falls are common in alzheimer 's dementia ( ad ) and lead to significant morbidity and mortality . compared to cognitively intact
older adults , patients with ad have a threefold increase in falls causing fractures , hospitalization , and increased rate of institutionalization .
poor balance and gait abnormalities seen in ad such as shortened step length , increased stride length variability , and decreased gait speed are risk factors for falls [ 3 , 4 ] .  
even low - intensity exercises are useful in improving balance and gait in deconditioned elders .
however , it is difficult to engage patients with ad in long - term exercise programs .
barriers to exercise programs include but are not limited to lack of motivation , limited access to exercise facilities , and high cost of exercise programs .
exercise programs are most effective if they are easy to access and perform . walking , for example , is a popular activity and the most commonly recommended home - based exercise for the elderly .
likewise use of readily available technologies might enhance exercise adherence because of their easy access , user friendly interface , and ability to provide high level of engagement at an affordable price .
while off - the - shelf gaming technologies lack specificity , they have the advantage of mass accessibility , broad affordability , and the potential for in - home use .
wii - fit , a nintendo gaming console , is one such ready - to - use technology that provides self - directed activity through a tv .
virtual trainers talk the user through the activity while tracking their progress and providing visual and auditory feedback .
the primary goal of our study was to compare the effect of the wii - fit program to a walking program on balance and gait in subjects with mild alzheimer 's dementia living in an assisted living facility .
a prospective randomized study with two intervention groups was conducted in an assisted living facility after obtaining approval from institutional review board ( irb ) .
all subjects signed a written assent while their legal surrogates signed a written informed consent .
subjects aged 60 years and older residing in an assisted living facility with a medical chart documenting a history of mild ad along with a mini mental state examination score 18 ( upper limit 29 ) were included in the study .
individuals were excluded for the following medical problems : myocardial infarction , transient ischemic attack or stroke in the previous 6 months , serious mental illness which impacted memory , active cancer diagnosis with the exception of skin cancer , poor prognosis for survival ( e.g. , severe congestive heart failure ) , severe sensory ( visual or auditory ) or musculoskeletal impairments , or a required use of a wheel - chair for ambulation .
the walkers wrap around the wii balance board so they used the walker while exercising .  
subjects were randomized using a random number generator to either the wii - fit intervention group or the walking group .
the goal was for subjects in both groups to participate in the activity for 30 minutes daily , five times a week , for 8 weeks .
the nintendo wii - fit console was connected to a mobile television unit which was transported daily to the exercise area of the assisted living facility .
research personnel set up and navigated the wii - fit console and software , and the subjects performed the exercises .
all subjects walked down from their rooms to the exercise area to do wii - fit and walked back to their rooms after the exercise .
this walk from and to the room was included as a warm - up and cool - down exercise .
similarly , the walking group walked to the start point to begin their walking exercise and the walk from and to their room was included as warm - up and cool - down exercise .  
based on the physical therapists recommendation , we encouraged patients to do exercises from each group of the wii - fit program that included strength training , yoga , and balance games .
the yoga exercises included the half - moon , warrior pose , chair , and sun salutation .
balance exercises included soccer heading , ski slalom , ski jump , table tilt , balance bubble , and penguin slide . since one third of the participants used some kind of assistive device , the aerobic exercise such as the running and step activity of the wii - fit were not used per recommendation of the physical therapist .
the wii - fit intervention was an individual exercise program wherein subjects exercised one on one with help from research personnel . in the wii - fit group , all subjects spent 10 minutes on yoga , 10 minutes on strength training , and 10 minutes on the balance games .
the walking arm walked at their own pace as a group of 3 or 4 subjects at any given time with research personnel .
tinetti test ( tt ) and the timed up and go ( tug ) were also measured .
the bbs   is a valid and reliable measure used to assess balance impairments in elderly , either statically or while performing various functional movements in a clinical setting .
the bbs consists of 14 subsets of tasks with each task scored on a five - point scale ( 04 ) according to the quality or the time of the performance .
a score of  0  indicates the lowest level of function while  4  indicates the highest level of function .
the maximum score is 56 , and a score of less than 45 is predictive of falls .
scoring is done on a three - point ordinal scale with a range of 0 to 2 .
the individual scores are then combined to form three measures ; an overall gait assessment score , an overall balance assessment score , and a gait and balance score .
the tug   test is widely employed in the examination of elders as a basic test for functional mobility .
the tug score measures speed and represents the time taken to rise from the chair , walk 3 meters , turn , walk back , and sit down .
the secondary outcome measures measured were functional ability , quality of life , and cognition .
functional ability was measured by activities of daily living ( adl ) , and instrumental activities of daily living ( iadl ) .
