed by Page and colleagues [30].

2.1. Eligibility Criteria

In this respect, the SPICE tool (Setting, Perspective, Intervention, Comparison, Evaluation) is not very different from the more widely used PICO formulation and is also very systematic in expressing focused clinical research questions and directing qualitative reviews. Thus, the SPICE structure will become a useful scheme for the structuring of our research questions in the way that high‐impact scholarly publication is expected. Specifically, the core components of our research would include: (i) Setting: Global publications; (ii) Perspective: Patients and healthcare providers; (iii) Intervention: immersive technologies; (iv) Comparison: The focus on the elderly population alone; and (v) Evaluation: The effectiveness of technology use in improving the lives of older adults. Clearly outlining these components of our research questions will ensure that they are incisive, evidence‐based, and sensitive to the needs and experiences of our target population, which in turn will increase the rigor and impact of our scholarship.

2.1.1. Inclusion Criteria

Studies that had all the following criteria were included in the review: (1) Original articles should be available (2) One of the diseases of depression, dementia, or motor problems, social interactions should have been used in it (3) One of the immersive technologies (Metaverse, Augmented Reality, Virtual Reality) was used for modeling (4) The effect of using technology in the lives of the elderly has been reported (5) Articles should be in English.

2.1.2. Exclusion Criteria

The criteria for participant withdrawal from the study were as follows: (i) the qualitative outcomes of the system evaluation had not been reported, and the impact of the technology on the lived experiences of the elderly cohort remained undescribed; (ii) book chapters and systematic review articles were excluded; and (iii) articles for which the complete English‐language text was unavailable.

2.2. Information Sources and Search Strategy

A systematic search across prominent electronic databases conducted, including Web of Science, Medline (via PubMed), Scopus, and IEEE, to identify relevant studies published from the inception of these resources up until March 1, 2024. The temporal scope of the literature search was limited to the preceding 8‐year period. Additionally, supplemented this effort by querying the Embase database through January 10, 2024. The search strategy employed a combination of keyword terms and medical subject headings (MeSH) related to “virtual reality,” “Metaverse,” and “Elderly.” The complete list of keywords and phrases utilized in the Scopus database search can be found in the Table 1. Reference management software (EndNote X8, Thomson Reuters) used to collate the references and remove any duplicate entries. The coverage dates for each of the databases consulted are provided in Table 1.

TABLE 1.

Vocabulary search formula in databases.

Search MESH term and formula
I: (elderly OR older adults OR aged) II: (met averse OR virtual reality OR Augmenter Reality) III: (Cognitive OR Dementia OR physical activity OR depression) Search strategy: I AND II AND III PUBMED: (“elderly” OR “older adults” OR “aged”) AND (“met averse” OR “virtual reality” OR “Augmenter Reality”) AND (“Cognitive” OR “Dementia” OR “physical activity” OR “depression”)

2.3. Study Selection

The researchers implemented a rigorous and collaborative approach to study selection. The titles and abstracts of the identified articles were independently screened by two reviewers (V.Z. and S.S.). If the article was deemed potentially relevant by both reviewers, the full text was examined. Any disagreements between the reviewers were resolved through discussion and consultation with a third researcher. The data extracted from the selected studies were entered into Excel in a structured manner, with the data extraction process carried out by each of the reviewers and the forms subsequently compared. The screening stages are depicted in FlowChart 1, in accordance with the PRISMA 2020 guidelines. Furthermore, the primary classification of the reviewed articles was independently determined by two authors. Two authors (S.S. and V.Z.) then analyzed, synthesized, and extracted the main features of the selected articles, after which the principal characteristics were validated by the next author (S.J.E.). The PRISMA flow diagram can be found in the Supplementary File.

FLOWCHART 1.

PRISMA flow diagram.

2.4. Data Collection Process and Data Items

The first reviewer (S.S.) meticulously gathered the required information from the selected studies, after which a second reviewer (V.Z.) carefully confirmed the accuracy of the accumulated data. Any discrepancies were thoroughly reviewed and resolved through discussions with a third reviewer (S.J.E.). The main data and characteristics of the selected articles are presented in a concise and organized manner in Table 1, reflecting the researcher's attention to detail and commitment to upholding the standards expected in high‐impact scholarly publications.

2.5. Study Bias Risk

The risk of bias assessed in the included studies using the Joanna Briggs Institute (JBI) critical appraisal checklist [6] for analytical cross‐sectional studies. This comprehensive evaluation aimed to rigorously evaluate the methodological quality of the studies. The checklist consisted of eight key questions: (1) Were the inclusion criteria for the sample clearly defined? (2) Were the study subjects and environment described in sufficient detail? (3) Was the exposure measured in a valid and reliable manner? (4) Were objective and standard criteria used to measure the outcome conditions? (5) Were confounding factors identified? (6) Were strategies to address confounding factors clearly stated? (7) Were the outcome measures valid and reliable? (8) Was appropriate statistical analysis employed? Each question could be answered with one of four options: (1) yes, (2) no, (3) unclear, or (4) not applicable. A “yes” answer corresponded to one point, and if 70% or more of the questions were answered positively, the study was considered to have a “low” risk of bias. If 50%–69% of the questions were answered positively, the risk of bias was deemed “moderate,” and a positive response rate of less than 50% was indicative of a “high” risk of bias (31). The checklist was completed by two authors (V.Z. and S.S.), and any disagreements were resolved through discussion with the third author (S.J.E.). The risk of bias of selected studies can be found in the (Appendix A).

