Validity, Diagnostic Accuracy, and Feasibility of Trail Making Test in Virtual Reality for Mild Cognitive Impairment
Abstract
Background: Immersive virtual reality (VR) adaptations of neuropsychological tests change how participants respond and must be validated in each clinical population. We evaluated the Trail Making Test in Virtual Reality (TMT-VR), a head-gaze version of the paper-and-pencil Trail Making Test (hereafter, TMT) that records completion times and wrong-target selections automatically, in older adults with and without mild cognitive impairment (MCI). Methods: In this case–control evaluation, 84 adults aged 60–89 years (42 with clinically diagnosed MCI, 42 healthy comparison participants) completed the TMT-VR, the TMT and the Mini-Addenbrooke’s Cognitive Examination (M-ACE), with pre- and post-exposure cybersickness ratings. Planned analyses examined feasibility, convergence, group differences and diagnostic accuracy for all 26 TMT-VR scores against their TMT counterparts and the M-ACE, with demographic adjustment, multiplicity correction, bootstrap validation and education-matched sensitivity analysis. Results: All participants completed both TMT-VR parts, and cybersickness ratings decreased over the session. Part B completion times correlated positively across formats within both groups. Participants with MCI were slower and made more wrong-target selections on TMT-VR Part B but not Part A. Score for score, the TMT-VR matched the TMT on Part B completion time and discriminated MCI more effectively on the Part B, total and B−A error scores and every Part B-specific derived score; these effects persisted after demographic adjustment and widened in the education-matched subsample. The TMT's advantage lay in Part A completion time, and its error scores carried little discriminatory information. With education equalised, the TMT-VR B−A scores gave balanced operating characteristics and approached the M-ACE, which every TMT score remained below. The M-ACE discriminated more accurately than any single trail-making score of either format. Conclusions: The TMT-VR is a feasible, well-tolerated adaptation with convergent validity against the TMT and known-groups validity for MCI. Because it discriminated MCI more effectively on the Part B-specific and error-based scores that carry the test's executive demand, it emerges as the preferable Trail Making Test format within neuropsychological batteries for MCI; whether it adds diagnostic information beyond global screens such as the M-ACE must be established in consecutive clinical referrals, together with age- and education-stratified normative cut-offs.
Related
- Semaglutide ameliorates neuroinflammation and cognitive impairment in APP/PS1 mice
- Atypical Chemokine Receptor DARC/ACKR1 Is Expressed Selectively by Neurons with Regional Heterogeneity and Protects against Neuroinflammation and Cognitive Impairment
- Diagnostic accuracy of Mycobacterium tuberculosis antigen-induced interferon-γ-inducible protein 10 for latent tuberculosis infection among high-risk groups: a systematic review and meta-analysis
- Diagnostic validity of ELISA-IgM, DPP® rapid test, and MAT for leptospirosis diagnosis in Brazilian reference laboratories: a latent class analysis
- Dementia Language Models: a generalizable and controllable representation of cognitive impairment
BibTeX
@misc{kourtesis2026validity,
title = {{Validity, Diagnostic Accuracy, and Feasibility of Trail Making Test in Virtual Reality for Mild Cognitive Impairment}},
author = {Panagiotis Kourtesis and Antonia Ioakeimidou and Myrto Dimakopoulou and Christina Anastasopoulou and Maria Roussou and Petros Roussos and Chrysanthi Nega and Ion Beratis},
howpublished = {PsyArXiv},
year = {2026},
month = sep,
doi = {10.31234/osf.io/wqx32_v1},
url = {https://osf.io/preprints/psyarxiv/wqx32_v1/},
note = {CC BY 4.0},
}
RIS
TY - UNPB
TI - Validity, Diagnostic Accuracy, and Feasibility of Trail Making Test in Virtual Reality for Mild Cognitive Impairment
AU - Panagiotis Kourtesis
AU - Antonia Ioakeimidou
AU - Myrto Dimakopoulou
AU - Christina Anastasopoulou
AU - Maria Roussou
AU - Petros Roussos
AU - Chrysanthi Nega
AU - Ion Beratis
PY - 2026
DA - 2026/09/27
PB - PsyArXiv
DO - 10.31234/osf.io/wqx32_v1
UR - https://osf.io/preprints/psyarxiv/wqx32_v1/
AB - Background: Immersive virtual reality (VR) adaptations of neuropsychological tests change how participants respond and must be validated in each clinical population. We evaluated the Trail Making Test in Virtual Reality (TMT-VR), a head-gaze version of the paper-and-pencil Trail Making Test (hereafter, TMT) that records completion times and wrong-target selections automatically, in older adults with and without mild cognitive impairment (MCI). Methods: In this case–control evaluation, 84 adults aged 60–89 years (42 with clinically diagnosed MCI, 42 healthy comparison participants) completed the TMT-VR, the TMT and the Mini-Addenbrooke’s Cognitive Examination (M-ACE), with pre- and post-exposure cybersickness ratings. Planned analyses examined feasibility, convergence, group differences and diagnostic accuracy for all 26 TMT-VR scores against their TMT counterparts and the M-ACE, with demographic adjustment, multiplicity correction, bootstrap validation and education-matched sensitivity analysis. Results: All participants completed both TMT-VR parts, and cybersickness ratings decreased over the session. Part B completion times correlated positively across formats within both groups. Participants with MCI were slower and made more wrong-target selections on TMT-VR Part B but not Part A. Score for score, the TMT-VR matched the TMT on Part B completion time and discriminated MCI more effectively on the Part B, total and B−A error scores and every Part B-specific derived score; these effects persisted after demographic adjustment and widened in the education-matched subsample. The TMT's advantage lay in Part A completion time, and its error scores carried little discriminatory information. With education equalised, the TMT-VR B−A scores gave balanced operating characteristics and approached the M-ACE, which every TMT score remained below. The M-ACE discriminated more accurately than any single trail-making score of either format. Conclusions: The TMT-VR is a feasible, well-tolerated adaptation with convergent validity against the TMT and known-groups validity for MCI. Because it discriminated MCI more effectively on the Part B-specific and error-based scores that carry the test's executive demand, it emerges as the preferable Trail Making Test format within neuropsychological batteries for MCI; whether it adds diagnostic information beyond global screens such as the M-ACE must be established in consecutive clinical referrals, together with age- and education-stratified normative cut-offs.
ER -