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Effect of Cognitive Training in Fully Immersive Virtual Reality on Visuospatial Function and Frontal-Occipital Functional Connectivity in Predementia: Randomized Controlled Trial

Contact Information


Seong-Jin Cho,

cognitive training; fMRI; mild cognitive impairment; virtual reality; visual network; visuospatial function.


Objective: We aimed to examine the hypothesis that cognitive training using fully immersive VR, which may facilitate visuospatial processes, could improve visuospatial functioning, comprehensive neuropsychological functioning, psychiatric symptoms, and functional connectivity in the visual brain network in predementia. Methods: Participants over 60 years old with subjective cognitive decline or mild cognitive impairment from a memory clinic were randomly allocated to the VR (n=23) or the control (n=18) group. 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 of both groups were evaluated for cognitive function using face-to-face comprehensive neuropsychological tests, including the Rey-Osterrieth Complex Figure Test (RCFT) copy task; for psychiatric symptoms such as depression, apathy, affect, and quality of life; as well as resting-state functional magnetic resonance imaging (rsfMRI) at baseline and after training. Repeated-measures analysis of variance was used to compare the effect of cognitive training between groups. Seed-to-voxel-based analyses were used to identify the cognitive improvement-related functional connectivity in the visual network of the brain. Results: After VR cognitive training, significant improvement was found in the total score (F1,39=14.69, P=.001) and basic components score of the RCFT copy task (F1,39=9.27, P=.005) compared with those of the control group. The VR group also showed improvements, albeit not significant, in naming ability (F1,39=3.55, P=.07), verbal memory delayed recall (F1,39=3.03, P=.09), and phonemic fluency (F1,39=3.08, P=.09). Improvements in psychiatric symptoms such as apathy (F1,39=7.02, P=.01), affect (F1,39=14.40, P=.001 for positive affect; F1,39=4.23, P=.047 for negative affect), and quality of life (F1,39=4.49, P=.04) 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. Conclusions: 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. Future trials using VR cognitive training with larger sample sizes and more sophisticated designs over a longer duration may reveal greater improvements in cognition, psychiatric symptoms, and brain functional connectivity.


Kang, J. M., Kim, N., Lee, S. Y., Woo, S. K., Park, G., Yeon, B. K., Park, J. W., Youn, J.-H., Ryu, S.-H., Lee, J.-Y., & Cho, S.-J. (2021). Effect of cognitive training in fully immersive virtual reality on visuospatial function and frontal-occipital functional connectivity in predementia: Randomized controlled trial. Journal of Medical Internet Research, 23(5).





Conent Area

Jae Myeong Kang

EWB-Related Construct

(2) life satisfaction;
(3) positive affect;

Study Design

Species or Study Population

(5) RCT

Sex (%Female)


Age (Mean, SD)


Younger Controls?


Longitudinal Data?


Sample Size



Cognitive Training

Ethnicity (%white)


Inclusion Criteria

(1) all participant had subjective cognitive complaints, including memory decline, but did not meet the criteria for diagnosis of neurocognitive disorder; (2)

Exclusion Criteria

(i) Korean version of Mini-Mental State Examination (MMSE) score <20; (ii) impaired activities of daily living; (iii) comorbidity of severe medical or surgical conditions; (iv) major psychiatric disorders; (v) history of any kind of dementia; (vi) history of neurodegenerative disorders, including Creutzfeldt-Jakob disease, Pick disease, Huntington disease, Parkinson disease, inflammation associated with HIV, and syphilis; (vii) structural abnormalities on MRI such as intracranial hemorrhage, cerebral, cerebellar, or brainstem infarction, hydrocephalus, traumatic brain injury, severe white matter hyperintensity, tumors, multiple sclerosis, or vasculitis; and (viii) inability to use the VR system.

EWB Measures

(1) 30-item Geriatric Depression Scale (GDS)
(2) 18-item Apathy Evaluation Scale (AES)
(3) Positive and Negative Affect Schedule (PANAS),

Non-EWB Behavioral

(1) Korean version of the Mini-mental State Examination, (2) Clinical Dementia Rating (CDR), (3) global deterioration scale, and instrumental activities of daily living scales, (4)Trail Making Test, (5) TMT-B: trail Making test, (6) Korean Version of the Boston Naming Testg (7) SVLT: Seoul Verbal Learning Test, (8) COWAT: controlled oral world association test,
(2) 30-item Geriatric Depression Scale (GDS)
(3) 18-item Apathy Evaluation Scale (AES)

Physiological Measures


Brain IMaging Modality

Brain IMaging Paradigm


Brain Region/Circuit

(1) increased of frontal-occipital functional connecitivy related to Rey-Osterrieth Complex Figure Test copy task improvement after virtual reality cognitive training;
(2) The areas with significantly increased connectivity in the seed-to-voxel visual networks: (a) from the right visual lateral cortices to the left paracingulate gyrus, right paracingulate gyrus, left frontal pole, left superior frontal gyrus, anterior cingulate gyrus, and white matter; and (b) from the visual medial cortices to the right insular cortex, right frontal pole, right frontal operculum cortex, right caudate, left caudate, right putamen, left insular cortex, and white matter.

Biological Measures

(4) resting fMRI

Other Neural Measures

Data Availability?


Data Avalability Details


Diagnostic Measures

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