Validity and Age Sensitivity of the Trail Making Test in Virtual Reality: A Comparison with the Paper-and-Pencil Test in Younger and Older Adults

The Trail Making Test (TMT) is among the most widely used neuropsychological tests, and its completion times slow with age. The Trail Making Test in Virtual Reality (TMT-VR) preserves the sequencing structure of the test but replaces pen movements with head-gaze selection in an immersive environment. However, the convergent validity and sensitivity to age of its English-language version in older adults are unknown. Forty-seven younger (20–38 years) and 44 older adults (64–81 years) completed the paper-and-pencil TMT and the TMT-VR in counterbalanced order. Nine scores were derived per format from Parts A and B: completion times, errors, error-adjusted times, and B−A difference scores. Part A and Part B completion times and error-adjusted times of the two formats correlated significantly in the whole sample, and Part B completion times did so within each age group, whereas errors did not. Older adults performed more poorly than younger adults on completion times in both formats, and the age groups were thus differentiated by both the paper-and-pencil TMT and the TMT-VR. The TMT-VR differentiated the age groups statistically better than the paper-and-pencil TMT on Part B completion times, error-adjusted times and errors, but both formats performed comparably on Part A scores. No paper-and-pencil score distinguished between the groups better than its TMT-VR counterpart. The TMT-VR is therefore a valid immersive adaptation of the TMT, and its advantage in age sensitivity lies in the Part B scores. Future studies should aim for clinical validation in older adults.