Move more, age well: prescribing physical activity for older adults

KEY POINTS

• Physical activity is a modifiable risk factor for more than 30 chronic conditions relevant to the older adult; 150 minutes per week of moderate physical activity can reduce all-cause mortality by 31% compared with no physical activity.

• Physical activity is one of the most important ways to preserve or improve functional independence, including among older adults who are frail or deemed to be at increased risk of falling.

• Higher levels of physical activity in older age are associated with improvements in cognition, mental health, and quality of life.

• Age, frailty, or existing functional impairments should not be viewed as an absolute contraindication to physical activity but, considering the benefits of physical activity interventions for older adults, a key reason to prescribe exercise.

Canada is poised to become a “super-aged” country in 2025, when at least 20% of the nation’s population will be aged 65 years and older; furthermore, over the next 2 decades the number of people in Canada aged 85 years and older is expected to triple.¹ People who survive to age 65 years are expected to live another 20 years on average; however, life expectancy gains have not corresponded with “compression of morbidity,” whereby extra years are largely lived in good health.² At least one-third of older adults in Canada live with 2 or more chronic conditions, and this rises to almost one-half after age 85 years.³

Physical activity is a modifiable risk factor for more than 30 chronic conditions relevant to the older adult (including coronary artery disease, heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, osteoporosis, depression, dementia, and cancer); regular physical activity can prevent these or reduce their severity and can improve functional independence. ⁴ Physical activity may act as an adjunct to treatment or, in some cases, obviate the need for medication or surgery⁴ and thus reduce polypharmacy.⁵ Further, at a health-system level, optimizing physical activity among older adults in the population may greatly reduce health care costs associated with treatment of preventable disease.⁶ Yet, physical activity remains underprescribed,⁷ and more than 80% of adults do not meet the recommendations of the Canadian Physical Activity Guidelines.⁸

The World Health Organization (WHO) recommends that older adults participate in 150–300 minutes of moderate-to-vigorous physical activity per week, along with resistance (strength) exercises 2 times per week and multicomponent exercises with a focus on balance 3 times per week.⁹ A 2015 systematic review found that even lower volumes of physical activity, between 83 and 166 minutes of moderate physical activity per week, are sufficient in reducing risks of morbidity and mortality in older adults by 22%.¹⁰

We review accumulated evidence related to health benefits of physical activity in older adults (Box 1) and discuss how and when to talk with patients about physical activity, as well as tools to make exercise prescription routine and useful. Definitions of terms are provided in Table 1.

Box 1: Evidence used in this review .

We searched the MEDLINE, Embase, and SPORTDiscus databases using keywords associated with a variety of conditions and adverse events (“cardiovascular disease,” “cancer,” “diabetes mellitus,” “falls,” “depression,” “mental health,” “frailty”), in conjunction with keywords for older adults (“older adults,” “elderly,” “geriatric”) and physical activity (“physical activity,” “exercise,” “fitness”). Two reviewers screened the search results. From these, only meta-analyses and systematic reviews were selected for inclusion.

Table 1:

Definitions of terms from the Canadian Society for Exercise Physiology¹¹

Term	Definition
Physical activity	Movements enacted through skeletal muscle contraction requiring energy expenditure, increasing heart rate and breathing
Exercise	A subset of physical activities involving planned, repetitive, structured, purposeful movements aimed at improving or maintaining a component or multiple components of physical fitness
Aerobic exercise	Exercise involving large muscle groups, resulting in substantial increases in heart rate and energy expenditure
Resistance exercise	Muscle strengthening exercises using body weight, resistance bands, weight machines, or hand-held weights
Balance exercise	Exercises designed to improve response to destabilizing stimuli or postural sway

How does physical activity affect the health of older adults?

The effects of physical activity for older adults are summarized in Figure 1.

Figure 1:

Benefits of physical activity in older adults.

