Disease/Disorder
See Exercise in the Elderly Part One
Essentials of Assessment
See Exercise in the Elderly Part One
Rehabilitation Management and Treatments
Available or current treatments
Physiatrists should be aware of the current exercise recommendations for older adults in order to maximize health benefits. Older adults should strive to perform at least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity per week, in combination with resistance training and balance exercises, in accordance with current public health guidelines.¹ In addition, older adults should perform balance training three or more days per week. It is also important to educate older adults on the components of an exercise prescription which includes exercise mode, frequency, intensity and duration. Aerobic exercise intensity has traditionally been prescribed using percentages of maximal oxygen consumption (VO₂ Max) or metabolic equivalents (METs), where 1 MET represents the energy expenditure at rest (approximately 3.5 mL O₂/kg/min). However, in older adults, intensity should be individualized using the Rating of Perceived Exertion (RPE) scale or the talk test rather than fixed MET targets, given variability in functional capacity, comorbidities, and physiologic response to exercise.² Resistance training should begin with low intensity (40-50% of 1 repetition max (RM)) and eventually progress to moderate (60-70% of 1 RM) and may progress in intensity based on individual tolerance, functional status, and comorbidities.³ Core and hip muscles should be strengthened to prevent falls. Additionally, high speed power training in older adults has been associated with increased speed related performances and may also benefit in fall prevention.⁴ Flexibility exercises are recommended for 10-30 seconds for static stretching and repeating the stretch 2-4 times in a session.2,5 Balance exercises aim to progressively decrease the base of support with dynamic movements that work postural muscles or reduce sensory input.⁵ Exercise programs for frail older adults should emphasize gradual progression, lower initial intensity, and functional goals such as improving gait, transfers, and independence.⁶ Tai chi and yoga incorporate such movements with sessions of varying duration. Exercise interventions are recommended for adults aged 65 years and older at increased risk of falls, with strong evidence supporting multicomponent programs that include strength and balance training.7,8 Low-intensity aquatic exercise programs may be beneficial for older adults with pain or mobility limitations, allowing improved participation through reduced joint loading. If older adults are unable to achieve the prescribed exercises due to chronic conditions or pain, they may need the assistance of a physiatrist for making functional modifications. Any amount of exercise or physical activity is better than none, and meaningful health benefits can occur even below recommended exercise targets.¹
Coordination of care
Physiatrists can coordinate with other allied health professionals to prepare patients for exercise activities. For older adults not accustomed to performing exercises, working with a fitness trainer may be an option. Patients with gait impairments may benefit from attending physical therapy sessions prior to engaging in exercise programs. Occupational therapy sessions may also aid a patient with balance issues to work on postural stability as well as energy conservation and safety techniques. Patients may also require dietary consultation due to changes in energy expenditure especially those with chronic diseases such as diabetes, COPD and cancer. Comprehensive geriatric assessment (CGA) programs are a multidisciplinary diagnostic process that evaluates medical, functional, psychological, and social capabilities of frail or vulnerable elderly persons in various clinical and community settings. These programs help develop a coordinated plan to maximize health with aging and include improving physical function.
Patient and family education
It is important to educate both the patient and family members about the health benefits of exercise in elderly adults. Involving family members may also help with exercise program compliance and ensure elderly adults have access to safe exercise environments. The benefits of aerobic exercise include improvement in VO₂ Max, lower heart rate at rest and during submaximal exercise, smaller increases in blood pressure, improved glycemic control, and improved postprandial lipid metabolism.⁵ Resistance training in the elderly leads to an increase in fat-free body mass, a decrease in total body fat and helps counteract sarcopenia. There is also an increase in motor unit recruitment and discharge rates as well as muscular endurance.⁵ The combination of aerobic and resistance training in elderly adults without disabilities results in increased functional independence.⁵ Flexibility training in elderly adults has been shown to increase range of motion, especially in the lumbar region and knee flexors, which may allow faster recovery from a perturbation and decrease the likelihood of a fall.⁵ Flexibility exercises have also been shown to reduce pain.⁵ Balance exercise programs are designed to improve neuromotor control of the lower extremities and enhance the vestibular component which reduces the likelihood of falling.7,8 Together, these various components promote physiologic changes in an elderly adult. However, an added benefit to a physically active elderly person is improving feelings of well-being, mood and improved quality of life which lowers the risk of dementia and cognitive decline.⁹
Emerging/unique intervention
Tele-exercise and digitally delivered programs, including videoconferencing and app-based interventions, have emerged as effective strategies to improve strength, balance, and physical function in older adults, particularly for those with limited access to in-person care.¹⁰ The goal of the physiatrist is to guide elderly patients towards initiating and maintaining an exercise program in order to maintain and improve their function and quality of life.
