REVIEW ARTICLE

Health benefits of physical activity in older patients:

a review
T. Vogel,1 P.-H. Brechat,1,2 P.-M. Leprêtre,1,3 G. Kaltenbach,1 M. Berthel,1 J. Lonsdorfer1,4

1
Pôle de gériatrie, Hôpital de la
SUMMARY
Review Criteria Robertsau, Hôpitaux
As the number of elderly persons in our country increases, more attention is being Universitaires de Strasbourg,
• Moderate but regular physical activity is
given to geriatric healthcare needs and successful ageing is becoming an important France
associated with a reduction in cardiovascular 2
topic in medical literature. Concept of successful ageing is in first line on a preven- Service de santé publique et
morbidity and mortality, reduction in diabetes
économie de la santé, groupe
tive approach of care for older people. Promotion of regular physical activity is incidence and optimization of blood pressure hospitalier Lariboisière-Fernand
one of the main non-pharmaceutical measures proposed to older subjects as low value and lipid profile, among older people. Widal (AP-HP), Paris, France.
rate of physical activity is frequently noticed in this age group. Moderate but regu- • Prevention of falls and increasing bone density Laboratoire d’analyse des
lar physical activity is associated with a reduction in total mortality among older are also associated with physical activities, with politiques sociales et sanitaires
conflicting results. (LAPSS) de l’Ecole nationale de
people, a positive effect on primary prevention of coronary heart disease and a
la santé publique (ENSP),
significant benefit on the lipid profile. Improving body composition with a reduction Rennes, France
Message for the Clinic
in fat mass, reducing blood pressure and prevention of stroke, as well as type 2 3
Laboratoire Adaptation et
• Epidemiological studies suggest that physical
diabetes, are also well established. Prevention of some cancers (especially that of Réadaptation à l’Effort, Faculté
activities are associated with a decreased risk of
des Sciences et du Sport,
breast and colon), increasing bone density and prevention of falls are also incidence of Alzheimer’s disease in older subjects. Amiens, France
reported. Moreover, some longitudinal studies suggest that physical activity • A protective effect of exercise, even moderate, 4
Service de Physiologie Clinique
is linked to a reduced risk of developing dementia and Alzheimer’s disease in with regard to the risk of stroke, whether et d’Exploration Fonctionnelle,
particular. ischaemic or haemorrhagic. Hôpitaux Universitaires de
• Benefits of physical activity (rather resistance Strasbourg, France
than endurance) for very older subjects or frail
elderly people are reported in terms of muscle Correspondence to:
Dr Docteur Thomas Vogel,
strength, physical performance, but with
Pôle de Gériatrie, Hôpitaux
inconsistent results regarding the beneficial
Universitaires de Strasbourg,
effects on disability outcomes. Hôpital de la Robertsau,
Pavillon Schutzenberger, 83 rue
Himmerich, 67091 Strasbourg,
cedex, France
account, the promotion of regular physical activity is Tel.: + 03 88 11 55 11
Introduction Fax: + 03 88 11 55 26
one of the main non-pharmaceutical measures that
Email: thomas.vogel@chru-
Most Western societies see a significant ageing of should be promoted in older subjects, especially strasbourg.fr
their population that will be further accentuated in regarding a preventive approach for ‘a successful age-
Disclosures
the coming decades. Among physiological changes ing’.
None.
that occur during the ageing process, decline in aero- For the general population, it is known that regu-
bic capacity estimated as peak oxygen consumption lar physical activity offers primary and secondary
(V02max) (5–10% per decade in untrained individu- prevention of several chronic conditions. Concerning
als) and the lost of muscle tissue resulting in dimin- older and very older subjects, the effect of physical
ished mass and strength (sarcopenia process) are the activity is less documented (3). The aim of this
most important with regard to quality of life, func- review is to assess the health benefits of physical
tional independence and mortality (1). The rate of activity in older subjects.
decline in aerobic capacity is probably not linear, but
accelerates dramatically with advancing decades (2).
Methods
Ability of older subjects to function independently
depends largely on maintenance of sufficient aerobic In this review, we searched the literature using the
capacity and muscle strength. keywords ‘elderly’, ‘older people’, ‘frail elderly’,
Elderly people with a poor aerobic capacity avoid ‘frailty’, ‘chronic conditions’, ‘functional limitations’,
physical activities and so lose their muscle mass and ‘exercise’, ‘physical activity’, ‘health’, ‘mortality’ and
strength, with further reduction in aerobic capacity, disease-specific terms such as ‘cardiovascular disease’,
causing a vicious cycle. Taking these concepts into ‘coronary hearth disease’, ‘ cholesterol’, ‘lipid’, ‘body

