The Picture Interpretation Test 360°: A Virtual Reality Screening Tool for Executive Dysfunction and Rehabilitation Stratification in Mild Cognitive Impairment

<b>Background/Objectives:</b> Mild Cognitive Impairment (MCI) represents a critical transition stage between normal aging and dementia, with executive dysfunction playing a key prognostic role. Traditional neuropsychological tests show limited ecological validity and may fail to detect early executive deficits. Virtual Reality (VR) offers an innovative alternative by reproducing everyday situations in realistic environments. This study investigated whether the Picture Interpretation Test 360° (PIT 360°), a VR-based assessment, can (1) discriminate between MCI patients and healthy controls (HCs); (2) identify executive dysfunction within the MCI group; and (3) correlate with standard neuropsychological measures. <b>Methods:</b> One hundred and one participants aged ≥65 years (53 MCI, 48 HCs) underwent a comprehensive neuropsychological assessment and PIT 360° evaluation. The PIT 360° requires interpreting a complex scene in a 360-degree virtual environment. Hierarchical linear regression, Receiver operating characteristic (ROC) curve analysis, and binary logistic regression were performed to examine group differences and diagnostic accuracy. MCI patients were stratified based on their performance on the Modified Five Point Test to identify visuospatial dysexecutive deficits. <b>Results:</b> MCI patients showed significantly longer PIT 360° completion times than HCs (92.6 vs. 65.3 s, <i>p</i> = 0.006), independent of age. MCI patients with visuospatial dysexecutive deficits exhibited the most severe deficits (median = 105 s, <i>p</i> = 0.017 vs. HCs). ROC analysis revealed adequate discriminative ability (AUC = 0.64, 95% CI [0.53, 0.75]) with a preliminary, sample-derived cut-off at ≥22 s, yielding high sensitivity (86.5%) but low specificity (42.6%). This threshold requires validation in independent samples. PIT 360° completion time correlated significantly with visuospatial executive functions, visual memory, and verbal fluency. <b>Conclusions:</b> The PIT 360° effectively screens for visuospatial executive dysfunction in MCI with high sensitivity, making it suitable for ruling out clinically significant impairment. Its ecological validity, brief administration, and correlations with traditional measures support integration into routine clinical practice for early detection and rehabilitation planning.