Cutting Edge Concepts and Practice
- With more evolving research on the positive effects of exercise, studies have focused on determining the most beneficial type of exercise for elderly patients specifically. Recently, resistance type exercise has demonstrated increased levels of insulin-like growth factors and superior effects in limiting age-related muscle atrophy compared to aerobic exercise.⁵
- It is widely recognized that with the aging process, there is a typical decline in bone mass in both men and women. Not all exercise regimens are equal in their effects on bone remodeling in the elderly. While walking alone is not enough to modify the loss of bone mineral density, it has been previously understood that optimal bone mineral maintenance is through a multicomponent training: weight-bearing aerobic training with high intensity and speed, strength training, progressive resistance training, and simulated functional tasks. Whole-body vibration may provide modest benefits in select populations; however, current evidence is limited and inconsistent, and it should be considered an adjunct rather than a replacement for standard exercise interventions.¹¹
Gaps in the Evidence-Based Knowledge
The medical literature continues to demonstrate the clinical effects and benefits of exercise in older adults. Although clinical studies have explored the effect of exercise on the elderly, basic science research relating to exercise in older adults has largely focused on skeletal muscle physiology and sarcopenia. Clinical inferences based on interpretation of molecular biology findings has occurred; however, large clinical studies correlating the molecular biologic effects of exercise and functional status in geriatric populations are needed.
References
- Centers for Disease Control and Prevention. Physical Activity Guidelines for Older Adults. Atlanta, GA: U.S. Department of Health and Human Services; 2025.
- Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, et al. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–1530.
- Lai X, Bo L, Zhu H, et al. Effects of lower limb resistance exercise on muscle strength and physical performance in pre-frail older adults. BMC Geriatr. 2021;21(1):447.
- Sayers SP, Gibson K. High-speed power training in older adults: A shift of the external resistance at which peak power is produced. J Strength Cond Res. 2014;28(3):616–621.
- Galloza J, Castillo B, Micheo W. Benefits of Exercise in the Older Population. Phys Med Rehabil Clin N Am. 2017;28(4):659–669.
- Lee H, Lee E, Jang IY. Frailty and comprehensive geriatric assessment. J Korean Med Sci. 2020;35(3):e16.
- U.S. Preventive Services Task Force. Interventions to Prevent Falls in Community-Dwelling Older Adults. JAMA. 2024;331(1):55–61.
- Thomas E, Battaglia G, Patti A, et al. Physical activity programs for balance and fall prevention in elderly: a systematic review. Medicine (Baltimore). 2019;98(27):e16218.
- Taylor D. Physical activity is medicine for older adults. Postgrad Med J. 2014;90:26–32.
- Toledano-Shubi A, et al. Remote exercise interventions in older adults: a systematic review and meta-analysis. J Med Internet Res. 2025.
- Ma C, Liu A, Sun M, et al. Effect of whole-body vibration training on bone mineral density in older adults: a systematic review and meta-analysis. Osteoporos Int. 2024;35(2):321–334.
Original Version on the Topic
David Z. Prince, MD. Exercise in the elderly. 9/20/2014
Previous Revision(s) on the Topic
Joe Mendez, MD, Melissa Mafiah, MD, Alexandre Mazar, MD. Exercise in the elderly. 8/20/2020
Jason Do, DO, Alex Vertes, MD, Simron Gill, MD, Haris Choudry, MD, Derek Ho, DO. Exercise in the Elderly Part Two: Rehabilitation Management and Treatments, 6/22/2023
Author Disclosures
Christine Mathew, MD
Nothing to Disclose
Vishal Anjutgi, MD
Nothing to Disclose
Apurva Srivastav, DO
Nothing to Disclose
Derek Ho, DO
Nothing to Disclose