3. Results

In this study, we selected 37 articles, summarized in Table 2, for in‐depth analysis. The findings reveal that Korea and China have been at the forefront in designing and deploying immersive technologies to empower their elderly populations (Figure 1). Over time, the development and integration of immersive interactive games and environments have steadily increased, as evidenced by the highest frequency of studies in 2021, underscoring the growing importance of leveraging these technologies to enhance the well‐being of the elderly (Figure 2).

TABLE 2.

Summary of the features of the extracted articles.

Names of authors, Country, year of publication	Technology	Tools/devise for used	How to use	Area used	Effect of used
Afsar SI [31] Turkey 2018	Immersive virtual reality (VR)	Game	All patients received 60 min of conventional therapy, Xbox Kinect	42 stroke patients (Rehabitation)	The Brunnstrom stage‐upper extremity and Box&Block Test gain for the experimental group were significantly higher compared to the control group, while the Brunnstrom stage‐hand, the Functional independence measure gain and Fugl‐Meyer gain were similar between the groups
Liang H [32] China 2022	Immersive virtual reality (VR) and Metaveres	Interaction tools	Virtual social center, cloud‐enabled multiplayer platform	Elderly with depression, anxiety, aggressive behavior	Mental state of the elderly who had used the virtual social center was significantly better than that of those who had not used it
Xu W [33] Greece 2023	Immersive virtual reality (VR)	Image‐based sentiment analysis and behavioral analysis to assess “Cap de Ballon”	Behavioral analysis as a technique to assess a social VR space for elders and present some promising preliminary results	Elderly with different Stress level
Lai YJ [34] Taiwan 2023	Metaveres and Immersive virtual reality (VR)	Games and social platforms puzzle gamesو celebrate birthday	Health promotion	Solve limitation of the elderly's mobility, cognitive ability, and social interaction
Beck D [35] USA 2017	3D Virtual, 3D Metaverse	The SMS system is used to send motivational messages available in the chatterbot basis by the motion sensor	Healthcare delivery	Exercising in an aerobics class, perform physical exercises	Virtual environment could increase motivation to being more physically active and that users are responsive to a virtual coach
Han X [36] USA 2023	Metaverse	AI‐based next‐generation sensors for enhanced rehabilitation monitoring and analysis along with other AI based	Exercise rehabilitation	Elderly patients with stroke, cerebral hemorrhage, and muscle atrophy	Showed that the metaverse for exercise rehabilitation for stroke patients could be successfully developed and would be feasible to be implemented in the future
Campo‐Prieto P [37] Spain 2022	Immersive Virtual Reality Exergame Program on Physical Functions	Exercise rehabilitation for disabled or elderly patients	Physical therapy tool	BOX VR game	Exercise rehabilitation for disabled or elderly patients
N Brandín‐De la Cruz [18] Spain 2020	Immersive virtual reality (VR)	Virtual reality helmet controlled by a two‐handed joystick	12 sessions of 30 min, distributed regularly over four consecutive weeks. Participants walked on a treadmill with a body weight support system set at approximately 20% of body weight and equipped with a virtual reality helmet controlled by a two‐handed joystick	Rehabilitation in Parkinson's disease	Was feasible to deliver and acceptable for the rehabilitation of patients with PD. Preliminary Evidence suggested that the proposed intervention has a positive effect on increasing gait Distance, gait speed, balance, and quality of life
Pawel Kiper [38] Italy 2022	Immersive virtual reality (VR)	VR TierOne software, which represents a virtual therapeutic garden	Immersive VR therapeutic garden with elements of psychotherapy and physical activity of the Upper extremities The first 3 weeks represent the period in which the patient underwent functional rehabilitation Combined with VR intervention (or Schultz's Autogenic Training in the control group)	Effectiveness of immersive VR therapy on both functional activity and depressive symptoms in Stroke survivors. 60 participants, 55–75 years of age, a history of ischemic stroke and a 30‐item Geriatric Depression Scale (GDS‐30) score of ≥ 10	The VR intervention with its therapeutic virtual garden did not change the functional aspects. Similar scores on the BI, IADL and RMA scales were observed in both study groups after the intervention and at follow‐up measurement
Jae Myeong Kang [39] Korea 2021	Immersive virtual reality (VR)	Semi‐immersive virtual reality (VR)‐assisted cognitive training	The participants in the VR group underwent VR cognitive training twice a week for a total of eight sessions in addition to their usual therapy	45 Participants over 60 years old with subjective cognitive decline or mild cognitive impairment	Significant improvement was found in the total score and basic components score of the RCFT copy task compared with those of the control group. The VR group also showed improvements, albeit not significant, in naming ability, verbal memory delayed recall, and phonemic fluency. Improvements in psychiatric symptoms such as apathy and quality of life were found in the VR group compared to the control group. Improvement in the RCFT copy task was associated with a frontal‐occipital functional connectivity increase revealed by rsfMRI in the VR group compared to the control group
Syed Hammad Hussain Shah [40] Norway 2022	Immersive virtual reality (VR)	VR headset/virtual environment	Social VR‐based exergame to facilitate full‐body exercise through a fruit‐picking game and Social collaboration through team‐based game tasks and reward mechanisms	The participants had to be above 60 years of age were currently residing or were awaiting an appointment at the municipal rehabilitation center	Over a five‐week period, playing the exergame collaboratively (compared to playing alone) was significantly more beneficial for motivation, enjoyment, social connectedness, and physical exertion. In terms of user experience, no motion sickness and high scores in comfort, usability, In addition, satisfaction were reported by the participants
Mateus Trombetta [41] Brazil 2017	Immersive virtual reality (VR)	Smart TV 3D and Oculus Rift	The game was developed with Unity game engine, supporting Kinect motion sensing input device and display devices like Smart TV 3D and Oculus Rift. It contemplates six activities considering exercises in a tridimensional space: flexion, abduction, shoulder adduction, horizontal shoulder adduction and abduction, elbow extension, wrist extension, knee flexion, and hip flexion and abduction. Motion Rehab AVE 3D also report about hits and errors to the physiotherapist evaluate the patient progress	A pilot study with 10 healthy participants (61–75 years old) tested one of the game levels	The game could be used as a useful tool to motivate the patients during rehabilitation sessions. All the participants (100%) classified the interaction process as interesting and amazing for the age, presenting a good acceptance