Longevity

The association between physical activity and mortality and morbidity is well established. A 2023 meta-analysis of large prospective studies that examined dose–response found that physical activity levels equivalent to the recommended 150 minutes per week of moderate physical activity reduced all-cause mortality by 31% compared with no physical activity.¹² The authors used metabolic equivalent of task (MET), the ratio of work metabolic rate to resting metabolic rate. One MET is equivalent to the energy cost of sitting quietly. A 2019 systematic review and meta-analysis found that, among middle-aged and older adults (aged ≥ 40 yr), higher levels of total physical activity were associated with reduced risk of death in a dose–response relation, such that the most, second-most, and third-most active quartiles were associated with 0.47, 0.35, and 0.28 hazard ratios, respectively, compared with the least active quartile.¹³ According to a large 2019 observational study, resistance exercise is also associated with reduced mortality independent of aerobic exercise.¹⁴ Two 2022 meta-analyses found, respectively, that 60 minutes of resistance exercise per week is associated with a risk reduction of 27% in all-cause mortality¹⁵ and that muscle-strengthening activities for 30–60 minutes per week is associated with a 10%–20% reduction.¹⁶

Cardiorespiratory fitness and peak exercise capacity are associated with mortality. Peak exercise capacity is a better indicator of risk of death than established cardiovascular risk factors such as smoking, hypertension, and diabetes mellitus.¹⁷ A study examining cardiorespiratory fitness in older adults found dose-dependent reductions in mortality across all age groups (including participants aged 60–69, 70–79, and 80–95 yr).¹⁸ Substantial improvements (approximately 16%) in VO_2max (an individual’s maximum rate of oxygen consumption, a strong indicator of mortality¹⁹) in older adults can occur with only 90 minutes of submaximal exercise per week over 16–20 weeks.²⁰

Strength is also associated with reductions in all-cause mortality in older adults. A 2022 systematic review and meta-analysis found a linear inverse relation between handgrip strength and all-cause mortality up to sex-dependent thresholds (42 kg for men, 25 kg for women) in older adults.²¹ In their 2018 systematic review and meta-analysis, the authors found both handgrip and knee extension strength to be predictors of all-cause mortality in adults, with most of the studies examining adults older than 65 years.²²

Functional independence

Functional independence, which is the ability to perform one’s activities of daily living, encompasses cognition, social belonging, and quality of life. Physical activity is one of the most important ways to preserve or improve functional independence, including among older adults who are frail or deemed to be at increased risk of falling.²³ Physical activity and resistance training improve muscle strength and overall mobility and prevent frailty.^24,25 A 2012 meta-analysis involving frail older adults found that physical activity can result in improvements in gait speed, balance, and performance of activities of daily living.²⁶ According to a 2015 systematic literature review, dance can also improve muscular strength and endurance, balance, and other aspects of functional fitness in healthy older adults.²⁷

Prevention of falls

A 2014 survey of older adults in the United States found that 1 in 3 reported having fallen in a given year.²⁸ Falls can lead to restriction of activity, serious injury and hospital admission, and death. A 2016 systematic review and meta-analysis showed that exercise interventions and physical activity among older adults reduce falls by 21%,²⁹ with a 2021 meta-analysis of randomized controlled trials (RCTs) finding that integrated exercise programs of more than 5 times per week and duration of more than 32 weeks were most effective in reducing fall risk.³⁰ The mechanism of prevention is through improved muscle strength, bone density, and, importantly, balance and coordination.

A 2019 meta-analysis found that exercise can prevent falls and associated fractures in older adults with cardiometabolic and neurologic diseases,³¹ and a 2022 systematic review of RCTs showed that exercise interventions increased postural stability among patients with Alzheimer disease.³² Two 2021 meta-analyses of studies of exercise interventions among community-dwelling older adults with mild-to-moderate cognitive impairment showed less clear effect.^33,34

Looking at specific exercises, a 2021 meta-analysis showed that Pilates training among older adults moderately improves balance, strength, flexibility, and functionality, and shows a large pooled effect with respect to reducing risk of falls (effect size 0.90, 95% confidence interval [CI] 0.41 to 1.38).³⁵ Pilates training and other core-strength exercises are easy to administer in a group or individual setting where little equipment and space is available.

