The Gerontologist

cite as: Gerontologist, 2016, Vol. 56, No. S2, S268–S280

doi:10.1093/geront/gnw031

Literature Review

Updating the Evidence for Physical Activity: Summative

Reviews of the Epidemiological Evidence, Prevalence, and

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Interventions to Promote “Active Aging”
Adrian Bauman, MD, MPH, PhD,1,* Dafna Merom, PhD,2 Fiona C. Bull, PhD,3
David M. Buchner, MD, MPH,4 and Maria A. Fiatarone Singh, MD5
1
School of Public Health, Sydney University, New South Wales, Australia. 2School of Science and Health, Western Sydney
University, New South Wales, Australia. 3Centre for Built Environment and Health, The University of Western Australia,
Perth, Australia. 4Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign. 5Exercise,
Health and Performance, Faculty of Health Sciences, Sydney University, New South Wales, Australia.
*Address correspondence to Adrian Bauman, MD, MPH, PhD, School of Public Health, Level 6, Charles Perkins Centre, D17, Sydney University,
NSW 2006, Australia. E-mail: adrian.bauman@sydney.edu.au

Received July 1, 2015; Accepted January 12, 2016

Decision Editor: Catherine d'Arcangues, PhD, MD

Abstract
Purpose of the Study: There is a global imperative to increase awareness of the emerging evidence on physical activity
(PA) among older adults. “Healthy aging” has traditionally focused on preventing chronic disease, but greater efforts are
required to reduce frailty and dependency and to maintain independent physical and cognitive function and mental health
and well-being.
Design and Methods: This integrated review updates the epidemiological data on PA, summarizes the existing evidence-
based PA guidelines, describes the global magnitude of inactivity, and finally describes the rationale for action. The first
section updates the epidemiological evidence for reduced cardiometabolic risk, reduced risks of falls, the burgeoning new
evidence on improved cognitive function and functional capacity, and reduced risk of depression, anxiety, and dementia.
This is followed by a summary of population prevalence studies among older adults. Finally, we present a “review of
reviews” of PA interventions delivered from community or population settings, followed by a consideration of interventions
among the “oldest-old,” where efforts are needed to increase resistance (strength) training and balance.
Results: This review identifies the global importance of considering “active aging” beyond the established benefits attrib-
uted to noncommunicable disease prevention alone.
Implications: Innovative population-level efforts are required to address physical inactivity, prevent loss of muscle strength,
and maintain balance in older adults. Specific investment in healthy aging requires global policy support from the World
Health Organization and is implemented at the national and regional levels, in order to reduce the burden of disease and
disability among older adults.
Key Words: Physical activity, Older adults, Evidence, Integrated review

The global increase in the aging population places increased will double to around two billion by 2050 (World Health
pressures on health systems and services for older adults. Organization [WHO], 2015). Of these older adults, 80% of
Demographic trends over the next three decades project the increase will occur in low-middle income countries (WHO,
that the global numbers of adults aged 65 years and older 2015). Furthermore, life expectancy is increasing at a similar

© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. S268
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The Gerontologist, 2016, Vol. 56, No. S2 S269

rate in less developed countries, and by 2050, the global num- provides an update of the health consequences of inactiv-
bers of adults aged 80 years and older will be 268 million in ity in older adults, with an increased emphasis on muscle
less developed countries, compared with 124 million in devel- strengthening and balance training. We then summarize PA
oped countries (United Nations Department of Economic and prevalence in old age and integrate epidemiological evi-
Social Affairs, Population Division, 2013). These demographic dence and prevalence data, which support the PA guidelines
trends will have an impact on resources to manage the result- (PAGs). Finally, we review the evidence on the effectiveness
ant increase in chronic disease, treat falls-related injuries, and of community-based and clinical interventions to increase
manage the costs of caring for older adults. One of the most activity among older adults and, as a special group, in the
important approaches to delay the morbidity associated with frail elderly adults. In general, systematic reviews were
aging is to increase physical activity (PA) among older people. used in all sections of this article, with reviews of existing
The concept of Active Aging is more than a decade old reviews or de novo summaries developed to support the
(Kalache, Aboderin, & Hoskins, 2002), and although it is role of PA in healthy aging.