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Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract, February 2009, 63, 2, 303–320
doi: 10.1111/j.1742-1241.2008.01957.x 303
304 Physical activity in older patients
composition’, ‘diabetes’, ‘stroke’, ‘hypertension’, ‘aer-
obic fitness’, ‘cancer’, ‘fracture’, ‘bone density’, ‘falls’,
‘cognitive’, ‘dementia’, ‘Alzheimer disease’ and ‘dis-
ability’. We selected individual studies regarding the
methodological quality in terms of study population,
design, primary outcome and nature of the physical
intervention. Studies frequently included in meta
analysis, systematic review as well as consensus treat-
ment were considered as an example of best evidence
and were selected. Reference lists of article retrieved
were systematically examined for further relevant ref-
erences. Only full articles limited to the English lan-
guage and studies that involved adult cohorts with a
mean age over 60 years were considered.
Results
Definition of older subjects and type of
physical activity
In this review, we focused on the benefit of physical
activity on elderly people in two different groups of
older people. First of all, we considered, in a large sec-
tion, the impact of endurance program for older sub-
jects (people aged 60 years or older). Such aerobic
exercises that target cardio-respiratory fitness through
activities such as walking or swimming are often pro-
posed not only for primary or secondary prevention of
cardiovascular risk factors but also for many chronic
conditions. To be capable of performing endurance
exercises, older subjects should not have significant
chronic conditions and functional limitations.
Secondly, we evaluated the impact of activities in
very older subjects (people aged 80 years or older) or
frail elderly people. This older age group, compared
with the ‘older subjects’ described above, often pre-
sents significant chronic conditions or geriatric syn-
dromes such as cognitive impairment, malnutrition,
functional limitations (e.g. arthritis), disability or poor
social conditions. The primary aim of physical activity
in this age group is to improve muscle strength and to
limit disability to maintain an independent living. The
goal is not primary or secondary prevention of
chronic condition. Nature of physical activity is
usually not only progressive resistance training, but
also flexibility exercises and balance training (4).
Benefit on mortality
Many longitudinal studies have reported a relation-
ship between physical activity and reduction in mor-
tality among older subjects (Table 1). Using data
from the Cardiovascular Health Study, Fried et al.
(5) established a significant relationship between the
amount of weekly physical activity and a reduction
of up to 40% for the total mortality in a commu-
nity-dwelling older population. Knoops et al.
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
observed the same tendency from the combined
results of the SENECA and FINE Studies including
older healthy European subjects. They reported that
healthy diet and lifestyle, including regular physical
activity, are associated with a significant decrease in
total mortality, cardiovascular disease mortality and
mortality from cancer (6). The same trend with a
decrease in mortality has been reported with occa-
sional physical activities (7) and with moderate but
regular exercise (walking). This was illustrated by
Hakim et al. (8) using the data from the Honolulu
Heart Program including retired older men, who
reported a mortality rate nearly twice among men
who walked < 1 mile per day that among those who
walked more than 2 miles per day during the
12 years follow-up period. Using the data of the Zut-
phen Elderly Study, Bijnen et al. (9) reported the
same results in observational study including older
men with a significant reduction in 10-year total
mortality among men who walk or cycle at least
three times per week for 20 min.
Using the Framingham Heart Study, Franco et al.
(10) observed that life expectancy in 9181 young-old
sedentary subjects (older than 50 years) is respec-
tively 1.5 and 3.5 years shorter than for those of the
same age engaging in moderate and vigorous physi-
cal activity, for both genders. The increase in life
expectancy for those engaging in exercise and physi-
cal activity is mainly because of an increase in life
expectancy without cardiovascular disease.
The relationship between the level of physical per-
formance and mortality has also been observed
among the very elderly people, as noted by Franco
et al. (10, Bijnen et al. and Rolland et al. (9,11). The
same trend was observed by Benetos et al. (12) with
a study population aged from 60 to 70 years and
comparing the modifiable risk factors among subjects
who died during the follow-up period (before
85 years for women and before 80 years for men)
with subjects who survived beyond these years of
age. Landi et al. (13) looked at the Italian Silver Net-
work Home Care Project, among frail community-
living elderly people and found that active patients
were less likely to die compared with those with no
or very low-intensity physical activity; this benefit
persists in patients aged 80 years and older. Recently,
Chakravarty et al. (14) using a 21-year longitudinal
study reported that vigorous exercise (running) at
middle and old ages was associated with a significant
survival benefit and a reduced disability.
Prevention of coronary heart disease
Using data from the Honolulu Heart Program,
Hakim et al. reported an increased relative risk (RR)
of developing a coronary event for those who walk
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 Physical activity in older patients 305