C Pazzaglia [42] Italy 2020	Immersive virtual reality (VR)	Using equipment for motion analysis and NIRVANA (BTS Spa, Garbagnate Milanese, Milan, Italy). NIRVANA is a markerless system based on optoelectronic infrared devices that allows patients to perform exercises in virtual settings with full audio‐visual sensory immersion	Six consecutive week virtual reality (VR) rehabilitation programme, with a 40‐min session three times per week	Fifty‐one patients with Parkinson disease	Rehabilitation is useful in Parkinson's disease, and the VR rehabilitation programme was more effective in determining overall improvement than the conventional rehabilitation programme
Sebastian Rutkowski [43] Poland 2020	Nonimmersive Virtual reality (VR)	The console (Xbox 360), a motion sensor (Kinect), and a projector with speakers	2‐week high‐intensity, five times a week intervention The patients in the ET group participated in a TPR program and endurance exercise training sessions. Patientsin the ET + VR group participated in a TPR, as well as both endurance exercise training and VR sessions using the Kinect system. Patientsin VR group participated in a TPR and VR sessions	120 patients diagnosed as having chronic obstructive pulmonary disease (COPD) female and male aged between 50 and 70 years	Hospitalized patients who used a VR rehabilitation system showed improvement in physical fitness in all the Senior Fitness Test components. Hence, this study suggests that a pulmonary rehabilitation program supplemented with virtual rehabilitation training is a beneficial intervention for enhancing physical fitness in patients with COPD
Yoon‐Hee [44] Choi Korea 2018	Immersive virtual reality (VR)	Mobile game‐based VR upper extremity rehabilitation program	Two weeks of treatment using the program	24 patients(age> 60) with stroke (MoU‐Rehab)	The mobile game‐based VR program effectively promotes upper extremity recovery in patients with stroke and it can substitute for some parts of the conventional therapy that are delivered one‐on‐one by an occupational therapist
Ying‐Yi Liao [45] Taiwan 2020	Immersive virtual reality (VR)	VR glasses on their heads and had motor controllers in both hands during the training. The Kinect system (Microsoft Corporation, Redmond, WA, USA) was used for capturing and tracking changes in limb segment motions with infrared light. This system also created a full‐body 3d virtual map	36 sessions over 12 weeks of VR‐based physical and cognitive training on cognitive function, brain activation and IADL and compared the VR intervention with combined physical and cognitive training	Thirty‐four community‐dwelling older adults with MCI (mild cognitive impairment)	VR‐based physical and cognitive training improves cognitive function, IADL and neural efficiency in older adults with MCI
Tuba Kanyılmaz [46] Turkey 2022	Immersive virtual reality (VR)	Smartphone (Samsung Galaxy‐S7) attached to a virtual reality goggle (Samsung Gear VR‐SM323)	30‐min a day, 5 sessions per week, 15 sessions in total for 3 weeks. The 3D videos consist of 2‐media recorded with a 360 camera (Samsung Gear‐360)	32‐patients aged 65‐years and older who applied to the otorhinolaryngology clinic with dizziness Complaint	The application of vestibular rehabilitation in a virtual reality environment can lead to additional improvements especially in dizziness symptoms, disability, balance, and mobility in the elderly with chronic dizziness
Saeed Yousefi Babadi [47] Iran 2021	Immersive virtual reality (VR)	Xbox Kinect, which includes Kinect and Console Sensors	Virtual reality training (a 60‐min session, 3 times per week, for 9 weeks)	36 elderlies (men and women) who are living in nursing homes	Virtual reality training program can be used as a new training method to improve the elderly's balance in daily programs of nursing homes
Justyna Mazurek [48] Poland 2023	Immersive virtual reality (VR)	The VRTierOne device by Stolgraf, Stanowice, Poland. VR HTC VIVE goggles (2017) and two controllers	VR therapy group underwent eight sessions (20 min each, twice weekly) of immersive virtual reality therapy (VR therapy)	68 osteoarthritis patients who had recently undergone either total hip or knee arthroplasty	Emphasize the promising role of VR therapy as a beneficial addition to the rehabilitation process for older adults' posthip and knee arthroplasty. The integration of psychological interventions in standard rehabilitation practices appears valuable, but further studies are needed to ascertain the long‐term advantages of such an approach
Zhilan Liu [49] China 2022	Immersive virtual reality (VR)	IVR uses a light HMD (head‐mounted device), stress‐free smart sensor/Android tablet	Immersive virtual reality training (IVR)/15 min per day, 6 sessions per week, for a total of 6 weeks	30 patients with mild poststroke cognitive impairment after stroke	VR‐based puzzle games may improve global cognitive, episodic memory, verbal memory, attention, and daily living ability, especially executive ability and spatial orientation, in elderly patients with poststroke cognitive impairments. This intelligent interactive experience has better applicability in elderly individuals. The IVR‐based puzzle game was well accepted and tolerated in Elderly stroke patients and can be recommended for use
Héctor Brito [50] China 2021	Immersive virtual reality (VR)	Virtual reality helmet HTC vive	Immersive virtual reality‐based sensorimotor rehabilitation (IVR‐SRB) intervention (6 weeks, three times a week with 25 min per session.)	111 older adults	IVR‐SRB is recognized as a great intervention tool among elderly population, showing its multidimensional approach capacity, properly responding to the reduction of symptoms associated with mental disorders
Rui Zhao [51] China 2023	Immersive virtual reality (VR)	VR rehabilitation training system (Nanjing Moxun Company, Motion2.0)	VR rehabilitation training system was used for training. The training regimen was 3 times per week, 50 min each time (including 5‐min of warm‐up exercise, 40‐min of VR sports game training and 5‐min of organized exercise), with total training period of 12 months	50 People (aged ≥ 65 years) with osteoporosis in an elderly care institution	VR training can improve anti‐fall ability and increase femoral neck and lumbar spine BMD and can effectively prevent and reduce the risk of injury among elderly people with osteoporosis
Jeonghun Ku [52] Korea 2018	Augmented reality system	3D‐ARS training system (utilizing a Microsoft Kinect sensor to track a subject's whole‐body motion and interaction with virtual objects in a 3D environment that was displayed on a large screen)	3D‐ARS training thrice per week (1 session = 30 min) for 4 weeks. Training comprised a balloon game for hip exercise, cave game for knee exercise, and rhythm game for one‐leg balance exercise	Thirty‐six participants (age, 56–76 years) who could independently walk and stand on one leg	Overall improvements occurred in stability index, weight distribution index, fall risk index, and Fourier transformations index of posturography for both groups. However, score changes were significantly greater in the 3D‐ARS group. Significant group × time interaction effect was observed for the fall risk index. This demonstrates that the 3D‐ARS system can improve balance in the elderly more effectively