For those at a higher risk of falls, clinicians may consider unique exercise modalities and very gradual progression after careful assessment of risk.³⁶ Brisk-walking programs may be contraindicated in individuals at high risk of falls. A 2021 systematic review found that high-intensity interval training is generally safe (e.g., on a cycling ergometer) and well tolerated for fall prevention but may initially cause temporary instability, especially after the first session.³⁷ A 2008 systematic review showed that tai chi is effective for reducing rates and fear of falling. ³⁸ Multicomponent (aerobic, resistance, balance) training interventions are effective in nursing homes as well.³⁹

Bone and joint health

Physical activity has beneficial effects on joint health in older adults. One in 5 adults in Canada, and almost half of adults older than 65 years, lives with arthritis.⁴⁰ The pathogenesis of osteoarthritis remains incompletely characterized; physical activity was previously thought to be the primary cause of joint degeneration (joint overuse). A 2018 review of epidemiology and risk factors for osteoarthritis summarized evidence that its development is multifactorial, with inflammation, traumatic injury, and metabolic health also contributing; although very high levels of physical activity may increase the risk of osteoarthritis developing, moderate levels of physical activity do not.⁴¹ Regular exercise is a key element of management to reduce pain and improve physical function.

Physical activity also results in protective effects on bone health. To prevent osteopenia, a combination of resistance training, aerobic activity (high impact, weight-bearing, or both), and whole-body vibration, alone or in combination with exercise, may be effective.⁴² Physical activity along with nutrition and pharmacotherapy are key elements of the management strategy for fracture prevention and should be individualized.⁴³ Bone mineral density testing should follow osteoporosis screening guidelines.

Cognition

In 2020, 597 300 people were living with dementia in Canada, and this number will be closer to 1 million by 2030 and 1.7 million by 2050.⁴⁴ Physical activity benefits cognition through a variety of potential mechanisms, including growth factors and stress hormone signalling, reductions in inflammatory cytokines, and improved cerebrovascular health.⁴⁵

A 2021 analysis of 14 longitudinal studies of aging found higher levels of physical activity in older age to be associated with reduced risk of developing mild cognitive impairment and of mild dementia progressing to severe dementia, as well as increased rates of returning to mild from severe cognitive impairment, compared with low levels of physical activity.⁴⁶ Physical activity may be protective against dementia developing, including Alzheimer disease,⁴⁷ but evidence is mixed regarding the magnitude of effect.⁴⁸ Yoga-based interventions may improve cognition in otherwise healthy older adults,⁴⁹ though limited studies exist. A 2023 meta-analysis found that in older adults with mild cognitive impairment, aerobic exercise was most effective at improving cognitive function (effect size 0.79, 95% CI 0.35 to 1.23), followed by resistance exercise (effect size 0.67, 95% CI 0.22 to 1.12), while neuromotor (tai chi, qigong) (effect size 0.57, 95% CI −0.06 to 1.19) and multicomponent exercises (effect size 0.37, 95% CI −0.18 to 0.92) were not as effective.⁵⁰ A 2021 systematic review and meta-analysis found that exergaming interventions (technology-driven physical activities such as Wii Sports and virtual reality) have also been associated with improvements in cognition in older adults.⁵¹

For people living with comorbidities, cognitive impairment, or frailty, physical activity interventions, including seated exercise, may also offer cognitive benefits.^50,51 Exercise has been found to be particularly effective for individuals with both cognitive impairment and later-life depression.⁵² It is important to consider the level of cognitive impairment when selecting an appropriate exercise modality, intensity, and duration, and whether supervision is necessary.⁵³

Mental health

Regular physical activity and exercise can have positive effects on overall mental health and mood in older adults, particularly depressive symptoms.^54,55 Mechanisms may include reduced loneliness if exercising with others, as well as endorphin release.^45,56 A 2022 systematic review found that exergaming is associated with an improvement in depressive symptoms, with exergaming interventions of 6–12-weeks being associated with improvements in mood, self-esteem, and affect, as well as anxiety and depression.⁵⁷

With regard to older adults in long-term care institutions, an RCT and 2022 meta-analysis showed that activities such as yoga and functional activity with individual goal-setting, as well as chair-based resistance band exercises, are associated with reduced depression and anxiety.^58–60 Resistance and aerobic exercise are effective, particularly together.⁵³ Self-selection of exercise modality likely improves adherence.⁶⁰ Caution should be applied with individuals who are underweight with a diagnosed eating disorder.⁶¹