Table 1 Physical activity and mortality

Population and interventions in

longitudinal observational studies Outcomes Reference

5201 community-dwelling subjects (73 years old) 5 years mortality, no exercise used as reference: (5)
Assessment at baseline of 78 characteristics with Moderate exercise (4100–7908 kJ ⁄ week):
5-year mortality including physical activities RR 0.72; 95%CI (0.55–0.93)
Follow up: 4.8 years Vigorous exercise (> 7908 kJ ⁄ week)
RR 0.56; 95%CI (0.43–0.74)
2339 community-dwelling subjects aged 70–90 years 10-year all-cause and cause-specific mortality (6)
in 11 European countries. Physical activity defined as the intermediate or
Assessment at baseline of adherence to a Mediterranean the highest tertile for either the Voorrips or Morris
diet and healthy lifestyle (including physical activities) questionnaires. No exercise used as reference:
with mortality HR total mortality: 0.63; 95%CI (0.55–0.72)
Follow-up: 10 years HR coronary heart disease mortality: 0.72; 95%CI (0.48–1.07)
HR cardiovascular disease mortality: 0.65; 95%CI (0.52–0.81)
HR cancer mortality: 0.64; 95%CI (0.48–0.84)
3206 community-dwelling subjects over 65 years Total mortality, no exercise used as reference: (7)
Analyses the association between different Physical activity occasionally: HR 0.72; 95%CI (0.64–0.81)
levels of physical activity and all-cause mortality Physical activity once a week: HR 0.60; 95%CI (0.50–0.71)
Follow up: 11.7 years Physical activity twice a week: HR 0.50; 95%CI (0.42–0.59)
Physical activity vigorously at least twice a week:
HR 0.60; 95%CI (0.46–0.79)
707 community-dwelling retired men, 61–81 years of age Mortality rate (8)
Distance walked at baseline recorded and Distance walked between 0.0 and 0.9 mile ⁄ day:
analyses the association mortality rate at 40.5%
between walking and mortality Distance walked between 1.0 and 2.0 mile ⁄ day:
Follow up: 12 years mortality rate at 27.4%; p = 0.003
(1.0–2.0 mile ⁄ day vs. < 1 mile ⁄ day.
Distance walked between 2.1 and 8.0 mile ⁄ day:
mortality rate at 23.8%; p = 0.001
(1.0–2.0 mile ⁄ day vs. < 1 mile ⁄ day
9181 community-dwelling subjects over 50 years Differences in total live expectancy at 50 years (years). (10)
Assessment of a baseline physical activity score of Low physical activity used as reference
physical activity Moderate physical activity. Men: 1.3; 95%CI (0.3–2.3).
Follow up: 12 years Women: 1.5; 95%CI (0.4–2.5)
High physical activity. Men: 3.7; 95%CI (2.6–4.8).
Women: 3.5; 95%CI (2.4–4.6)
802 men, mean age 71 years 10-year mortality for the highest tertile of physical activity (9)
Physical activity assessment at baseline (the lowest tertile use as reference)
using questionnaire All-cause mortality: RR: 0.77; 95%CI (0.59–1.00);
Follow up: 10 years P for trend: 0.04
Cardiovascular disease mortality: RR: 0.70; 95%CI
(0.48–1.01); P for trend: 0.04
7250 community-dwelling older HR for death for SPPB (95%CI) (good performer at SPPB (11)
women (80.5 years old) with a score between 10 and 12 used as reference):
Physical activity assessment at baseline using Fair performer (score: 7–9): 1.35 (1.10–1.65)
the short physical performance battery (SPPB), Poor performer (score: 0–6): 1.81 (1.44–2.27)
Follow up: 3.8 years
7467 community-dwelling older Odds ratio of survival at advanced age for physical activity, (12)
subjects (65.3 years old) no physical activity used as reference (95%CI):
Physical activity assessment at baseline using 1.52 (1.27–1.83); p = 0.0001
self-administered questionnaire
Follow up: 10–15 years: 5591 subjects alive

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306 Physical activity in older patients
Table 1 (continued)
Population and interventions in
longitudinal observational studies
2757 frail community-living older subjects
Physical activity assessment at baseline using the
Minimum Data
Set for Home Care (MDS-HC)
Follow up: 10 months
538 members of a running club (58 years old) and
423 healthy control (62 years old)
284 runners (78 years old) and 156 controls
(80 years old) completed the 21-year follow up
RR, relative risk; HR, hazard ratio; 95% CI, 95% confidence interval.
< 0.25 miles a day compared with those who walk
more than 1.5 miles a day [RR: 2.2; 95% confidence
interval (95%CI): 1.3–3.7] among 2678 physically
capable elderly men aged 71–93 years and followed
during 4 years. This relationship is not altered after
adjustment for the main cardiovascular risk factors
(15).
As regards secondary prevention of coronary heart
disease (CHD) among elderly people, Wannamethee
et al. (16) examined data from the British Regional
Heart Study and noted a decrease in both total and
cardiovascular risk of mortality over a 5 years follow-
up period among 777 men (aged 40–59 years) with
diagnosed CHD senior engaging in regular, physical
activity. Benefits were observed for moderate level of
physical activity such as walking or gardening (RR:
0.42; 95%CI: 0.25–0.71). Despite the results of this
study, benefits of physical activity on mortality of
older patients with preexisting CHD are still debated.
Benefit on lipid Profile
Current National Cholesterol Education Program
Adult Treatment Panel III guidelines recommend the
general population to change lifestyle as it is a major
modality of LDL-lowering therapy. Such multifaceted
lifestyle approach includes a reduced intake of fat
(and an increased intake of fibre), a weight reduction
and an increased physical activity (17).
Specific effects of exercises on lipid parameters in
elderly people have been evaluated in few small stud-
ies (Table 2). Petrella et al. (18) in a 10-year follow
up of two cohorts, one ‘active’ and the other ‘seden-
tary’ compared after 10 years the changes in lipid
profiles between the two groups. During the follow-
up period, the LDL cholesterol increased by 6.89%
in the control group and only by 3.85% in the active
group (p < 0.002). Similarly, the HDL cholesterol
decreased by 18.18% in the control group and
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Outcomes Reference
Risk ratio for death during the follow-up period for physical (13)
activity, no physical activity used as reference (95%CI):
0.51 (0.35–0.73)
HR for death for runners vs. healthy controls (95%CI): (14)
0.61 (0.45–0.082)
increased by 9.09% in the active group (p < 0.001).
Sunami et al. confirmed the same tendency in a
small randomised study. These subjects followed a
low intensity aerobic training programme over
a 5-month period. This study reveals an improved
profile of HDL cholesterol and of its subfractions
compared with a control group without any training
(19). Halverstadt et al. (20) observed a significant
improvement of LDL cholesterol and triglycerides
after a 24-week endurance exercise training proposed
to healthy older subjects.
For reasons of the high incidence of cardiovascular
events in older people, even a small reduction in RR
(e.g. small reductions in LDL cholesterol through
physical activity) should be taken into account in
terms of absolute risk reduction.
Modification of body composition
Several studies show that physical activity among
elderly people leads to a reduction in fat mass between
1% and 4% (21). Irwin et al. using findings from the
Physical Activity for Total Health Study, included in a
randomised controlled trial 173 overweight postmeno-
pausal women aged from 50 to 75 years. In this study,
45 min of exercise 5 days a week of gradually increas-
ing intensity up to 75% of the theoretical maximum
frequency led to statistically significant differences
concerning: body weight ()1.4 kg; 95%CI: )2.5 to
0.3 kg), total body fat ()1.0%; CI 95%:)1.6 to
)0.4%), intra-abdominal fat ()8.6 g ⁄ cm2; 95%CI:
)17.8 to 0.9 g ⁄ cm2) and subcutaneous abdominal fat
()28.8 g ⁄ cm2); 95%CI: )47.5 to )10.0 g ⁄ cm2). In
fact, a significant decrease is noticed concerning:
weight, total fat, intra-abdominal and subcutaneous
fat in the intervention group (22).
An exclusive hypocaloric diet leads to a joint
reduction in both fat and lean body mass (with a
risk of accelerating age-related sarcopenia), whereas
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 Physical activity in older patients 307

