Abstract

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 (R) 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.