Quality of life

Recent systematic reviews and meta-analyses have found that physical activity and exercise are associated with improvements in overall quality of life among older adults,⁶² including those with Alzheimer disease or depression,^63,64 with a study showing that Nordic walking, also called pole walking, led to greater improvement in quality of life than resistance exercise.⁶⁵ Two 2021 meta-analyses underscored the effects of both outdoor exercise parks and aquatic exercise on improved quality of life, mood, anxiety, and other neuropsychological outcomes among older adults.^66,67 Tai chi has also been shown to be associated with a significant positive effect on quality of life in older adults.⁶⁸

How should physical activity be prescribed for older adults?

Duration, intensity, and type

World Health Organization guidance recommends 150–300 minutes weekly of moderate-to-vigorous physical activity for all adults, provided chronic conditions are stable and the person is physically well.⁹ Although older adults should be encouraged to follow this guidance, many may not be able to, particularly those with chronic conditions, those with physical impairments, or those who are sedentary; these older adults should be encouraged to progress gradually toward the WHO-recommended level of physical activity (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.231336/tab-related-content).

A target of 150–300 minutes of moderate intensity or 75–150 minutes of vigorous intensity aerobic physical activity as tolerated per week should be suggested for all but those with hypertension, for whom moderate intensity is more appropriate than vigorous activity. The choice of physical activity modality may depend on risk assessment and participant preference. Moderate-intensity physical activity is activity a participant would rate as 5 or 6 for effort on a scale of 0–10⁶⁹ or that leads to a heart rate increase to 64%–76% of the person’s maximum.⁷⁰ Vigorous-intensity physical activity would be rated at 7 or 8 on the effort scale or result in a heart rate increase to 95% of their maximum.⁷⁰

Muscle-strengthening exercise (e.g., resistance training) for all major muscle groups twice weekly as tolerated should be suggested. Resistance training should be individualized based on specific patient factors and available equipment (resistance bands, machines, free weights, body weight). General guidelines advise 2–3 sets of 1–2 exercises per major muscle group, performing 5–8 repetitions or achieving intensities of 50%–80% of their 1-repetition maximum. Training should be incorporated 2 times per week and guided by the principle of gradual progression.⁷

Strategies

The World Health Organization developed a 5-step framework (the “5As”) for the promotion of physical activity.⁹ In brief, this involves assessing the patient’s current physical activity level and assessing risks and contraindications; advising the patient on the specifics of physical activity (how much, what type, etc.) and the reduction of sedentary behaviour; agreeing on a physical activity goal informed by the patient’s individual preferences; assisting with support strategies (problem-solving common barriers to physical activity, such as time and financial commitment); and arranging a follow-up visit for reassessment. A supporting manual for implementing interventions for noncommunicable disease risk factors supports the 5As framework⁷¹ and provides a toolkit for promotion of physical activity specific to older adults.⁹

Home-based programs can be individually tailored and may be ideal for those reluctant or unable to attend group classes, although the latter provides more opportunity for supervision and socialization.⁷ Promoting mobility and physical activity remains especially important in long-term care settings where many residents are living with dementia or some degree of functional decline. Canada’s National Long-Term Care Services Standard recommends that a long-term care home’s physical environment offer space for group activities including mobility programs and exercise classes, access to nature and outdoor activities, and meaningful daily activities that contribute to satisfying residents’ physical needs.⁷²

In addition to aerobic activity, progressive resistance training improves muscle strength and functional performance for older adults living in long-term care homes, even for those who have chronic disease, sedentary habits, and functional disabilities.⁷³ Increasing leisure time physical activity or walking can improve physical function and body composition of frail older adults in long-term care settings.⁷⁴