Table 2 Physical activity and lipid profile

Population and interventions Outcomes Reference

Longitudinal observational study
Active group: 193 community-dwelling
subjects (68 years old)
three times per week, 30–45 min exercise sessionsEnd of follow up: 2.7 (active group) and 3.1 (control group); p < 0.02
at 75–80% V02max (walking, jogging)
Sedentary group 187 community-dwelling
subjects (67 years old)
Follow up: 10 years
Randomised control trial: 20 community-dwelling LDL cholesterol (g ⁄ l) changes between active and control group
subjects (67 years old) allocated either
Active group (two to four times per week,
60 min exercise sessions at 50% V02 max)
and 20 community-dwelling subjects
(68 years old) allocated to control group:
Follow-up: 5 months
One hundred sedentary, healthy 58 years
old community-dwelling subjects perform
three times per week, 60 min exercise sessions HDL cholesterol (g ⁄ l) changes after vs. before exercise sessions:
at 50–70% V02 max (ergometer cycling,
treadmills, stepping machine,…)
Follow up: 24 weeks
LDL cholesterol (mmol ⁄ l) changes between active and control (18)
group during follow up:
At baseline: 2.6 (active group) and 2.9 (control group)
HDL cholesterol (mmol ⁄ l) changes between active and control
group during follow up:
At baseline: 1.1 (active group) and 1.1 (control group)
End of follow up: 1.2 (active group) and 0.9 (control group); p < 0.001
Triglyceride (lmol ⁄ l) changes between active and control
group during follow up
At baseline: 2.1 (active group) and 2.2 (control group)
End of follow up: 1.9 (active group) and 2.9 (control group); p < 0.001
(19)
during follow up:
At baseline: 1.33 (active group) and 1.34 (control group)
End of follow up: 1.38 (active group) and 1.42 (control group); NS
HDL cholesterol (g ⁄ l) changes between active and control group
during follow up:
At baseline: 0.51 (active group) and 0.49 (control group)
End of follow up: 0.56 (active group) and 0.48 (control group); p < 0.05
Triglyceride (g ⁄ l) changes between active and control group
during follow up:
At baseline: 0.84 (Active group) and 1.08 (control group)
End of follow up: 0.87 (active group) and 1.11 (control group); NS
LDL cholesterol (g ⁄ l) changes after vs. before exercise sessions: (20)
1.29 (baseline); 1.22 (end of follow up); p = 0.0001
0.48 (baseline); 0.51 (end of follow up); p < 0.09
Triglycerides (g ⁄ l) changes after vs. before exercise sessions:
1.48 (baseline); 1.32 (end of follow up); p < 0.0001

LDL, low-density lipoprotein; HDL, high-density lipoprotein.