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well established in the policy framework in some countries, it The overall aim of this article is to update the rationale
remains less well implemented in many nations. It describes for increasing PA for all older adults, from a practitioner
the processes of “healthy aging,” resulting in reduced rates and policy perspective, and to provide new guidance on
of chronic disease, more productive older years, and greater benefits of PA and on the types of PA required for health.
cognitive and functional capacities to carry out tasks and to
participate and enjoy social and cultural life (WHO, 2002).
Among the behavioral and lifestyle factors, PA is the most
The Range of Benefits of PA in Older Adults
important determinant of “active aging” and has a major role Epidemiological evidence is used to characterize the health
in improving the quality of life, in reducing disability, and in consequences of physical inactivity for population health.
the “compression of morbidity” in later life (Crimmins, 2015; Overall, physical inactivity is the fourth leading risk factor
Kalache et al., 2002). For older adults, PA includes large mus- contributing to deaths and the burden of disease globally
cle “aerobic activities,” such as walking, cycling, and many ranking ahead of overweight or obesity (Lee et al., 2012).
recreational activities and sports. In addition, important A summary of the range of health benefits specifically for
dimensions of PA include muscle strength and balance train- older adults is shown in Figure 1, which includes effects on
ing, which also have a major role in health promotion and improving functional status, psychological status and well-
disease prevention in older adults (Garber et al., 2011). being, and social benefits, as reviewed in the U. S. distilla-
As a component of both primary and tertiary preven- tion of evidence for the health benefits of PA (U.S. Health
tion, PA is an important component of the World Report and Human Services, 2008). The epidemiological evidence
on Ageing and Health 2015 (WHO, 2015). This article for these benefits has accumulated over several decades,

Figure 1. A conceptual framework for the benefits of physical activity in older adults. *Reported as “strong” epidemiological evidence, U.S.
Department of Health and Human Services. 2008 Physical Activity Guidelines Advisory Report. Retrieved from http://www.health.gov/paguidelines/
guidelines
S270 The Gerontologist, 2016, Vol. 56, No. S2

with the newest evidence focusing on neurological health as increasing PA may contribute to healthy biological and
and psychosocial and mental well-being. functional aging (Chodzko-Zajko et al., 2009).
The general population evidence on PA benefits for Emerging evidence suggests that PA can improve cogni-
reducing all-cause mortality risk, preventing cardiovascular tion in people without dementia, reduce the incidence of
disease and diabetes, and evidence on benefits on lipid lev- dementia, and improve health among people with existing
els, hypertension and reducing the risks of breast and colon dementia (Angevaren, Aufdemkampe, Verhaar, Aleman, &
cancer, also apply to older adults (Batty, 2002; Chodzko- Vanhees, 2008; Blondell, Hammersley-Mather, & Veerman,
Zajko et al., 2009; Vogel et al., 2009). Some initial meta- 2014; Sofi et al., 2011). There is increasing evidence from
analytic evidence suggests that protective benefits accrue for epidemiological and clinical studies that PA can improve
older adults at levels of PA well below current recommenda- cognitive function (Paterson & Warburton, 2010); further,
tions (Hupin et al., 2015), but this needs further examina- this evidence is biologically plausible, given evidence of
tion in those with and without comorbidity. Further, there cognitive function improvement and neuroplasticity from