Ehab M Abd El‐Kafy [53] Saudi Arabia 2023	Immersive virtual reality (VR)	C‐Mill virtual reality treadmill	C‐Mill virtual reality treadmill training. The program lasted 1 h, three times per week, over four consecutive weeks	Sixty Saudi elderly of both sexes, aged 65–75 years	C‐Mill virtual reality treadmill training shows potential in improving gait parameters and walking tolerance in the elderly in Saudi Arabia
Magdalena Sylwia Kamińska [54] Poland 2018	Immersive virtual reality (VR)	The Xbox 360 Kinect	The participants underwent 30‐day VR training using an Xbox 360 Kinect. They trained 3 times a week, with each exercise lasting 30 min	23 residents of the daytime social welfare institution	VR training increases the possibilities of motor training and can help reduce the risk of falls by improving the static and dynamic balance
Kenji Tsuda [16] Japan 2016	Immersive virtual reality (VR)	Wii Balance Board (Nintendo, Kyoto, Japan)	Performing virtual reality exercise using the Wii Balance Board (Nintendo, Kyoto, Japan) with the Nintendo Wii Fit once a day, five times a week, from the start of chemotherapeutic treatment until hospital discharge	16 hospitalized patients with hematologic malignancies aged ≥ 60 years	Virtual reality exercise using the Wii Fit may be feasible, safe and efficacious, as demonstrated in our preliminary results, for patients with hematologic malignancies receiving chemotherapy
Valerie Elliott [17] Canada 2015	Immersive virtual reality (VR)	Virtual reality component of the class session used a computer with a freeware dance game program, StepMania	12‐weekPFM/VRR training program	Twenty‐four women (70.5 ± 3.6 years)	A combined PFM/VRR program is an acceptable, efficient, and satisfying functional treatment for older women with MUI and should be explore through further RCTs
Wong KA et al. [18] Singapore 2023	Virtual reality metaverse	Remote perimetry in a metaverse environment had good concordance with gold standard perimetry using the HVF and could avail functional eye screening in out‐of‐hospital settings			investigates the performance of a novel remote perimetry application designed in a virtual reality metaverse environment to enable functional testing in community‐based and primary care settings
Gueye T et al. [19] Prague 2021	Virtual reality therapy (VRT)‐ stroke	Hedset	Montreal Cognitive Assessment (MoCA), Functional Independence Measure (FIM) and Fugl Mayer Assessment Upper Extremity Scale (FMA‐UE) were performed before and after the three‐week therapy with 12 therapeutic sessions. The results of participants < 65 and ≥ 65 years old were compared	Using a randomized controlled study design, participants within 30 days after stroke with arm paresis were, in addition to a daily rehabilitation programme, assigned to an intervention group (45 min Armeo IG n = 25; mean age 66.5 years) performing VRT, or to a conventional physiotherapy (45 min) control group (Armeo CG, n = 25, mean age 68.1 years)	Paretic upper arm function improved significantly in both the IG and CG groups, the improvement in FMA‐UE was significantly higher in the IG compared to the CG (p = 0.02), and patients ≥ 65 years old presented an equal magnitude of improvement in paretic arm function compared to younger patients
Kang JM et al. [20] Korea 2021	Semi‐immersive virtual reality (VR)‐assisted cognitive trainingو fully immersive VR		The VR group participants received multidomain and neuropsychologist‐assisted cognitive training in a fully immersive VR environment twice a week for 1 month. The control group participants did not undergo any additional intervention except for their usual therapy such as pharmacotherapy	Participants over 60 years old(n = 41)	After VR cognitive training, significant improvement was found in the total score, Fully immersive VR cognitive training had positive effects on the visuospatial function, apathy, affect, quality of life, and increased frontal‐occipital functional connectivity in older people in a predementia state
Maranesi E et al. [55] Italy 2022	Nonimmersive virtual reality exergames for Parkinson's disease	Game		Thirty PD patients	Nonimmersive virtual reality exergaming technology offers the opportunity to effectively train cognitive and physical domains at the same time
Oliveira J et al. [22] 2021 Portugal	Virtual Reality‐Based Cognitive Stimulation‐ Alzheimer's disease (AD)	Stimulation	Comprised twelve cognitive stimulation sessions delivered by clinical neuropsychologists for 45 min sessions	17 patients ‐This intervention lasted 2 months, with a total of 10 sessions (two sessions/week)	The preliminary results suggested an improvement in overall cognitive function in the experimental group, with an effect size corresponding to a large effect in global cognition, which suggests that this approach is effective for neurocognitive stimulation in older adults with dementia, contributing to maintaining cognitive function in AD
Liao YY et al. [23] Taiwan 2019	Virtual reality	VR program	Thirty‐four community‐dwelling older adults	12 weeks of VR‐based physical and cognitive training on cognitive function, brain activation and IADL	VR‐based physical and cognitive training improves cognitive function, IADL and neural efficiency in older adults with MCI
Sadeghi et al. [24] Iran 2021	Virtual reality	Three games: mini‐game, Xbox Kinect game, the Target Kick, and Goalkeeper mini‐games	The training groups exercised for 40 min, 3 times per week, for 8 weeks. Isokinetic quadriceps and hamstrings strength on the dominant and nondominant legs were primary outcomes measured by the Biodex Isokinetic Dynamometer	64 community‐dwelling older men	The moderate to large effect sizes in strength and large effect sizes for balance and functional mobility underline that MIX is an effective method to improve falls risk among older adult
Yang JG et al. [25] Korea 2022	Virtual reality	Games	Twenty‐four sessions of VRCT (3 days/week) were performed, and each session was 100 min long. Exercise intervention consisted of aerobic and resistance trainings performed in 24 sessions for 60 min (2 times/week for 12 weeks)	99 participants (70.8 ± 5.4) with MCI in the VRCT	VRCT and exercise training enhances brain, cognitive, and physical health in older adults with MCI
Riaz W et al. [56] Poland 2021	Virtual reality	Virtual environments	Received biweekly VR‐based environmental enrichment over a course of 6 months	Seven participants (four patients with MCI and three with mild dementia)	VR can be a feasible, tolerable, and potentially effective tool in long‐term support of older adults with MCI and mild dementia
Hwang NK et al. [57] Korea 2021	Semi‐immersive virtual reality‐based cognitive training	Simultaneous	The experimental group received VRCT combined with locomotor activity for 30 min a day, three times a week, for 6 weeks. The control group received tabletop activity‐based cognitive training for the same amount of time	18 older adults participated (n = 18)	Semi‐immersive VRCT combined with locomotor activity is useful for improving cognitive function and gait ability in older adults. Therefore, VRCT combined with locomotor activity can be used as a simultaneous intervention for cognitive rehabilitation and functional capacity improvement in older adults