A 2024 RCT⁷⁵ found that using interpersonal behaviour-change strategies (e.g., discussion of physical activity with peers) was effective at increasing physical activity levels in older adults at 1 week, 6 months, and 12 months after the intervention, compared with intrapersonal techniques (e.g., individual goal-setting and self-assessment) and compared with controls. Thus, integration of interpersonal strategies into exercise prescription may be an effective tool for improving adherence. Referral to a physiotherapist, exercise specialist, or other health professional may be appropriate for providing guidance for the older adult unfamiliar with exercise.⁷

Physicians and other health care practitioners face barriers to physical activity prescription; these include time constraints, lack of training, and lack of belief that patients will follow their advice.⁷ Considering inputting physical activity as a vital sign to follow over time, or employing eHealth tools during scheduled clinic visits, may assist with these barriers, and numerous initiatives exist to assist with training medical learners in prescribing physical activity.^76–79

Considering risks and adverse effects

Despite its considerable benefits, physical activity may put some individuals at risk of injury or may interfere with chronic disease management. Table 2 summarizes some general considerations for older adults with particular conditions, based on the Physical Activity Readiness Questionnaire⁸⁰ self-screening tool. Limitations on exercise volume in older adults hinges on individual pathologies, comorbidities, and exercise capacity.⁴ Sedentary but otherwise healthy older adults can progress toward WHO-recommended activity levels in a gradual manner. Individuals with bony metastases or low bone density are at increased risk of fractures,^81,82 which should be considered when deciding on exercise type and intensity. Whereas patient self-screening tools may suggest physical activity to be inappropriate, physicians should evaluate individual patients to determine absolute and relative contraindications to exercise (as outlined in Table 3).

Table 2:

Indications to seek further information before engaging in physical exercise, from the Physical Activity Readiness Questionnaire⁸⁰

Health condition	Important considerations before embarking on exercise
Arthritis, osteoporosis, or back problems	Difficulty controlling condition; joint problems causing pain; a recent, osteoporotic, or cancer-related fracture; displaced vertebra, spondylolysis
Cancer	Lung cancer, multiple myeloma, head or neck cancer, ongoing cancer treatment (e.g., chemotherapy or radiotherapy)
Cardiovascular disease (coronary artery disease, congestive heart failure, arrythmia)	Difficulty controlling condition, arrhythmia requiring medical management, chronic heart failure, coronary artery disease without regular exercise in previous 2 months
Hypertension	Difficulty controlling condition, resting systolic blood pressure > 160 mm Hg or diastolic blood pressure > 90 mm Hg
Metabolic condition (type 1 diabetes mellitus, type 2 diabetes mellitus, prediabetes)	Difficulty controlling blood glucose levels, hypoglycemic symptoms, diabetic neuropathy, vascular or cardiac complications, chronic kidney disease, liver disease
Respiratory disease (chronic obstructive pulmonary disease, asthma, pulmonary hypertension)	Difficulty controlling condition, low oxygen saturation at rest or exercise, supplemental oxygen, ongoing asthma symptoms, rescue medication use more than twice in previous week, pulmonary hypertension
Spinal cord injury (tetraplegia, paraplegia)	Symptomatic hypotension, autonomic dysreflexia
History of stroke (or transient ischemic attack or other cerebrovascular event)	Mobility impairment, nerve or muscle impairment in previous 6 months, stroke in previous 6 months
Other medical conditions	Ongoing respiratory infection or fever, head injury with loss of consciousness in previous 12 months, epilepsy, other neurologic conditions, other kidney conditions, 2 or more current medical conditions

Table 3:

Considerations and contraindications to physical activity for different medical conditions, with examples of investigations to guide interventions