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is evidence that muscle strength and resistance training may exercise animal studies, and preliminary evidence of the
also contribute to noncommunicable disease (NCD) preven- biochemical mechanisms and pathways (Ahlskog, Geda,
tion, for example through glycemic control, independent of Graff-Radford, & Petersen, 2011; Bherer, 2015; Blondell
aerobic activities (Chodzko-Zajko et al., 2009). et al., 2014; Sofi et al., 2011). Additionally, low muscle
PA reduces the risk of developing stroke in older adults mass and muscle strength have each been linked to cogni-
of differing age groups and diverse populations (Goldstein tive impairment or dementia and brain atrophy in cross-sec-
et al., 2006; Wannamethee & Shaper, 2014). Two meta- tional (Burns, Johnson, Watts, Swerdlow, & Brooks, 2010)
analyses estimated that the relative risk reduction for all and prospective cohort studies (Boyle, Buchman, Wilson,
forms of stroke was 11%–15% for moderate PA (Diep, Leurgans, & Bennett, 2009). Clinical trials of both aerobic
Kwagyan, Kurantsin-Mills, Weir, & Jayam-Trouth, 2010; and resistance training show positive effects on executive
Wendel-Vos et al., 2004) and 19%–22% for vigorous PA; function, attention, and processing speed, with inconsistent
this relationship was stronger for men, with only vigor- evidence for memory and other domains (Scherder et al.,
ous activity being protective among women (Diep et al., 2014). Further, among those who exercise, there is clini-
2010). The benefits of moderate-intensity aerobic activ- cal and neuroimaging evidence of larger hippocampal vol-
ity are well established in the prevention of type 2 dia- umes (Erickson et al., 2011), better cerebrovascular flow,
betes, blood pressure, and other cardiometabolic diseases and better performance of functional MRI-defined cogni-
(Chodzko-Zajko et al., 2009). Emerging evidence now tive tasks (Ahlskog et al., 2011). More recently, it has been
supports similar benefits for muscle strength training, noted that motor fitness (e.g., movement speed, balance,
especially in maintaining or increasing muscle mass, which and motor co-ordination) is also associated with cognitive
attenuates the metabolic and functional consequences of performance but differentially related to cognitive pro-
muscle loss with aging, known as sarcopenia (Grøntved, cesses than physical measures of fitness (Voelcker-Rehage,
Rimm, Willett, Andersen, & Hu 2012; Grøntved et al., Godde, & Staudinger, 2011).
2014). Recent reviews point to a 28% reduced risk of devel-
One review (De Rezende, Rey-López, Matsudo, & do oping dementia among the physically active older adults
Carmo Luiz, 2014) has examined the separate behavior (Ahlskog et al., 2011; Blondell et al., 2014). It appears
of prolonged sitting time, a sedentary behavior independ- that physical inactivity is the most important preventable
ent of PA, among adults aged 60 and older and noted an risk factor for Alzheimer’s dementia, with the population-
increased association with all-cause mortality, metabolic attributable fraction estimated to be around 20% (Norton,
syndrome, and waist circumference. “Too much sitting” Matthews, Barnes, Yaffe, & Brayne, 2014). This implies
may add to the risk of NCD posed by low PA, but as this that approximately 10 million new cases of Alzheimer’s
is a new area of epidemiology, the evidence base remains dementia could be prevented each year globally if older
limited, particularly among older adults. adults met PA recommendations (Norton et al., 2014).
PA is associated with biomarkers of aging; active older For tertiary prevention evidence, 16 trials show improve-
adults show less telomere (end chromosomal) shortening ments in physical function among people with Alzheimer’s
and fragmentation, compared with their inactive counter- disease who are prescribed exercise (Blankevoort et al.,
parts, even in twin studies (Kaliman et al., 2011; Ludlow 2010). Other neurological conditions, including the risk
et al., 2008). This suggests that active adults may have of developing Parkinson’s disease, are typically 20%–30%
reduced oxidative stress, or positive epigenetic changes lower among older adults who are physically active (Chen,
induced by PA (Kaliman et al., 2011). A recent randomized Zhang, Schwarzschild, Heman, & Ascherio, 2005; Thacker
controlled trial (RCT) suggested that this might be attrib- et al., 2008); again, tertiary prevention trials have shown
utable to reduced sitting time, instead of only increased benefits of exercise interventions for people with estab-
PA (Sjögren et al., 2014). Although this study involved a lished Parkinson’s disease, with benefits to strength (Lima,
very small sample and hence may be subject to random Scianni, & Rodrigues-de-Paula, 2013), walking, motor
error, it suggests that reducing sedentary behavior as well control, and balance (Shu et al., 2014).
The Gerontologist, 2016, Vol. 56, No. S2 S271

Maintaining functional status is an important part of Hughes, Linck, Russell, & Woods, 2010). Higher intensity
active aging and reducing age-related morbidity; it facili- resistance training is also effective in reducing depression
tates independent living, improves quality of life, and symptoms (Chodzko-Zajko et al., 2009). For the less well-
reduces health care costs (Chodzko-Zajko et al., 2009; defined measure of “well-being,” intervention evidence
Nelson et al., 2007). A systematic review concluded that PA is less clear (Windle, 2014; Windle et al., 2010). There is
reduces the age-related decline in functional capacity and some evidence for social benefits of PA, but confined to
maintains muscle strength and mass among adults aged individual measures of confidence, mastery, and self-esteem
65–85 years (Paterson & Warburton, 2010). A 50% reduc- and to reported social interaction, reduced isolation, and
tion in the relative risk of developing functional limitations increased community engagement (McAuley et al., 2000).
or disability was reported among those participating in The limited literature does suggest the possibility of a
moderate-intensity PA (Paterson & Warburton, 2010, Tak, bidirectional relationship between PA and both social net-
Kuiper, Chorus, & Hopman-Rock, 2013). Among older works and relationships, as well as social capital (McNeill,