FIGURE 1.

Research on the use of augmented reality, virtual reality, and metaverse technologies among elderly people in different countries.

FIGURE 2.

Development and design of interactive immersive games and environments for elderly people in various studies over time.

Virtual reality technology has emerged as the predominant modality, likely due to its more mature and established nature, compared to the relatively newer metaverse technology, which has seen limited application in elderly rehabilitation thus far, despite its potential when combined with artificial intelligence (Figure 3). Of the 37 studies, 31 utilized virtual reality to address cognitive impairments in the elderly, while 5 studies explored the use of metaverse technology to improve social interactions and alleviate symptoms of depression, anxiety, and Alzheimer's disease. Additionally, one study incorporated augmented reality to facilitate physical exercise‐based rehabilitation.

FIGURE 3.

Statistics of studies on immersive technologies to assist elderly people in various cases.

The research objectives spanned a range of therapeutic goals, including cognitive symptom improvement (13 studies), stress and anxiety relief (7 studies), enhanced social interaction (7 studies), physical and motor rehabilitation (4 studies), and Parkinson's symptom management (3 studies) (Figure 3). The most widely adopted approach was the integration of immersive technologies into various rehabilitation modalities, such as cognitive exercises and physical activities, whereas the use of metaverse‐based physical exercises and environments was the least common (Figure 4). As metaverse technology continues to mature, the researcher anticipates a growing prevalence of its application in future elderly care initiatives.

FIGURE 4.

Use of immersive technologies in various ways to assist elderly people in the extracted studies.

Only two studies were assessed with moderate risk of bias (39,599) and one with high risk of bias [57]. The questions “were confounding factors identified? and were there strategies for dealing with confounding factors?” It was not applicable to our included studies, as our studies were not experimental research.

3.1. Cognitive and Neuropsychological Interventions and Outcomes

3.1.1. VR‐based cognitive training efficacy

The sources provide substantial evidence that VR‐based interventions are effective in improving cognitive function across a spectrum of populations including older adults, individuals with Mild Cognitive Impairment (MCI), and post‐stroke patients. These interventions demonstrate efficacy in enhancing various cognitive domains, including:

• Global cognition: Improvements were consistently observed in Montreal Cognitive Assessment (MoCA) scores, indicating a positive impact on overall cognitive performance.

• Executive function: Multiple studies report significant gains in executive function measured by the Trail Making Test (TMT), the Symbol Digit Substitution Test (SDST), and the Frontal Assessment Battery (FAB). These findings highlight VR's capacity to improve higher‐order cognitive processes. The digit symbol substitution test (DSST) is noted to measure executive function.