the association of a moderate caloric restriction
intake and physical exercise reduces the fat mass with
less effect on sarcopenia (23).
In contrast, Raguso et al. (24) observed that lei-
sure-time physical activity does not seem to prevent
decline in muscle mass and body fat accumulation in
a longitudinal evaluation over 3 years of body com-
position changes including 140 healthy subjects aged
more than 65 years.
Prevention of type 2 diabetes
The benefit of exercise and physical activity on the
prevention of diabetes in the general population is
well established, in particular among people with a
high risk of diabetes (25). Both resistance and aero-
bic exercises are associated with a decreased risk of
type 2 diabetes (Table 3). Exercise programmes for
diabetes prevention are often integrated in lifestyle
intervention that includes diet control and weight
loss. In a randomised controlled trial (Diabetes Pre-
vention Program Research Group) including middle-
aged, non-diabetic subjects with elevated fasting
plasma glucose, such lifestyle modification appeared
more effective than antidiabetic drugs (metformin)
to reduce the incidence of type 2 Diabetes (26).
This positive effect of exercise for diabetes preven-
tion was demonstrated also among ‘young’ older
people, even at low levels of activity. This was shown
by Hu et al. (27) using the data of The Nurses’
Health Study, an epidemiological study with non-
diabetic female nurses aged from 40 to 65 years.
Van Dam et al. (28) reported in a 5-year cohort
study that physical activities such as gardening and
bicycling are associated with a lower plasma glucose
concentrations and a lower prevalence of glucose
intolerance in elderly men, aged 69–89 years.
Folsom et al. (29) found in prospective cohort of
older women that greater leisure time physical

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308 Physical activity in older patients
Table 3 Physical activity and diabetes prevention
Intervention and population
3234 non-diabetic persons
(51 years old) with elevated fasting
and postload plasma glucose
concentrations randomised placebo (1082),
metformin (1073) and lifestyle (1079)
Follow up: 2.8 years
70,102 female non-diabetic nurses
aged 40–65 years
Assessment of physical activity
using questionnaire
Follow up: 8 years
424 non-diabetic males, aged 75 years
Assessment of physical activity at baseline
by questionnaires
Follow up: 5 years
34,259 women aged 55–69 years
free of type 2 diabetes
Assessment of physical activity by
mailing questionnaire
Follow up: 12 years
74,240 non-diabetic Caucasian
women (63.8 years old)
Assessment of physical activity at
baseline by questionnaires
Follow up: 5.1 years
487 subjects with impaired glucose tolerance
(55 years) randomised in an active group
(moderate-to-vigorous exercise for at
least 30 min per day)
and in a control group
Assessment of physical activity by
questionnaires at baseline
and during yearly follow-up visits
Follow up: 4.1 years
5125 female nurses (50 years old)
with type 2 diabetes
Assessment of physical activity by
questionnaires at
baseline and during follow up
Follow up: 14 years
RR, relative risk; 95% CI, 95% confident interval; OR, odds ratio; HR, hazard ratio; MET, metabolic equivalent task.
activity is associated with a reduced risk of type 2
diabetes over 12 years of follow up. Hsia et al. (30)
reported that walking and total physical activity score
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Outcomes Reference
Primary outcome: reduction in diabetes incidence (95%CI) (26)
Lifestyle vs. placebo: 58% (48–66%)
Metformin vs. placebo: 31% (17–43%)
Lifestyle vs. metformine: 39% (24–51%)
RR of type 2 diabetes (95%CI) by quintile of MET score, first (27)
quintile used as reference
Fourth quintile (15.7 MET-hours per week): 0.62; (0.52–0.73)
Fifth quintile (35.4 MET-hours per week): 0.54; (0.45–0.64)
OR (95%CI) for glucose intolerance by specific activities: (28)
Bicycling 20 min per day: 0.37 (0.20–0.70)
Gardening 20 min per day: 0.33 (0.16–0.66)
Talking a walk 20 min per day: 0.92 (0.46–1.88)
RR of incident diabetes (95%CI) for moderate physical activity (29)
(six METs or less) and vigorous physical activity (more than six METs),
no physical activity used as reference
Moderate physical activity (2–4 times per week): 0.86 (0.76, 0.98)
Moderate physical activity (more than four times per week): 0.73
(0.62, 0.85); p for trend < 0.001
Vigorous physical activity (2–4 times per week): 0.88 (0.70, 1.11)
Vigorous physical activity (more than four times per week):
0.64 (0.41, 1.01); p for trend < 0.05
HR (95%CI) for incident type 2 diabetes by total (30)
physical activity quintile,
first quintile used as reference: quintile 5: 0.67; (0.56–0.81);
p for trend 0.002
Hazard ratio for incident type 2 diabetes by walking quintile,
first quintile used as reference: quintile 5: 0.74; (0.62–0.89);
p for trend < 0.001
RR (95%CI) of developing incident type 2 diabetes: (31)
0.5 h of leisure-time physical activity per week: 0.52 (0.31–0.89)
3.8 h of leisure-time physical activity per week: 0.34 (0.19–0.62)
RR (95%CI) of incident coronary heart disease according (32)
to average hours of
moderate to vigorous activity per week
(< 1 h of activity per week used as reference):
1–1.9 h ⁄ week: 1.07 (0.75–1.54)
2–3.9 h ⁄ week: 0.86 (0.60–1.22)
4–6.9 h ⁄ week: 0.61 (0.40–0.92)
‡ 7 h ⁄ week: 0.49 (0.19–1.23)
are associated with a lower incidence of type 2 diabe-
tes in Caucasian women, participants of the
Women’s Health Initiative.
ª 2009 The Authors