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groups (aged 70–75 years), functional status may be pre- Kreuter, & Subramanian, 2006), with active older adults
served with even lower amounts of PA. It remains less clear more engaged in their communities, but conversely, well-
whether progressive resistance training alone can influence integrated communities also fostering PA.
functional performance, although the Cochrane collabo-
ration review reported significant independent effects of
resistance training on strength and on capacity to perform Physical Activity Guidelines: What
activities of daily living (Liu & Latham, 2009). Related to Proportion of Older Adults Is Meeting Them?
these outcomes, there are consistent associations between PAGs (or recommendations) distil the epidemiological evi-
PA and quality of life or vitality measures in older adults dence into behavioral guidance for professionals and for
(Klavestrand & Vingård, 2009; Motl & McAuley, 2010), the general population. In 2010, the WHO released PAGs
but findings were stronger in cross-sectional than in longi- for adults aged 65 years and older. The guidelines com-
tudinal studies, with too few interventions to clearly assess prised specific recommendations for strength and balance
whether the associations are causal (Voukelatos et al., or flexibility, as well as for aerobic (large muscle) activ-
2015). ity throughout the week (Table 1). There are slight differ-
A major source of morbidity and health costs among ences in country-specific interpretations of the PAGs for
older adults is the increased rate of falls, injuries, and older adults, which are shown in the right hand column of
fractures. The primary risk factors for falls, including Table 1. Differences include mention of prolonged sitting
osteopenia, poor balance, and muscle weakness, are all time (UK only), omission of the “10-minute threshold” for
modifiable by appropriate exercise (Chodzko-Zajko et al., health-enhancing activity (Australia), and slight differences
2009). Targeted interventions to improve balance and mus- in the interpretation of 150 minutes/week of activity. The
cle strength can reduce falls risk (Howe, Rochester, Neil, global PAGs are designed to provide global guidance for
Skelton, & Ballinger, 2011). There is consistent controlled all older adults in all countries; some adaptation may be
trial evidence that structured exercise programs reduce required for special populations, such as for older adults
rates of falls. Multicomponent community-based trials with specific disabilities or with specific chronic health
show a 29%–32% reduced risk of falls (Gillespie et al., problems (WHO, 2010a).
2012; McClure et al., 2005) and a 66% reduced risk of National or regional PA surveillance systems are used to
falls-related fracture. By contrast, the evidence for falls pre- monitor the proportion of adults meeting the recommended
vention for people in hospital and in health care settings amounts of PA for health. Usually self-report questions are
is less clear for PA and exercise programs (Cameron et al., asked in surveillance, as different objective measurement
2012). It is important to note that isolated walking inter- instruments provide different population estimates and
ventions have no clear benefits in falls prevention. By con- still remain to be standardized for surveillance (Pedišić &
trast, as a single activity, tai chi was found to be efficacious Bauman 2015). There are infrequent cross-national moni-
in falls prevention (Howe et al., 2011). Weight bearing toring surveys of reported PA to compare proportion of
aerobic, high impact and resistance training can improve older adults meeting the PA levels recommended for health.
bone mineralization, resulting in maintained or improved For this review, two such international surveys were ana-
bone density in older women (Chodzko-Zajko et al., 2009; lyzed, the World Health Survey (WHS, 2002) collected in
Howe et al., 2011) to prevent osteoporosis and falls-related around 70 countries between 2002 and 2004 and the Study
injuries. on Global AGEing and adult health (SAGE, 2007–2010
Mental health and social benefits among older adults [WHO, 2010b]) survey in major transitional countries. The
are attributed to PA. There is some evidence that aerobic country estimates for people meeting the 150 minutes/week
PA can reduce symptoms of depression and possibly reduce guideline were examined for older adults, and the median
anxiety and improve mental health among older adults estimates of “meeting the PAGs” for the 70 countries in the
(Bridle, Spanjers, Patel, Atherton, & Lamb, 2012; Netz, WHS are shown in Table 2. There are substantial increases
Wu, Becker, & Tenebaum, 2005; Windle, 2014; Windle, in the proportions not meeting the PAGs after age 60, with
S272 The Gerontologist, 2016, Vol. 56, No. S2

Table 1. Physical Activity Guidelines (PAGs) for Older Adults (65 Years and Older), WHO 2010a

WHO PAGs 2010 for adults 65 years and older Reflection on the recommendations in the UK, Canadian,
and Australian PAGs for older adults 2011–2013

Total volume of PA for older adults Was described as 30 min/day (most days in AUS; revised to
 Older adults should do (a total of) at least 150 min of 150 min/week in 2014)
moderate-intensity aerobic PA per week or do ≥75 minutes of Described as 150 min/week (UK, CAN) or in equivalent
vigorous-intensity aerobic PA or an equivalent combination of combinations of moderate and vigorous minutes/week
moderate- and vigorous-intensity activity
Minimum duration of activity No longer any mention of 10-min minimum (AUS)
 Aerobic activity should be performed in sessions of at least Mention minimum bout length, 10 min (CAN, UK)
10-min duration
Upper limit—How much additional activity confers benefit? Carry on vigorous activity if lifelong (provided risks are

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 For additional health benefits, older adults can increase their considered; AUS)
activity to 300 min per week, or engage in 150 min of vigorous-intensity More PA provides greater benefits (CAN)
aerobic PA per week, or an equivalent combination of moderate- and Should minimize time spent in prolonged sitting (UK); generic
vigorous-intensity activity recommendation
Falls prevention activity Older adults should do a range of PA including fitness,
 PA to enhance balance on 3 or more days per week. Muscle- strength, balance, and flexibility (AUS)
strengthening activities, involving major muscle groups, should Those with poor mobility should do balance training to
be done on 2 or more days a week. prevent falls (CAN)
At risk of falls, balance exercise two times/week (UK)
Add muscle and bone strengthening 2 days/week (CAN, UK)
Activity for older adults with chronic disease Start with any amount if inactive or have health problems
 When older adults are limited in their PA due to health conditions, (reflected in all guidelines; UK, AUS)
they should be as physically active as their abilities and conditions allow