adl assesses a subject 's independence in performing basic tasks of daily living such as bathing , eating , and toileting , while iadl assesses the subject 's independence in performing hierarchical activities , such as preparing meals , handling finances , and using telephone .
the higher the score of adl and iadl , the better the functional state of the subject
. quality of life was measured by the quality of life - ad ( qol - ad ) .
the qol - ad is a 13-item scale which assesses patient 's physical condition , mood , interpersonal relationships , ability to participate in meaningful activities , financial situation , and overall assessment of self and quality of life as a whole .
the data were analyzed using spss ( version 17.0 for windows , spss inc . ,
independent sample t - tests were used to test for intergroup differences at baseline . in the primary analyses , repeated measures analyses of variance ( rm - anova ) were used to determine if there was a significant group by time interaction for any outcome when comparing the wii - fit and the walking groups over the three time points of the study , baseline and weeks 4 and 8 .
post - hoc analyses using paired t - tests were performed on each group to determine within subject changes between the baseline and postintervention values .
data were analyzed with intent - to - treat analyses . for subjects who did not complete the study , the last data were carried forward to week 8 .
after completing the baseline assessments , subjects ( n = 22 ) were randomly assigned to either the wii - fit intervention or the walking group ( n = 11 each ) . study recruitment and participation are illustrated in figure 1 .
the subject in the wii - fit group voluntarily withdrew while the subject in the walking group was discharged from the facility to his home .
there were no adverse events related to the study . however , unrelated adverse events occurred for several subjects .
two subjects ' sustained falls ( one from each arm ) , but these events did not occur during the intervention and did not require an emergency room visit or hospitalization .
one subject was hospitalized for small bowel obstruction which resulted in the subject being much weaker and requiring the use of a walker upon return to the study .
two subjects ( one from each arm ) developed viral gastroenteritis and were quarantined for a total of four days , two days of which were their exercise participation days during which time they could not participate in the exercise activities .
there were no statistically significant differences between these groups for any of the variables listed .
there were also no significant differences between groups for the number of comorbidities present , medications prescribed , or for the need of assistive walking devices .
the total time of participation in the study interventions ( used as an indicator of compliance ) was not significantly different between the wii - fit and walking groups ( table 1 ) . the wii - fit and walking
the most common reasons for not participating in exercise activities included other scheduled activities such as field trips , bus rides , crafts and decorations , family visits , and doctor 's appointments .  
the mean bbs score in both groups was less than 45 indicating that the subjects were at high risk for falls .
however , there were no significant group - by - time interactions on the measures of bbs ( p = 0.56 ) .
there was also no significant group - by - time interactions on the measures of tt ( p = 0.97 ) and tug ( p = 0.52 ) ( table 2 ) .
intragroup analysis of the wii - fit group showed significant improvement on measures of bbs ( average improvement 6.27  5.27 , p = 0.003 ) , and tt ( average improvement 1.82  2.04 , p = 0.013 ) ( table 2 ) .
scores on tug improved with wii - fit but did not reach statistical significance ( average improvement 0.82  2.56 , p = 0.31 ) ( table 2 ) .
intragroup analysis of the walking group showed a trend towards improvement on the bbs ( average improvement 5.27  7.36 , p = 0.06 ) and tug ( average improvement 2.1  3.45 , p = 0.07 ) and significant improvement on tt ( average improvement 2.0  1.89 , p = 0.006 ) ( table 2 ) .
the mean bbs improved nonsignificantly over the first 4 weeks in both groups , however the walking group plateaued from week 4 to 8 while the wii - fit group continued to improve ( figure 2 ) .
there was no significant group - by - time interaction on measures of functional state , adls ( p = 0.11 ) , iadls ( p = 0.11 ) , quality of life ( qol - ad ) ( p = 0.61 ) , or cognition ( mmse ) ( p = 0.7 ) .
however , intragroup analysis of walking group showed improvement on the measures of quality of life ( p = 0.03 ) .
this study shows that the use of wii - fit is feasible in an assisted living environment in elderly patients with mild dementia .
those in the wii - fit group readily accepted and enjoyed participating in the exercise program .
the mean baseline bbs score in both groups was less than 45 indicating that all the subjects were at high risk for falls .
thus the use of wii - fit was also safe and feasible in subjects at high risk for falls .
these results demonstrated that the wii - fit program was as effective as the robust monitored walking program in improving balance , gait , and physical performance in subjects with mild ad .
