Background <p>Impaired balance is among the leading causes of injury, hospitalization, and death in older adults. Previous studies have shown that exergaming is a viable and well-accepted strategy for promoting optimal functional levels in older adults. Hence, this systematic review aimed to examine the effects of commercially available exergame interventions on balance performance among institutionalized older adults.</p> Methods <p>This study was a systematic review of recent randomized controlled trials (RCTs) in care facility settings published between 2016 − 2025. Four electronic databases (CENTRAL, PubMed, CINAHL, and SPORTDiscus) were searched. RCTs examining the effects of commercial exergame systems on balance performance among care facility residents aged 60 years and older were included. Random-effects models were used for meta-analyses. Risk of bias (RoB) and certainty of evidence (CoE) assessments were conducted using the Cochrane RoB2 and GRADE tools, respectively.</p> Results <p>A total of 14 RCTs (<i>n</i> = 724; age: 66.5─86.8 years) were included. Overall, our pooled data showed that exergame interventions significantly improved balance performance among older adults in care facilities [Timed Up-and-Go (TUG) (11 RCTs; <i>n</i> = 588): standardized mean difference (SMD)=-0.87&#xa0;s, 95%CI -1.47 to -0.27&#xa0;s, <i>P</i> = 0.004, <i>I</i>^<i>2</i> = 91%; Berg Balance Scale (BBS) (6 RCTs; <i>n</i> = 354): weighted mean difference (WMD) = 2.88, 95%CI 0.36 to 5.41, <i>P</i> = 0.03, <i>I</i>^<i>2</i> = 93%; Tinetti test (2 RCTs; <i>n</i> = 56): WMD = 4.58, 95%CI 2.64 to 6.51, <i>P</i> &lt; 0.00001, <i>I</i>^<i>2</i> = 0%]. By excluding studies having high RoB, our sensitivity analyses with lower heterogeneity consistently showed that exergame interventions improved TUG test time (6 RCTs; <i>n</i> = 280; SMD=-0.53&#xa0;s, 95%CI -0.99 to -0.07&#xa0;s, <i>P</i> = 0.03, <i>I</i>^<i>2</i> = 70%) and BBS test scores (5 RCTs; <i>n</i> = 228; WMD = 4.20, 95%CI 1.25 to 7.16, <i>P</i> = 0.005, <i>I</i>^<i>2</i> = 47%). Compared with usual care, exergame training also induced significant improvements in balance [TUG (6 RCTs; <i>n</i> = 194): SMD=-0.80&#xa0;s, 95%CI -1.37 to -0.23&#xa0;s, <i>P</i> = 0.006, <i>I</i>^<i>2</i> = 70%; BBS (4 RCTs; <i>n</i> = 131): WMD = 5.48, 95%CI 4.46 to 6.50, <i>P</i> &lt; 0.00001, <i>I</i>^<i>2</i> = 0%]. However, there was no significant difference when compared with other types of exercise training (e.g., conventional balance training, multicomponent exercises, and routine activities), suggesting that exergame training exhibited comparable effects on balance with conventional physical training. Further subgroup analyses showed that higher training doses (≥ 9 weeks) were more likely to result in improvements in balance control. Additionally, care facility types and exergame systems served as moderators in the subgroup analyses. No study-related adverse events or fall incidents were reported. The RoB ranged from “some concerns” to “high”, whereas the CoE was very low.</p> Conclusion <p>Despite very low CoE, exergaming can be considered as a therapeutic modality adjuvant to already existing options to enhance the comprehensiveness of services provided in care facilities. Given that only a small number of studies are included in most of our analyses, further high-quality RCTs with larger samples of participants are urgently needed.</p> Funding <p>College Research Grant (CRG2023/01) and School Research Grant (2023-04-52-SRG230401) from Tung Wah College, Hong Kong SAR.</p> Protocol registration number <p>PROSPERO CRD42023469693.</p>