Notes. Adapted from WHO, 2010a. Retrieved December 2014, from www.who.int/dietphysicalactivity/factsheet_olderadults/en/
With input from (i) the Canadian PAGs 2010 (Public Health Agency of Canada, 2011; Warburton, Charlesworth, Ivey, Nettlefold, & Bredin 2010). Retrieved from
http://www.csep.ca/CMFiles/Guidelines/CSEP_Guidelines_Handbook.pdf). (ii) the UK Stay Active report 2011. Retrieved from http://www.nhs.uk/Livewell/fit-
ness/Documents/older-adults-65-years.pdf; and (iii) the Australian older adult PAGs 2014. Retrieved January 2015, from http://www.health.gov.au/internet/main/
publishing.nsf/Content/phd-physical-rec-older-guidelines
PA = physical activity; PAG = physical activity guideline.

Table 2. Data From the World Health and SAGE Surveys, Median Prevalence of Not Meeting the Minimum Aerobic PAGs by
Age Group

Age group (years)

18–29 30–44 45–59 60–69 70–79 Older than 80

World Health Surveya not meeting PAGs (%)

Males, median prevalencea 7.0 8.8 8.6 18.8 29.5 42.1
Females, median prevalence 12.3 10.7 14.0 24.5 38.4 54.6
SAGE surveysb, not meeting PAGs (%)
Males, median prevalence 9.2 12.8 17.7 21.9 34.4 51.1
Females, median prevalence 22.8 19.5 17.5 23.4 36.4 58.9

Notes. Bold values represent data of older adults.

PAG = physical activity guideline; SAGE = Study on Global Ageing and Adult Health
a
World Health Survey median prevalence by age group from the n = 70 participating countries.
b
SAGE countries: China, Ghana, India, Mexico, Russia, South Africa (WHO, 2010b).

marked increases after age 80 years, where nearly half the the guidelines, so that this may over-report true levels of
populations did not meet the minimal threshold for health. activity; however, relative differences by age group are
The WHS used the generic International Physical Activity likely to be valid. Similar increases in the median estimates
Questionnaire (IPAQ) short measure (Craig et al., 2003), of the proportions not meeting the guidelines with increas-
which allows all domains of self-report activity work, lei- ing age are seen in the five-country SAGE survey. The pol-
sure, transport, and domestic PA to be included to reach icy implications of these data are that inactivity increases
The Gerontologist, 2016, Vol. 56, No. S2 S273

substantially with age across countries, based on “aerobic systematic reviews that focused on settings such as pri-
activity” measures. mary care interventions (Neidrick, Fick, & Loeb, 2012) or
A recent systematic review examined sedentary behav- home-based versus center-based interventions (Ashworth,
iors in older adults and reviewed data from 22 studies Chad, Harrison, Reeder, & Marshall, 2005) and five narra-
(Harvey, Chastin, & Skelton, 2015). This review noted the tive reviews, for example, traditional and recent approach
consistent increase in sedentary time with increasing age, to promote balance (Granacher, Muehlbauer, Zahner,
even when considering those with and without comorbid- Gollhofer, & Kressig, 2011). The reviews were summarized
ity, with sitting time averaging 9+ hours/day among older by their scope, inclusion criteria and age of population, set-
adults. This suggests the need to consider reducing seden- ting, the PA target of the intervention or approaches, if tar-
tary time, alongside efforts to increase PA. get was not specified, and their effectiveness. When reviews
A key challenge in the area of surveillance is the omis- included interventions that deliver to younger populations
sion of major dimensions of PA related to strength training (younger than 65 years), we summarized only those that