Physical activity is also associated with a lower risk
of incident diabetes among ‘young’ older subjects
with impaired glucose tolerance, as found by Laakso-
nen et al. (31) in a post hoc analysis of a randomised
trial including 487 participants (mean age 55 years)
from the Finnish Diabetes Prevention Study, observ-
ing a protective effect of leisure-time physical activity
(RR of 65%).
For diabetics, physical activity is associated with a
reduced number of cardiovascular events, as estab-
lished by Hu et al. on the basis of the Nurses’ Health
Study following 5125 diabetic middle aged women
(mean age 50) over a period of 14 years (32). Posi-
tive effects of physical activity on glycaemic control
are related to a greater sensitivity to insulin and
notably to an increase in some glucose transporters
(GLUT 4) (33–35).
Prevention of strokes
Several studies have noticed an inverse association
between regular physical activity and the risk of stroke.
Using data from the Northern Manhattan Stroke
Study, Sacco et al. (36) in a case–control study includ-
ing 1047 subjects (mean age 69.9 years) report that lei-
sure-time physical activity is significantly protective for
ischaemic stroke, with a dose-response relationship for
both intensity and duration. Bijnen et al. (9) observed
in a longitudinal study (Zutphen Elderly Study)
including 802 elderly men (mean age 71.4 years) a
significant reduction in 10-year stroke mortality for
tertiles of time spent on physical activity (with the low-
est tertile as reference) (RR: 0.3; 95%CI: 0.14–0.66).
Using data from a meta analysis comprising 31 longitu-
dinal studies, not specifically including older patients,
Wendel-Vos et al. (37) observed a protective effect of
exercise, even moderate, with regard to the risk of
stroke, whether ischaemic or haemorrhagic. In another
meta analysis that did not specifically include elderly
people, Lee et al. (38) reported the same trend.
The literature provides little data on the benefit of
cardio-circulatory training after a stroke in terms of
secondary prevention. In a systematic review of only
three randomised studies (75 patients), Meek et al.
(39) find no significant benefit.
Prevention and control of hypertension
Inactivity is associated with an increased risk (30–50%)
of developing high blood pressure among the middle-
aged. Benefits of aerobic activity on blood pressure
value are a robust evidence. In a meta analysis involv-
ing 2419 people aged from 21 to 79, Whelton et al. (40)
reported that aerobic exercise is associated with a
lowering of both systolic blood pressure and diastolic
blood pressure. The positive effect of resistance exercise
on blood is a matter of debate because of conflicting
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Physical activity in older patients 309
results. In a meta analysis including older subjects,
Cornelissen and Fagard (41) showed a non-significant
reduction in systolic blood pressure and a significant
reduction in diastolic blood pressure. Although these
blood pressure reductions seem the modest, a signi-
ficant blood pressure reduction of 3 mmHg is associ-
ated with a reduced cardiac morbidity by 5–9%, stroke
by 8–14% and all-cause mortality by 4% (42).
Benefits of physical activity on blood pressure in
older subjects are less consistent (Table 4). In a small
randomised trial including sedentary healthy normo-
tensive subjects aged, Braith et al. (43) reported a
significant decrease in both systolic and diastolic
blood pressure after 6 months in the exercise group
compared with the control group. Jessup et al. (44)
showed, in a randomised study, a significant benefit
of physical activity on 24-h systolic blood pressure
and 24-h diastolic blood pressure in the active group
compared with the control group.
Vaitkevicius et al. (45) observed in a small pilot
study including 22 elderly subjects (mean age of
84 years) a significant reduction in resting systolic
blood pressure (146 ± 18 vs. 133 ± 14 mmHg,
p = 0.01) without significant effects on resting dia-
stolic blood pressure, after 6 months of aerobic exer-
cise training (at 60–80% of maximal heart rate).
Kelley and Sharpe Kelley (46) in a meta analysis
including individuals aged more than 50 years
reported after an aerobic programme a significant
decrease in blood pressure values only for systolic
pressure. Such benefits on the blood pressure profile
are observed for moderate intensity exercises such as
walking, but other physical activities such as swim-
ming do not seem to be associated with these posi-
tive benefits (47).
Concerning secondary prevention, aerobic exercise
reduces blood pressure in both hypertensive and nor-
motensive persons in general population (40). In the
meta analysis of Dickinson et al. (48) physical activity
led to a reduction in both systolic blood pressure and
diastolic blood pressure. The effect of physical activity
on blood pressure of older patients with hypertension
has been assessed on smaller groups, with apparent
smaller benefits than for middle-aged patients (49).
Hagberg et al. (50) in a non-randomised study includ-
ing older hypertensive subjects (mean age 64 years),
followed up during 9 months, report a significant
reduction in systolic blood pressure only in the low-
intensity group and not in the moderate intensity
group compared with the control group.
Cardio-respiratory performances
Aerobic fitness (V02max) in older people is related to
all-cause mortality, CHD, health status and func-
tional capacity (51). V02max declines with ageing and
310 Physical activity in older patients