• Visuospatial abilities: The Rey‐Osterrieth Complex Figure Test (RCFT) showed specific enhancements in visuospatial abilities after VR cognitive training. This test's complexity reveals its sensitivity to improvements in visual recognition, memory, and motor output. The RCFT and related copy task performance have been shown to be associated with the parietal, occipital, and frontal cortices in both hemispheres.

• Verbal memory: VR interventions resulted in better performance in verbal memory tasks, as indicated by the Chinese version of the California Verbal Learning Test (CCVLT).

• Language: The Korean version of the Boston Naming Test (K‐BNT) showed improvements after VR interventions, suggesting a positive impact on language abilities.

• Attention: Digit span tests and TMT‐A were used to evaluate attention with mixed results, with TMT‐A demonstrating improvements in some cases. VR‐based exercise training is also shown to have a positive impact on attention‐related functions.

• Neural correlates of VR training: Research using rsfMRI indicates that VR cognitive training leads to increased frontal‐occipital functional connectivity. This finding suggests that VR not only improves cognitive performance but also modulates the functional organization of the brain. Specifically, the visual cortex (medial and right lateral) and middle frontal cortices showed increased connectivity associated with RCFT task improvements. Furthermore, EEG studies suggest that VR‐based interventions can modulate brain activity patterns, specifically theta and beta band powers, which have been linked to cognitive function.

3.2. Comparative Analysis With Other Interventions

3.2.1. VR versus Traditional Exercise

VR cognitive training showed superior improvements in cognitive function compared to traditional exercise programs, although exercise programs yielded greater enhancements in physical function. These differential outcomes suggest that VR is uniquely effective for targeting cognitive decline, while exercise alone primarily benefits physical health.

3.2.2. VR versus Control Groups

Studies comparing VR to control interventions (often treatment‐as‐usual) consistently demonstrate greater gains in cognitive function in VR groups.

3.3. Physical Function and Motor Rehabilitation

3.3.1. VR for Physical Therapy

VR is not only a tool for cognitive enhancement but also demonstrates efficacy in physical rehabilitation across multiple studies.

3.3.2. Gait and Balance

VR‐based therapies have demonstrated improvements in balance, mobility, and gait, measured through the Timed Up and Go (TUG) test, Berg Balance Scale (BBS) and the Tinetti test. The Functional Gait Assessment (FGA) is also used to assess balance and gait.

3.3.3. Upper Extremity Function

Immersive VR games, such as those using the Xbox Kinect, have been shown to improve upper extremity function in stroke patients. This suggests that interactive VR environments can be effective in motor rehabilitation. The Brunnstrom stage and the Box and Block Test showed higher gains in experimental groups using immersive gaming compared to control groups.

3.3.4. Functional Mobility

Studies utilizing the Performance Oriented Mobility Assessment (POMA) show that VR can improve both total scores and gait specifically when combined with traditional therapy.

3.3.5. Impact of Exergaming

VR‐based exergames offer a therapeutic approach that combines physical activity and cognitive stimulation, demonstrating potential for long‐term care facilities.

Integration of VR with traditional therapy: Several sources suggest the potential benefits of combining VR with conventional therapeutic approaches for rehabilitation.

3.4. Psychological and Emotional Dimensions

3.4.1. Mental Well‐Being and Mood

VR interventions have shown potential in improving mental well‐being, particularly in patients with MCI and dementia1. VR has also shown to support the recovery of depressive symptoms in post‐stroke rehabilitation. The Hospital Anxiety and Depression Scale (HADS) is used to measure mood.

3.4.2. Stress Reduction

Studies using image‐based sentiment analysis within a social metaverse indicate that VR environments can be designed to create positive emotional experiences for users, characterized by calmness and positivity. Behavioral analysis of movement in VR also contributes to stress level detection.

3.4.3. Self‐Efficacy

Increased self‐efficacy has been shown to be a predictor of functional improvement in stroke survivors.

3.4.4. Motivation

VR exergaming has been found to positively impact factors of motivation such as enjoyment, effort, and usefulness. The Intrinsic Motivation Inventory (IMI) is used in some studies to measure these variables.

3.4.5. Adverse Effects

Although VR has many benefits, some studies note the occurrence of cyber sickness and other adverse reactions. Tools such as the Simulator Sickness Questionnaire (SSQ) are used to measure these effects.

3.5. Methodological Rigor and Statistical Frameworks

3.5.1. Study Designs

The majority of the studies employed robust methodologies, including randomized controlled trials (RCTs) with control groups and pre‐ and post‐intervention assessments. This enhances the reliability of the evidence. Single‐blinded designs were used in some studies where outcome assessors were blinded.

3.5.2. Statistical Analyses

Studies used a variety of statistical methods, including ANOVA, t‐tests, and non‐parametric tests such as the Wilcoxon test and Mann–Whitney U‐test, ensuring appropriate data analysis. Many studies used repeated measures ANOVA. Statistical significance was generally set at p < 0.0535.

3.5.3. Addressing Confounding Variables

Many studies controlled for confounding variables such as age, education, sex, depressive symptoms, and pharmacotherapy in the statistical analyses to improve the reliability of the results.

3.5.4. Sample Size

Sample sizes varied considerably, and many studies noted the need for larger studies to confirm results and improve the generalizability of findings.

3.5.5. Use of Standardized Instruments

The consistent use of standardized assessment tools such as the MoCA, MMSE, TMT, and various scales for physical and psychological well‐being ensures comparability across studies.

