Exercise in the Elderly — Beneficial or Harmful?

"There is no age above which physical activity ceases to have benefits across a wide range of diseases and disabilities." Exercise is feasible in nursing home residents up to 101 years of age and in hip fracture patients within 12 weeks of surgery.

"Insufficient physical activity and excess sedentary behaviour are lethal conditions; physical activity is the antidote." Sedentary behaviour is a potent risk factor for all-cause and cardiovascular mortality, obesity, sarcopenia, hypertension, insulin resistance, diabetes, stroke, colon cancer, depression, dementia, osteoarthritis, osteoporosis, recurrent falls, frailty and disability.

Ageing and disuse produce nearly identical physiological changes — much of what is attributed to chronological age is in fact deconditioning.

Habitual physical activity increases average life expectancy by about two years.

Exercise reduces cardiovascular disease risk by about 50%, even after controlling for smoking, obesity, hypertension and dyslipidaemia.

It is never too late: sedentary middle-aged adults with low fitness who became fit at follow-up had markedly reduced cardiovascular mortality — "preventive exercise prescriptions instituted in middle age or beyond may be as important as those initiated at younger ages."

Body composition: exercise prevents the decreases in muscle mass and bone density and the increase in central adiposity. A 5% fall in total body fat can produce a 25% or greater reduction in visceral fat.

Sarcopenia: high-intensity resistance training is the optimal prescription, and — less well known — it improves aerobic capacity as much as moderate-intensity aerobic training, addressing both major deficits with one prescription.

Frailty: a 12-week multicomponent programme with explosive resistance training in institutionalised frail nonagenarians improved muscle cross-sectional area, muscle fat infiltration, maximal strength, power output, balance, gait and sit-to-stand ability, with a reduction in falls. Frailty is not a contraindication to robust exercise — it is one of the strongest indications for it.

Depression: high-intensity aerobic exercise is equipotent with antidepressants in older adults with major depression. High-intensity progressive resistance training produced a 61% clinical response, versus 29% with low-intensity training and 21% with GP care (equivalent to placebo).

Cognition: high-intensity resistance training is the most promising modality, particularly in mild cognitive impairment; four months of low-intensity high-speed resistance training improved both cognition and physical performance in MCI.

Fracture prevention: in the EPIDOS study of 6901 women over 75, low physical activity more than doubled the risk of proximal humerus fracture (RR 2.2) — a greater risk than low bone density (RR 1.4), maternal history of hip fracture (RR 1.8) or impaired balance (RR 1.8).

Hospital and institutional settings: exercise reduces functional decline in very elderly patients during acute hospitalisation and improves cognition; triceps strength is critical to transfer ability, and improving it reduces nursing home admission after hip fracture. The VIVIFRAIL programme protected institutionalised older adults from severe functional decline through 14 weeks of COVID confinement.

Randomised trial evidence exists for exercise in the prevention of secondary cardiovascular events, diabetes mellitus and osteoporotic fracture. Part B — The Case for Harm (where marks are actually won)

WRONG MODALITY IS HARMFUL. "Falls-prevention programmes inclusive of walking are inferior to those focusing on strength and balance exercises and have also been associated with increases in osteoporotic fracture rates in those at risk." Walking is not a falls-prevention intervention.

WRONG SEQUENCE IS HARMFUL. "Prescribing progressive aerobic training in the absence of sufficient balance or strength is likely to result in knee pain, fear of falling, falls, fractures, and limited ability to progress aerobically — and is not recommended."

Musculoskeletal injury with power training: risk of injury to tendons and cartilage, particularly the rotator cuff and knee where degenerative tears are commonplace, and exacerbation of abdominal or inguinal hernias. Avoid heavy repetitive workloads and unfavourable positioning such as overhead or military press in rotator cuff disease.

BUT the measured risk is very small: a systematic review of resistance training in frail older adults reported only ONE case of shoulder pain across 20 studies and 2544 subjects.

HIIT is unproven in the frail: high-intensity interval training (85–95% peak heart rate for 1–4 minutes) has been studied mainly in healthy and cardiovascular cohorts; its feasibility in frail older adults with multiple comorbidities remains to be established.

Low-intensity exercise is not "safer" — it is ineffective, which is its own harm. Low-intensity resistance training is ineffective in peripheral vascular disease; low-intensity aerobic training in depression is no better than social contact; and there is no evidence of benefit for low-intensity, minimally progressive multimodal exercise for cognitive outcomes.

Uncertain benefit in care homes: a Cochrane meta-analysis concluded the evidence is uncertain regarding the effect of exercise, medication review or multifactorial interventions on fall rates in care homes.

Non-responders exist: there is significant inter-individual variability in response to exercise, including adverse metabolic responses in a minority.

Acute illness requires caution: in hospitalised patients, "it is crucial to pay special attention to clinical vital signs before performing the physical exercise intervention, to prevent adverse events." Part C — How to Prescribe Safely (Pathy's Table 7.9)

World Falls Guidelines — exercise stratified by risk. The 2022 WFG classify an older adult with no fall history, or a single non-severe fall without gait or balance problems, as low risk — needing primary prevention and annual reassessment. Those with a single non-severe fall plus gait or balance problems are intermediate risk and benefit from a strength and balance exercise intervention. High risk includes those with a fall plus any of: accompanying injury, two or more falls in 12 months, known frailty, inability to get up for at least an hour, or suspected transient loss of consciousness. Developed by 96 multidisciplinary experts from 39 countries. (Age and Ageing 2022)

AGS endorsement and additions (2024). The AGS response to the WFG endorsed several additions to the earlier AGS/BGS guideline: assessment and intervention for hearing impairment and concern about falling, assessment and individualised exercises for older adults with cognitive impairment, and performing a standardised assessment such as STOPPFall before prescribing a medication that could increase fall risk. (JAGS 2024)

Global exercise recommendations for longevity (Izquierdo 2024). Comprehensive global recommendations developed through an international consensus process from the ICFSR. Because programmes should be individualised, they form part of the evolving discipline of precision medicine; recommendations include structured exercise supplemented by incidental lifestyle activity, and strongly support multicomponent interventions extending beyond aerobic exercise. (J Nutr Health Aging 2025)

Resistance training and mobility disability. A meta-analysis of 24 articles from 22 studies (3,656 participants, mean age 63–87) found resistance training produced greater improvements than control in 6-minute walk distance (+16.1 m), lower extremity strength, and usual gait speed (+0.05 m/s) — results held whether resistance training was the sole intervention or part of a multicomponent programme.

Falls prevention in aged care — where evidence remains weakest. WHO guidelines recommend all older adults undertake physical activity for falls prevention and other benefits including reduced mortality and improved cardiovascular, mental and cognitive health — but trial endpoint meta-analyses in long-term residential aged care continue to show this is the setting where evidence is least certain, consistent with the textbook position. (Age and Ageing 2023)

"Frailty is not a contraindication to robust exercise — it is one of the most important reasons to prescribe it."

"Falls-prevention programmes based on walking are inferior to strength-and-balance programmes and have been associated with increased fracture rates in those at risk."

"It is not ethical to withhold exercise from frail older adults — that is doing harm by withholding effective treatment."