Table 4 Physical activity and blood pressure

Population and interventions Outcomes Reference

Effect of resistance training on resting blood Average net change in blood pressure related to (40)
pressure: a meta analysis of 54 randomised aerobic exercise (mmHg)
controlled trials 2419 subjects (aged 21–79 years) Systolic blood pressure: )3.84; 95%CI ()4.97
to )2.72), p < 0.001
Diastolic blood pressure: )2.58; 95%CI ()3.35
to )1.81), p < 0.001
Effect of resistance training on resting blood Overall pooled net effect of training on: (41)
pressure: a meta analysis of nine randomised Systolic blood pressure: )3.2 mmHg (p = 0.1)
controlled trials involving 341 subjects Diastolic blood pressure: )3.5 mmHg (p < 0.001)
(69 years old)
Randomised controlled trial: 44 sedentary healthy Blood pressures changes after 6 months in training (43)
subjects (60–79 years) assigned either to groups (mmHg) (control group used as reference):
moderate intensity group (70% of V02max), high Systolic blood pressure (p < 0.005)*
intensity group (70 to 85% of V02max) or control Moderate intensity group: )9
Follow up: 6 months High intensity group: )8
Diastolic blood pressure (p < 0.005)*
Moderate intensity group: )8
High intensity group: )7
31 elderly subjects (68.5 years) randomised in a 24-h ambulatory systolic (ASBP) and diastolic (39)
training group (50–85% of maximal workload, (ADBP) blood pressures changes after 16 weeks
3.6 h per week) and a control group training
Follow up: 16 weeks Training group
ASBP: )7.9 mmHg (p = 0.0001)*
ADBP: )3.6 mmHg (p = 0.002)*
Control group: NS
22 elderly subjects (84.5 years) enrolled in a Blood pressure changes after 6 months training: (45)
6-month moderate-intensity aerobic exercise Systolic blood pressure: 133 vs. 146 mmHg;
training program p = 0.01
Pretest ⁄ posttest design Diastolic blood pressure: NS
Effect of aerobic exercise and resting blood Average net change in blood pressure related to (46)
pressure in elderly adults: a meta analysis of aerobic exercise (95%CI)
seven randomised controlled trial Systolic blood pressure: )2 mmHg ()4
to )1 mmHg)
Diastolic blood pressure: )1 mmHg ()2
to 0 mmHg)
Randomised controlled trial: 116 sedentary Average net change in blood pressure related (47)
normotensive women (55 years old) assigned to aerobic exercise (95%CI):
either a 6-month swimming or walking Systolic supine blood pressure: 4.4 mmHg
programme or a control group (1.2–7.5 mmHg); p = 0.008
Diastolic supine blood pressure: 1.4 mmHg
()0.14 to 3.0 mmHg); p = 0.07
Effect of lifestyle interventions to reduce raised Net reduction in blood pressure (95%CI): (48)
blood pressure: a meta analysis of 105 Systolic blood pressure: )6.1 mmHg ()10.1
randomised controlled trials 6805 subjects to )2.1 mmHg)
(25 years old) Diastolic blood pressure: )3.0 mmHg ()4.9
to )1.1 mmHg)

*Compared with placebo group. 95%CI, 95% confident interval; NS, no significant differences.

a value of 15–18 ml ⁄ kg ⁄ min must be maintained to
be independent for daily activity. The V02max of
endurance-trained subjects is higher than that of sed-
entary subjects for the same age. In addition, V02max
in endurance-trained older subjects has been
reported as similar to V02max in sedentary young
subjects (52). Nevertheless, the rate of V02max decline
with ageing in both trained and sedentary-group is a
matter of debate. Discrepant results are observed in
both genders, especially between the absolute rate of