3.6. Technological and Implementation Aspects

3.6.1. VR Modalities

Both immersive VR systems with head‐mounted displays and non‐immersive systems using computer screens were used, showing positive results in both types of VR. Fully immersive systems are noted to be potentially superior for visuospatial tasks.

3.6.2. Accessibility

Studies explore VR in remote and out‐of‐hospital settings for functional eye screening and cognitive training.

3.6.3. Usability

Tools like the System Usability Scale (SUS) were used to assess the usability and acceptance of VR technology.

3.6.4. Metaverse Applications

The potential for the metaverse for social interaction and long‐term care is explored, demonstrating a move toward innovative healthcare solutions.

4. Discussion

The present systematic review was conducted to investigate the effects of immersive technologies to assist the elderly and improve the quality of life of the elderly population. This review included 37 selected articles that provided insight into the use of these technologies to assist the elderly. The analysis of the selected studies showed that countries like Korea and China are at the forefront of designing and using immersive technologies for the elderly population (Figure 1), indicating the growing recognition of the importance of empowering and assisting the elderly through such technologies. The findings show a growing trend in the development and design of interactive immersive games and environments over time (Figure 2). The higher frequency of studies in 2021 is very evident and indicates a shift toward more comprehensive and interactive interventions for the elderly. Virtual reality technology appeared to be the most used immersive technology among the reviewed studies (Figure 3). This can be attributed to the maturity of VR technology compared to other immersive technologies and its widespread use for rehabilitating the elderly.

One of the indicators that well expresses the condition of the elderly is the quality of life index. On the other hand, the loneliness and social isolation of the elderly can have severe negative effects on their mental and physical health and initiate mental and cognitive problems. Older people become lonelier and more isolated due to major life events such as retirement or loss of loved ones. The best and most effective methods of preventing depression in the elderly are community presence and family relationships [56]. The results of Mata's research showed that 7 studies of VR and Metaverse were designed for social interactions and reducing the isolation of the elderly, that grandparents can have a social experience. Experience with family and friends, as if they are actually spending the day together and can do things like watching TV and other family activities with them.

24% of the studies investigated physical exercise in virtual reality for the elderly (Figure 4), which accounted for a large part due to the increase in life expectancy in different societies and the increase in the number of elderly people and the prevalence of physical problems related to this era. The investigation of low‐risk methods that is very important to be able to improve the physical fitness and daily activities of the elderly. Light and regular exercise can increase cognitive function in the elderly. Due to degenerative neuromuscular changes, usually 14% of the elderly lose their ability to perform a number of daily activities every year. As the ability to balance and walk decreases as a result of neuromuscular analysis, there is a lack of balance, which is considered to be the main cause of elderly people falling down, and the sprain of the ankle joint, especially its external sprain, is one of the most common injuries [57] This age group benefits from these training methods in the metaverse and virtual reality; they can prevent the disturbance of balance and the unfortunate consequences after the inevitable thing that follows the increase in age, and also improve their quality of life.

According to experts, dementia is a syndrome characterized by progressive cognitive decline and various diseases that affect brain structures and functions. Suffering from cognitive disorders becomes more tangible due to the fact that every normal person loses about 1000 nerve cells daily and new cells do not replace them. Things like stress, distress and depression, snoring and insufficient sleep can cause cognitive disorders, memory impairment or even dementia by affecting the hippocampus area of the brain. Making appropriate and necessary changes in lifestyle can minimize the risks and severity of cognitive disorders in the long run. Virtual reality technology can have a significant effect in reducing psychological symptoms (stress, anxiety and depression) of elderly people [58].

Many studies in the sources employed RCTs as a core methodology, This design is crucial for establishing causal relationships between VR interventions and outcomes by comparing an experimental group to a control group, However, the “control” condition varied significantly, ranging from “treatment as usual” to structured exercise or cognitive training programs, This variability can make it challenging to isolate the specific impact of VR itself. Several studies used a “treatment as usual” (TAU) control, which may include a variety of non‐standardized activities. This variability can affect the interpretation of results. Some studies compare VR to alternative treatments like exercise, which provides a more rigorous comparison, but introduces a different kind of complexity.

The results of our research showed that 27% of studies were done through game design and virtual reality environments to help improve cognitive problems and depression of the elderly. This study found that the use of immersive technologies can cover various aspects of the lives of the elderly and improve their quality of life. Thus, immersive technology can enhance the quality of life of the elderly and assist in their rehabilitation. However, these technologies have challenges and limitations such as the heaviness of the equipment used and causing headaches in the elderly, which will fade over time and with the discovery of new solutions. One of the limitations of this research is the lack of full access to the EMBASE database.

The findings of this research align with the results of earlier systematic reviews in this field. For instance, Baragash et al. [9] found that virtual reality positively influences the reduction of depression and enhances social interactions among the elderly. Additionally, a review by Shu and Woo [8] highlighted how the metaverse contributes to greater social engagement and cognitive rehabilitation. In contrast to these studies, this review analyzed a broader scope of immersive technologies, such as augmented reality and mixed reality, and aimed to understand their diverse effects on the quality of life for older adults.

Moreover, unlike Margrett et al. [1], which primarily concentrated on the influence of virtual reality on physical activity, this study investigated the impact of immersive technologies across several domains, including memory, depression, social engagement, and physical rehabilitation. Consequently, this research offers a more extensive understanding of the various applications of these technologies in enhancing the elderly's quality of life.

4.1. Key Limitations

The VR interventions were highly variable, including different types of VR (immersive vs. non‐immersive), different content and tasks, and different durations, this heterogeneity makes it difficult to determine the most effective components of VR therapy.