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and balance. These are rarely assessed in monitoring sur- delivered to older groups, when possible (King, Rejeski, &
veys, and when they are, show much lower rates of meeting Buchner, 1998; van der Bij, Laurant, & Wensing, 2002). Six
the guidelines than the aerobic measures in Table 1. For systematic reviews or meta-analyses were identified in the
example, the U.S. monitoring data show that around 20% past 20 years (Supplementary Table).
of older adults meet the strength training frequency and the Initially, interventions were mostly based in commu-
aerobic activity 150 minutes guideline (Centers for Disease nity centers. The proportion of home-based interventions
Control and Prevention [CDC], 2006, 2013), and rates increased over time; for example, in the review by Chase
are similar in the few countries that assess this; these are (2015) covering the period 2000–2012, half of the inter-
much lower than the proportion meeting the 150 minutes ventions were home based. The PA targets in early reviews
of moderate-intensity PAG alone. Similarly, scant data exist mostly focused on planned (structured) sessions of aero-
on participation in specific balance exercise; in Australia bic activity or muscle strengthening; fewer involved mul-
only 6.2% reported to do so (Merom et al., 2012). These timodal activities, such as balance or functional capacities
important health-related dimensions are seldom moni- (King et al., 1998; van der Bij et al., 2002). The promotion
tored, and as a result, are often omitted from public health of walking or lifestyle PA as stand-alone interventions com-
estimates for assessing “sufficiently active,” or from strate- prised 35% of the RCTs delivered only to older population
gies to increase PA, or in clinical advice to older adults. in the period 1960–2000 (Conn, Minor, Burks, Rantz, &
Pomeroy, 2003). It is unknown whether walking promo-
tion increased over times as the PA target was not systemat-
Review of Community Interventions to ically reported in the most recent reviews by Chase, which
Promote PA in the Elderly Adults focused on program-related moderators.
The majority of older people (90%–95%) prefer to remain In terms of effectiveness, earlier reviews typically
in their own homes and communities even if that means liv- assessed attendance at program sessions, which was high in
ing alone (National Institute on Aging, 2011). Identifying this population (>70%), with few primary studies report-
best practice strategies to increase PA among community- ing reported changes in PA or intervention effect sizes
dwelling older adults is important to maintain functional (ESs). However, in intervention studies where changes were
independence. This section reviews published systematic reported, 50% also observed changes in PA in the control
reviews of interventions to promote PA among commu- groups (van der Bij et al., 2002). The second review by
nity-dwelling older adults aged 65 or older to identify Conn that was limited to older adults found that slightly
gaps in knowledge in assessing their effectiveness. Medline more than half of the interventions (58%) showed sig-
searches were complemented by CINAHL and Cochrane nificant between-group effects. The meta-analytic ES was
database. Keywords comprised “intervention studies” or modest, ES = 0.26 (Conn, Valentine, & Cooper, 2002), a
“promotion” or “health promotion” AND “physical activ- value similar to the ES = 0.18 obtained in a more recent
ity” or walking or exercise or physical fitness or aerobic meta-analysis; this approximates to an increase of 73 min-
fitness or sports or muscle strength or resistance training utes/week more in intervention over control participants
or physical training or balance or postural balance AND (Chase, 2015). Successful interventions used mailed or
limiting the search to adults 65 years old and beyond, audiovisual components and used behavioral theory and
English language, years 1990–2015, human and review motivational approaches (Chase, 2015). Importantly, the
articles. Inclusion criteria were reviews that summarized effects of moderate-intensity and prescribed exercise were
primary intervention studies and reported on measures stronger than interventions that promoted low-intensity PA
of adherence or PA change as main outcomes. This search or had no prescription. In all other interventions, no effect
yielded 172 review articles, 159 were excluded based on over control was detected, with the exception of one walk-
title and abstract, of those, 90% reviewed the effect of PA ing intervention that reported significant effect in favor
or exercise on various health outcomes. Full text of 13 of control. The magnitudes of changes in PA were seldom
review articles were assessed, and we excluded additional reported in interventions in this review.
S274 The Gerontologist, 2016, Vol. 56, No. S2

The superiority of center- versus home-based approach defined as meeting three out of five phenotypic criteria
was discussed in three reviews; two found that the effects indicating compromised function: low grip strength, low
of home-based interventions were similar to that of center- energy, slowed waking speed, low PA, and/or unintentional
based interventions (Chase, 2015; van der Bij et al., 2002), weight loss, and “prefrailty” as meeting one or two crite-
whereas Conn and colleagues (2002) indicated that center- ria (Fried, Tangen, & Walston, 2001). Although frailty may
based interventions had greater effects compared with occur at younger ages, the majority of the literature focuses
home-based interventions (ESs 0.47 vs 0.24), but without on the demographic group at highest risk, the oldest-old
controlling for intervention duration. The majority of inter- (older than 85 years). Given the global trends in aging,
ventions reviewed were short term (<6 months), and the there are advantages to addressing physical inactivity in
differences between these two approaches were small, yet this group, with a particular focus on addressing age- and
in “real world” settings, there is a substantial decline in disease-related disuse and loss of muscle strength and func-
attendance at center-based classes for seniors (Ecclestone, tion, the hallmark of sarcopenia.