Condition	Considerations	Practical example	Contraindications	Appropriate investigations
Cardiovascular disease	Higher-intensity exercise places high demands on the heart.	About 30 min stationary cycling (RPE 5/10), 5 times/wk	Absolute: unstable angina, uncontrolled arrhythmia, recent and debilitating symptom onset83 Relative: arrhythmia in the presence of hypoglycemia and/or dehydration83	In the presence of cardiac risk factors, stress testing to guide intensity and volume of exercise prescription
Cancer	Sequelae of specific cancers (e.g., anemia, thrombocytopenia, paraneoplastic syndrome, pathologic fracture) should guide modality, intensity, and volume.	About 40 min aquafit (RPE 5/10), 4 times/wk	Absolute: undergoing active chemo- or radiotherapy with low leukocyte count, hemoglobin, or thrombocyte count; fever or febrile neutropenia;4 exercises that place high loads on bone with metastases, or that place high demand on musculature that attaches at the site of bony metastases82 Relative: seek oncology team clearance in setting of thrombocytopenia, neutropenia, or low hemoglobin84	Specific to cancer type; blood tests to rule out low leukocyte count, hemoglobin, or thrombocyte count; febrile neutropenia; imaging as needed to rule out bone or other metastases
Type 2 diabetes mellitus	Autonomic neuropathy may contribute to hypotension at high exercise intensities. Retinal and renal complications may warrant reductions in intensity. Balance training exercise may reduce peripheral neuropathy–associated risk of falling.85	About 30 min of brisk walking (RPE 5/10), 5 times/wk	Absolute: high risk of hypoglycemia, unstable or untreated proliferative retinopathy, recent eye surgery85 Relative: autonomic neuropathy, chronic kidney disease85	Routine investigations to assess severity and response to exercise
Hypertension	Exercise at 90%–100% of VO2max should be avoided in patients with hypertension, as well as very intense strength training.84 Overhead and isometric exercises* raise blood pressure and should be used with caution.	About 40 min brisk walking (RPE 5/10), 4 times/wk	Absolute: systolic blood pressure > 200 mm Hg, diastolic blood pressure > 115 mm Hg84 Relative: systolic blood pressure > 180 mm Hg and diastolic blood pressure > 105 mm Hg without pharmacologic treatment84	Routine investigations to assess severity and response to exercise; blood pressure measurement during exercise
Chronic obstructive pulmonary disease	Intensity and duration should allow saturation to remain in an appropriate range.84	About 20 min high intensity interval cycling (2 min at 80% HRmax, 2 min rest, 5 times)	Absolute: uncontrolled heart failure, syncope, respiratory failure, oxygen saturation ≤ 85% at rest84 Relative: hypertrophic cardiomyopathy, severe pulmonary hypertension84	Functional testing including oxygen saturation before exercise prescription84
Frailty	Exercise modality selection should consider associated fall and fracture risk. Exercise should be introduced gradually for previously sedentary individuals.4	Multicomponent exercise for 30–45 min, 3 times/wk Exercise using resistance bands an effective alternative to the use of body weight or machines4	No specific contraindications	Fracture risk established via radiographic imaging and bone mineral density testing as indicated
Osteoarthritis	Excessive joint loading with pain should be avoided, and modalities that minimize injury risk are preferable.41,84 Aquatic exercises, tai chi, and yoga are associated with reduced pain and improved physical function.86	About 40 min of swimming/aquafit (RPE 5/10), 4 times/wk Nordic walking (i.e., with walking poles) an optimal choice for people with hip osteoarthritis,65 with moderate loading on weight-bearing joints87	Relative: Generalized osteoarthritis, fibromyalgia84	Routine imaging
Osteoporosis	Consider fracture risk when prescribing exercise. The safety of impact exercises (running, vertical jumping) in individuals with high fracture risk is unclear.43	Balance training (catching and throwing a ball, standing on 1 foot, shifting body weight) and functional training (chair stands, stair climbing) 2 times/wk43 Resistance training targeting back extensors (inclined hyperextensions, bird dogs) and abdominal muscles (front plank, side plank), 2 times/wk43	Relative: safety or efficacy of impact exercise uncertain in people at high fracture risk	Bone mineral density according to osteoporosis screening guidelines

Note: HR_max = maximum heart rate, RPE = rate of perceived exertion, VO_2max = maximum oxygen uptake.

^*Isometric exercise involves static contraction of a muscle without any visible movement in the angle of the joint.

Conclusion

Physical activity is underused as a health intervention both in the community and in the delivery of health care for older adults. Age, frailty, or existing functional impairments should not be viewed as absolute contraindications to physical activity but rather key reasons to prescribe it, considering the benefits of physical activity interventions for older adults. Older adults who become more physically active can potentially add years to their lives as well as higher quality of life to those years.