Visual attention during non-immersive virtual reality balance training in older adults with mild to moderate cognitive impairment: an eye-tracking study.

Background: Older adults with cognitive impairment often present with balance deficits, reduced walking speed, and attentional difficulties-particularly in executive function. These challenges increase fall risk and complicate traditional rehabilitation approaches. Eye-tracking technology offers an objective way to evaluate attention by analyzing oculomotor behavior during tasks, but its use in clinical rehabilitation contexts is still limited. Objective: The aim of this study is to investigate visual attention using eye-tracking metrics during a non-immersive virtual reality-based balance training program in older adults with mild to moderate cognitive impairment. Methods: This was an exploratory pilot study with a prospective, descriptive cohort, based on a non-controlled, quasi-experimental design of seven older adults with mild to moderate cognitive impairment. Each patient underwent VR-based balance training using Rehametrics® software, while their attention was assessed via eye-tracking (Tobii Pro TX300). Clinical assessments included the Mini-BESTest, Functional Gait Assessment, 6-Minute Walk Test, 4-Meter Walk Test, and Montreal Cognitive Assessment (MoCA). Eye-tracking data focused on fixation patterns, microsaccades, and pupil diameter as indicators of attentional processing. Results: Patients showed a small numerical increase, without reaching statistical significance in task difficulty progression (p = 0.016), lower limb endurance (p = 0.016), and single-leg support time (p = 0.031). Clinical tests revealed a slight increase, though results were not statistically significant in balance and walking speed (p = 0.063). Eye-tracking data indicated increased fixation stability and decreased pupil diameter, suggesting more efficient attention allocation during motor tasks. Conclusions: Eye-tracking provided valuable metrics into attentional behavior during balance training in older adults with cognitive impairment. Its integration into non-immersive virtual reality rehabilitation may help better understand and address cognitive-motor interactions. Further studies with larger samples are needed to confirm these preliminary findings.