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Myers, & Paterson, 1998; van der Bij et al., 2002). Barriers and goals for PA vary markedly across the life
Overall, there were some methodological issues over- span, are particularly relevant in the most inactive segment
looked in these reviews. First, reports of attendance rate of the population, the oldest-old and frail elderly adults,
did not categorize this outcome using the intention-to-treat for whom low PA levels form part of the definition (Baert,
principle and may have overestimated program effective- Gorus, Mets, Geerts, & Bautmans, 2011; Fried et al., 2001).
ness. Second, the measurement tools used were reported Although attitude toward PA and access to safe and appro-
only in the review by Chase (2015), and may have omit- priate venues or providers are always important (Franco
ted measures of specific intervention components. Third, et al., 2015), in the oldest-old and frail adults, individual
the review by Chase in 2015 did not consider partici- ability to exercise must also be addressed, as the physical
pants’ baseline PA levels. Those who are physically inac- capacity to safely engage in activity is critical to participa-
tive but hard to reach may demonstrate greater scope for tion, even when attitude and access are not limiting factors.
PA change. The performance of interventions against pub- Many reviews and position statements support the
lic health guidelines was seldom reported. Finally, limited benefits of PA for function, chronic disease outcomes, and
consideration was given to the moderating effect of inter- mortality benefits in older adults, and these functional ben-
ventions performed in diverse environments and targeting efits extend to frail elders (Chou, Hwang, & Wu, 2012; de
diverse socioeconomic or disadvantaged groups. Labra, Guimaraes-Pinheiro, Maseda, Lorenzo, & Millan-
The limitation of this summary is its focus on system- Calenti, 2015; Theou et al., 2011).
atic reviews of primary trials. It lacks reference to “best The physical capacities most relevant to mobility
practice” programs and recommendations developed by impairments and independence in this group are muscle
organizations such as the CDC Taskforce on Community strength and power (Cruz-Jentoft et al., 2014) and bal-
Preventive Services or the U.S. National Council on Aging. ance, although including aerobic activity (walking) has
There are several effective programs and increasing evidence been shown to improve mobility impairment (inability to
from translational research for successful community- walk 400 m independently) in community-dwelling elders
based interventions. For example, scaling up PA programs with pre-existing deficits on the Short Physical Performance
through YMCA-related settings in the United States identi- Battery (SPPB; Pahor et al., 2014). Recent large-scale tri-
fied factors associated with uptake; these included profes- als affirm the benefits of multicomponent interventions to
sional and organizational support, program adaptations, increase PA, strength, and balance on objective measures of
and delivery mechanisms (Petrescu-Prahova, Belza, Kohn, frailty, compared with “successful aging” controls (Cesari
& Miyawaki, 2015). et al., 2015, de Labra et al., 2015).
As the intervention field grows, we have highlighted Given the centrality of weakness to the definitions of
areas for improvement, including measures used, evalua- frailty (Fried et al., 2001; Liu & Fielding, 2011), PA and
tion methods for assessing program effectiveness, and accu- exercise programs in the oldest-old have often empha-
mulating better evidence of the effects of scaling programs sized resistance training (also called strength training or
up to the population level. weight lifting) as a direct antidote for sarcopenia (Chin,
van Uffelen, Riphagen, & van Mechelen, 2008; Peterson,
Sen, & Gordon, 2011). Resistance training interventions,
PA Interventions for the Oldest-old and at moderate-to-high intensity, have been shown to improve
Frail Adults sarcopenia and functional status (Liu & Latham, 2011;
Frailty may be defined as a state of increased vulnerability Valenzuela, 2012), bone density (Kemmler, Haberle, & von
resulting from age-related decline in reserve and function Stengel, 2013), cardiometabolic health (Kay & Fiatarone
across multiple physiologic systems, attenuating the abil- Singh, 2006; Sagar et al., 2015; Yang, Scott, Mao, Tang,
ity to cope with acute and chronic stressors, resulting in & Farmer, 2014), mental health and cognitive impairment
loss of homeostasis (Xue, 2011). Although many variations (Chung, Thilarajah, & Tan, 2016; Gates, Fiatarone Singh,
have emerged over the years, frailty has been operationally Sachdev, & Valenzuela, 2013; Heyn, Johnson, & Kramer,
The Gerontologist, 2016, Vol. 56, No. S2 S275

2008; Silveira et al., 2013; Windle et al., 2010), hip frac- improve balance (Orr, Raymond, & Fiatarone Singh,
ture (Fiatarone Singh, 2014; Singh et al., 2012), among oth- 2008). However, the best interventions to prevent falls
ers. Robust outcomes for resistance training interventions and reduce injuries and fractures (El-Khoury, 2013) are
have been linked to higher intensities (Raymond, Bramley- seen after programs of combined resistance and balance
Tzerefos, Jeffs, Winter, & Holland, 2013; Steib, Schoene, training (Sherrington et al., 2011; Thomas, Mackintosh,
& Pfeifer, 2010), supervision, and progression in resistance & Halbert, 2010). The promotion of moderate- or vig-
training (Gordon, Benson, Bird, & Fraser, 2009). Notably, orous-intensity aerobic activity typically through walk-
aerobic capacity improves after isolated resistance training ing to older adults should consider adverse effects such
in older adults, because strength and muscle mass contrib- as falls and fractures. Walking can be recommended when
ute to aerobic capacity, and thus resistance training may older adults have the strength, balance, and cognition to
subsequently result in increased ability to engage in endur- perform it safely and within their limitations, otherwise
ance activities like walking. For example, resistance train- the risks of falling may increase (Jefferis et al., 2015). For