Some studies lacked active control groups. An active control group is one that receives a different type of intervention rather than no intervention or treatment as usual. The lack of active control groups can confound the results with placebo effects.

Although some studies addressed possible confounding factors in the analyses, factors such as socio‐economic status and pre‐existing conditions were not always taken into account.

Many studies lacked longitudinal follow‐up, which means it's unclear whether the gains from VR interventions are maintained over time. This limits the conclusions that can be drawn about long‐term effectiveness.

The studies did not always fully address practical issues with VR implementation, such as the need for technical support, or the potential for motion sickness. These issues must be resolved for VR to become widely usable. The sources often note the importance of informed consent Ethical guidelines must be followed during VR research, particularly when working with vulnerable populations such as the elderly.

4.2. Future Research Directions

There is a need to standardize VR protocols in terms of type of VR, content, duration, and intensity of training. This would allow for more rigorous comparisons across studies and help identify the most effective VR treatments.

Future studies should use larger sample sizes and multi‐center designs to improve statistical power and generalizability. This is especially important for VR interventions, as the results are specific to the setting and population.

Longitudinal studies are crucial to establish the long‐term benefits and maintenance of effects after VR interventions. These studies will help to determine how long the positive impacts of VR last over time.

There is a need for more research into the underlying mechanisms of action of VR, using techniques like EEG, fMRI, and fNIRS. These studies can improve our understanding of how VR affects the brain and cognitive functions.

Future research should investigate how VR interventions can be personalized to individual patient needs. This includes considering factors such as cognitive reserve, pre‐existing conditions, and personal preferences.

There is a need for more studies comparing VR with other interventions using active control groups to isolate the specific benefits of VR as compared to an alternative therapy. This approach reduces the possibility that a study is confounded by placebo effects.

Factors like cognitive reserve may contribute to inter and intra‐individual differences when it comes to VR cognitive interventions, and these factors should be considered in future studies.

There is a heterogeneity of VR programs in these studies and further research is required to find the optimal combination of content, intensity, and duration.

5. Conclusion

Although the use of the Metaverse and immersive equipment can be effective in all dimensions of disabilities occurring in the elderly phase of human life and empower the elderly, they require the establishment of organizations to provide comprehensive services and support to the elderly, and equipment should be designed to have the least side effects on the elderly. Immersion technology, particularly VR, significantly enhances the quality of life for older adults. VR interventions show promise in improving physical health by boosting balance and mobility, while also supporting cognitive function through tasks that improve executive functions and memory. Furthermore, VR has a positive impact on psychological well‐being, reducing depression and anxiety, and fostering social engagement. These findings suggest that VR is a valuable tool for addressing the challenges of aging and can be adapted to meet individual needs, making it an effective and enjoyable approach for promoting overall health and well‐being. By implementing these solutions, immersive technologies can be used more widely in elderly care and play a key role in improving their quality of life.

Author Contributions

Solmaz Sohrabei: conceptualization, investigation, original draft, writing, data curation. Vahideh Zolfaghari: conceptualization, investigation, writing, data curation. NE: Searched and Data Collected. Seyed Jafar Ehsanzadeh: revised and confirmed the final version of the manuscript. All authors have read and approved the final version of this manuscript.

Ethics Statement

The authors have nothing to report.

Consent

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A. Risk of Bias

Risk of bias	D1	D2	D3	D4	D5	D6	D7	Overall
Afsar SI [31] Turkey 2018
Liang H [32] China 2022
Xu W [33] Greece 2023
Lai YJ [34] Taiwan 2023
Beck D [35] USA 2017
Han X [36] USA 2023
Campo‐Prieto P [37] Spain 2022
N Brandín‐De la Cruz [18] Spain 2020
Pawel Kiper [38] Italy 2022
Jae Myeong Kang [39] Korea 2021
Syed Hammad Hussain Shah [40] Norway 2022
Mateus Trombetta [41] Brazil 2017
C Pazzaglia [42] Italy 2020
Sebastian Rutkowski [43] Poland 2020
Yoon‐Hee [44] Choi Korea 2018
Ying‐Yi Liao [45] Taiwan 2020
Tuba Kanyılmaz [46] Turkey 2022
Saeed Yousefi Babadi [47] Iran 2021
Justyna Mazurek [48] Poland 2023
Zhilan Liu [49] China 2022
Héctor Brito [50] China 2021
Rui Zhao [51] China 2023
Jeonghun Ku [52] Korea 2018
Ehab M Abd El‐Kafy [53] Saudi Arabia 2023
Magdalena Sylwia Kamińska [54] Poland 2018
Kenji Tsuda [16] Japan 2016
Valerie Elliott [17] Canada 2015
Wong KA et al. [18] Singapore 2023
Gueye T et al. [19] Prague 2021
Kang JM et al. [20] Korea 2021
Maranesi E et al. [55] Italy 2022
Oliveira J et al. [22] 2021 Portugal
Liao YY et al. [23] Taiwan 2019
Sadeghi et al. [24] Iran 2021
Yang JG et al. [25] Korea 2022
Riaz W et al. [56] Poland 2021
Hwang NK et al. [57] Korea 2021

Domains	Judgment
D1: Were the criteria for inclusion in the sample clearly defined	Low
D2: Were the study subjects and the setting described in detail
D3: Was the exposure measured in a valid and reliable way	Moderate
D4: Were objective, standard criteria used for measurement of the condition
D5: Were confounding factors identified
D6: Were strategies to deal with confounding factors stated
D7: Were the outcomes measured in a valid and reliable way	Serious