our results are consistent with the published literature about the impact of wii - fit exercises on balance and gait in the elderly . in a previous study conducted in an elderly population , improvement in balance ( bbs score ) and an increase in walking speed
were noted with the use of the balance games component of wii - fit . in another study conducted on nine elderly patients , an improvement in balance as measured with the bbs
was seen along with a decreased risk of falls after five - week use of wii - fit . in a study conducted by williams et al . on community - dwelling fallers over 70 years ,
improvement in balance ( bbs score ) was noted in the wii - fit group while no improvement in balance scores was noted in the standard care group . in a study conducted in long - term care ,
residents reported positive experiences playing wii and rated wii bowling as a favorite recreational activity . in a small study of 7 patients with ad , yamaguchi et al .
our study is different from the above - mentioned studies in that we had a robust arm of a monitored walking program .
the walking group had greater exercise compliance ( i.e. , walked longer than the wii - fit intervention time ) although this difference in time did not reach statistical significance .
this could explain why the wii - fit intervention in our study failed to separate from the walking arm .
nonetheless , subjects in the wii - fit arm improved as well as the walking arm .
people may adhere more to the wii - fit intervention since it has been engineered to be socially engaging and entertaining .
wii - fit is enjoyable , easily accessible , and is not limited by a safe place to walk .
one technical difficulty was encountered while using the wii - fit that might have reduced the effectiveness of the intervention . in the version of the wii - fit used in this study , the actual time spent on exercising
was less than the half hour allotted because switching between the exercises consumed time . on an average
an upgrade in the newer software , wii - fit plus , helps subjects customize and personalize a workout to suit their own needs .
they can create their own routine exercises and save them in  my routine exercise  folder which can be accessed in sequence , thus saving time .
unlike the aforementioned studies , we utilized multiple components of the wii - fit program such as yoga , strengthening , and balance games in the current study .
it found that exercise interventions resulted in statistically significantly greater improvements in balance compared to usual activity .
furthermore , interventions involving multiple domains such as gait , balance , coordination and functional exercises , muscle strengthening , and multiple exercise types appeared to have the greatest impact on indirect measures of balance . in another study
, gait exercises resulted in improved dynamic balance and gait function . since our primary outcome measure was that of balance ( bbs ) , a better outcome may be obtained if we specifically targeted balance exercises .
the major strength of the study is the study design , a randomized trial comparing the widely available video game to walking , the most commonly used exercise strategy in the elderly .
limitations of the study include , but are not limited to , the small sample size and inclusion of the bbs as the primary outcome measure which is prone to a ceiling effect , particularly in subjects with higher levels of balance .
other limitations include nonblinded assessors , lack of a usual care control group , and failure to strictly control the intensity of the exercises in each group .
having the groups led by peers or having the subjects exercise independently might make the results more translatable to clinical practice .
future studies could control for the intensity of the exercise by measuring perceived level of exertion , total number of exercises conducted or distance traveled per session , or other parameters .
inclusion of more sophisticated methods for testing balance and gait such as biomechanical assessment might help avoid the ceiling effect of the bbs .
the newer version of the wii - fit , the wii - fit plus , may be a better tool given its wider variety of exercises and the ability to program the amount of time spent in exercising .
using wii - fit in a group setting might have social benefits , which could result in greater improvement in quality of life measures .
this pilot study demonstrates the safety and efficacy of using wii - fit in an assisted living facility in subjects with mild ad .
use of wii - fit resulted in significant improvements in balance and gait , and these benefits were comparable to those experienced by the subjects who participated in the robust monitored walking program .
such a study should probably employ peer - led , family - led , or independently conducted exercise interventions , more sophisticated methods of testing for gait and balance and valid techniques to control the intensity of the interventions .
 
 objectives . to determine the effects on balance and gait of a wii - fit program compared to a walking program in subjects with mild alzheimer 's dementia ( ad ) . methods . 
 a prospective randomized ( 1  :  1 ) pilot study with two intervention arms was conducted in an assisted living facility with twenty - two mild ad subjects . in both groups 
 the intervention occurred under supervision for 30 minutes daily , five times a week for eight weeks . 
 repeated measures anova and paired t - tests were used to analyze changes . 
 results . 
 both groups showed improvement in berg balance scale ( bbs ) , tinetti test ( tt ) and timed up and go ( tug ) over 8 weeks . 
 however , there was no statistically significant difference between the groups over time . 
 intragroup analysis in the wii - fit group showed significant improvement on bbs ( p = 0.003 ) , and tt ( p = 0.013 ) . 
 the walking group showed a trend towards improvement on bbs ( p = 0.06 ) and tug ( p = 0.07 ) and significant improvement in tt ( p = 0.06 ) . 
 conclusion . 
 this pilot study demonstrates the safety and efficacy of wii - fit in an assisted living facility in subjects with mild ad . 
 use of wii - fit resulted in significant improvements in balance and gait comparable to those in the robust monitored walking program . 
 these results need to be confirmed in a larger , methodologically sound study . 
1. Introduction
2. Methods
3. Results
4. Discussion
5. Conclusion