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ing has been shown to increase habitual PA level in frail older adults without sufficient capacity for walking pro-
nursing home residents (Fiatarone Singh et al., 1994) with- grams, a staged approach is recommended to regain suf-
out any direct promotion of, or change in access to, other ficient strength and balance before walking unsupervised;
activities, but the intensity of resistance training remains otherwise, a paradoxical increase in risk of fractures may
important (McGinley, Armstrong, Boule, & Sigal, 2015; be observed in osteoporotic populations advised to walk
Schoenfeld, Wilson, Lowery, & Krieger, 2014; Thiebaud, as their only intervention for bone health.
Funk, & Abe, 2014). By contrast, balance training alone Currently the most robust evidence for the oldest-old
does not improve strength or aerobic capacity, and aerobic and frail adult supports targeted specific exercise recom-
training alone (most commonly walking) does not gener- mendations addressing pervasive deficits of sarcopenia and
ally improve balance or strength. mobility impairment and elevated risk of injurious falls
These observations lead to clear practice and policy impli- with resistance training and balance training, respectively
cations. For very frail adults who have minimal ability to walk (Chodzko-Zajko et al., 2009). In addition, aerobic activi-
safely or who are completely nonambulatory, seated resist- ties such as walking are important to add where appropri-
ance training under supervision is the most feasible exercise ate and safe, to optimize the functional and NCD-related
modality and should be the first activity recommended. Once benefits.
standing is possible, it is important that the frail individual Unfortunately, existing community programs for the
can avoid falls and injuries, and thus standing balance exer- frail elderly adults often fall short of such evidence-based
cises can be added to resistance training. Independent walk- standards (Burton, Lewin, & Boldy, 2015). In addition, the
ing requires sufficient muscle strength and balance to carry plethora of benefits of isolated resistance training are often
one’s body weight through space, and once this threshold is unrecognized as a rationale for this modality of exercise.
reached, it is then important to enhance aerobic capacity so Given that improvements in muscle strength and balance
that walking can be maintained over clinically relevant dis- are achievable with evidence-based, progressive, and robust
tances. By contrast, mild-to-moderately frail adults, such as resistance and balance training strategies (Chodzko-Zajko
those in the structured LIFE study of mobility-impaired adults et al., 2009), this staged approach to improvement in func-
aged 70–89 years (Pahor et al., 2014), may safely undertake tional and health status in the oldest-old is critical to desired
all three modalities of exercise (strength, balance, and walk- outcomes.
ing) simultaneously with proven benefit for incident mobility
disability. Unstructured, unsupervised PA recommendations
have generally not been shown to improve mobility or func- Conclusions
tion in frail adults. There is some support from a systematic This review highlights the importance, and complexity, of
review that exercise interventions in frail elders that combine promoting PA among older adults. In considering global
strength, balance, training, and endurance may offer benefits health, PA promotion needs to extend beyond policies
in terms of function, mobility, falls prevention, and strength focusing on NCD prevention alone, to areas of preserving
(Cadore, Rodriguez-Manas, Sinclair, & Izquierdo, 2013), functional capacity, neuromotor abilities, balance co-ordi-
but the data are mixed and other reviews suggest that such nation, reaction time, and neurological or cognitive health.
multicomponent programs are heterogeneous in their efficacy PA is a major contributor to successful “healthy aging,”
for functional improvements in frail elders (Gine-Garriga, encompassing clinical, psychological, and social benefits.
Roque-Figuls, Coll-Planas, Sitja-Rabert, & Salva, 2014), Population-level strategies need to consider creating aware-
although effective in community-dwelling elders with early ness among policymakers of the importance of PA in healthy
mobility impairment (Pahor et al., 2014). aging, as this occurs currently in few low-to-middle–income
Balance training reduces fear of falling and improves countries. Policy and community priorities should focus on
mobility and balance in older adults at high fall risk raising awareness of relationships between PA and health
(Sherrington, Tiedemann, Fairhall, Close, & Lord, 2011), in older adults, as well as providing better facilities and
whereas isolated resistance training does not consistently PA programs in the community which cater to individual
S276 The Gerontologist, 2016, Vol. 56, No. S2

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