Virtual reality (VR) and serious games (SG) are emerging digital interventions for cognitive rehabilitation in older adults with mild cognitive impairment (MCI). However, their relative effectiveness across cognitive functional, and emotional outcomes remains uncertain

This study aimed to compare the effects of VR and SG interventions, relative to conventional controls, on cognitive function, daily functioning, and depressive symptoms using a network meta-analysis

A total of 28 randomized controlled trials involving 1621 participants were systematically identified and analyzed from PubMed, Embase, web of science, Scopus, and the Cochrane library up to December 2024. Interventions included immersive VR, non-immersive SG, and conventional care. Primary outcomes were cognitive function assessed by the Mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA), while secondary outcomes included activities of daily living (ADL) and depressive symptoms measured by the geriatric depression scale (GDS). Pooled mean differences (MD) with 95 % confidence intervals (CIs) were calculated, and surface under the cumulative ranking curve probabilities were estimated

A total of eight studies ( n  = 214) reported ADL, eight studies ( n  = 373) evaluated GDS, 18 studies ( n  = 789) analyzed MMSE, and eight studies ( n  = 245) assessed MoCA. SG significantly improved MMSE (MD = 1.63, 95 % CI [0.69, 2.62]) and MoCA (MD = 2.84, 95 % CI [0.61, 5.01]) compared to control. In contrast, VR showed a significant decline in MMSE (MD = −1.18, 95 % CI –2.18,–0.20]) and no significant effect on MoCA (MD = –0.12, 95 % CI [−2.19, 2.07]). Regarding activities of daily living (ADL), no significant differences were found for VR versus control (MD = −0.07, 95 % CI [−2.23, 2.07]) or for SG versus control (MD = −1.34, 95 % CI [−4.99, 3.06]). Similarly, for depressive symptoms (GDS), no significant improvements were observed for VR versus control (MD = 0.98, 95 % CI [−2.63, 4.52]) or for SG versus control (MD = −3.18, 95 % CI [−6.76, 0.29]). However, exploratory probability ranking analysis suggested that SG had the highest likelihood of being the most effective intervention for both ADL (77.1 %) and GDS (83.5 %)

SG demonstrated superior cognitive benefits compared to VR and conventional care, particularly in MMSE and MoCA outcomes, and ranked highest across all outcomes. These findings highlight SG as a more practical and accessible digital intervention for older adults with MCI, although its superiority in functional and emotional domains is based on probability rankings rather than statistically significant differences. Future head-to-head studies are needed to confirm these findings and guide clinical implementation

Registration: CRD42025636363.