ª 2009 The Authors

Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320

decline and the relative rate of decline (percent
decrease from baseline in young adulthood) (53).
Benefit of endurance training programmes on the
V02max among elderly people is established, in small
sample-size studies. In these studies, older or very
older subjects have to be able to participate in a high
intensity endurance programme. Thus, they are in
some regard selected, often healthy and well-motivated
without significant orthopaedic diseases and comor-
bidities. Malbut et al. (54) noted in a small group of
elderly people in a 24-weeks endurance programme
(75–80% of V02max) a 15% increase in the V02max
among women. Similarly, Evans et al. (34) reported in
10 subjects (80.3 years old) an increase of 15% of
V02peak after 108 exercises sessions of an endurance
training program with an intensity at 60–85% of
V02peak. Older subjects with a lower baseline V02peak
seem to have the greatest improvement in V02peak
after training as shown by Vaitkevicius et al. (45) in
small non-randomised study. Moreover, some data
suggest that endurance exercise training in elderly peo-
ple results in a compensatory reduction in the physical
activity throughout the rest of the day (55). Evans
et al. (34) did not observe such phenomenon but
noted an inverse trend with an increase in the total
energy expenditure by 400 kcal ⁄ day as the result of an
increase in physical activity.
Prevention of cancers
Evidence is accumulating that high levels of physical
activity are associated with a reduced risk of some
cancers (56). The relationship between physical activ-
ity and a reduced risk of colon cancer is among the
most consistent findings in the epidemiologic litera-
ture, reported in the studies of occupational activity,
leisure activity and total activity, but not specially in
older population (57,58). As reported by Friedenr-
eich (59) the risk reduction is between 10% and
more than 50% with an average risk reduction in at
least 40%. There is a difficult issue of taking into
account potential confounding factors. Indeed, physi-
cally active subjects may exhibit other lifestyle char-
acteristics that are associated with a risk reduction of
the colon cancer (60). Concerning breast cancer, the
overall evidence reveals a reduced risk of breast can-
cer with increased physical activity (61). The risk
reduction ranges from 20% to 80% and appears
higher for postmenopausal breast cancer than for
premenopausal breast cancer (62). Numerous ques-
tions remain regarding the putative association
regarding the underlying mechanisms or the dose-
response aspect as well as the possibility of con-
founding factors (63). Concerning other cancers, the
benefit of physical activity is not clearly proved. As
reported by Friedenreich, the evidence for an aetio-
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Physical activity in older patients 311
logical role of physical activity in reducing the risk of
cancer can be classified as follows: probable for pros-
tate cancer, possible for lung and endometrial can-
cers, insufficient for testicular and ovarian cancers
(64).
Benefit on bone mineral density and risk of
fracture
Impact of exercise on bone density and fall-related
injuries is complex and a matter of debate, especially
concerning risk of fracture (Table 5). There is no
randomised controlled trial specifically designed to
evaluate the role of physical activity in reduction in
fracture rate. Moreover, some authors suggest a
U-shape association between physical activity and
fracture risk, with an increase risk of falls with certain
type of exercise. Beyond the bone density, it is impor-
tant to take into account the established risk factors
for falls such as impaired balance, decreased reaction
time, impaired vision and cognition, weakness in
lower-extremity muscles, sarcopenia and medications.
In a cohort study involving women aged 65 years
or older, Cummings et al. assessed the risk factors
for incident hips fractures and observed in a multi-
variate model that women who regularly walk for
exercise have a 30% lower risk of hip fracture. Nev-
ertheless, after adjustment for mineral bone density
and history of fracture, this difference loses its signif-
icance (65). Ebrahim et al. (66) did not report any
significant net change for the femoral neck bone
mineral density in the exercise group compared with
the control group, but observed a significant
increased risk of falls in the active group compared
with the control group. Robbins et al. (67) observed
in a large prospective study a significant greater OR
of incident hip fracture in the inactive postmeno-
pausal women compared with those who practise
activities.
Concerning the effect of physical activities on bone
mineral density, results are disparate. In a meta anal-
ysis including 10 randomised trials of 595 postmeno-
pausal women (mean age 65 years), Kelley and
Kelley (68) evaluated the impact of exercise on bone
mineral density at the femoral neck and did not
reports significant results.
In a meta analysis, Wolff et al. (69) reported that
physical activity does not offer significant benefit on
the bone mineral density among postmenopausal,
using randomised and non-randomised control trials,
for endurance and also strength training. Finally, in a
meta analysis of randomised trials and including
postmenopausal women, Wallace and Cumming (70)
observed that on the lumbar spine, both impact and
non-impact exercises have a positive effect on bone
mineral density.
312 Physical activity in older patients
Table 5 Physical activity, mineral bone density and fractures
Population and interventions
Prospective study cohort: 9516 white women (72 years old)
without previous hip fracture.
Assessment of physical activity by questionnaires at
baseline
Follow up: 4.1 years
Randomised controlled trial: 91 postmenopausal women
assigned to either an exercise (n = 46; age: 66.5 years;
104 weeks of walking three times each week for 40 min
per session) or control (n = 45; age: 68.2 years) group
Follow up: 2 years (with 68 dropped out subjects)
Prospective study cohort: 68,132 postmenopausal women
Assessment of physical activity by questionnaires at
baseline
Follow up: 7.6 years
Meta analysis of 10 randomised controlled trial including
595 older subjects (65 years old): effect of physical
activity on bone mineral density
Meta analysis of 25 trials: effect of exercise training
programs on bone mineral density:
Meta analysis of 24 randomised controlled trial including
postmenopausal women: effect of exercise training
programs on bone mineral density
Prospective study: 43 osteopenic postmenopausal women
(57 years old) allocated either an exercise group (treadmill
walking at 70% V02max) or a control group
Follow up: 24 weeks
Randomised controlled trial: 35 osteoporotic
postmenopausal women assigned either to a 2-year
exercise group (n = 8), 1-year exercise group (n = 7)
or a control group (n = 20).
Follow up: 2 years
Prospective study cohort: 61,200 postmenopausal
women (61 years old)
Assessment of physical activity by questionnaires
at baseline
Follow up: 12 years
Prospective study cohort: 3262 men (44 years old or older)
Assessment of physical activity by questionnaires
at baseline
Follow up: 21 years
DEXA, dual–energy X-ray absorptiometry; NS, no significant differences; RR, relative risk.
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Outcomes Reference
Relative risk of incident hip fracture (95%CI): walking for (65)
exercise vs. not walking for exercise: 0.7 (0.5–1.0)
Net changes (intervention group changes minus (66)
control group changes) in femoral neck bone mineral
density at 2 years (95%CI): 0.019 g ⁄ cm2 ()0.0026
to +0.041 g ⁄ cm2)
Cumulative falls risk at 2 years (rate per 100 persons-year):
70.3 (walking group), 55.1 (control group); p < 0.01
Cumulative fractures risk at 2 years (rate per 100
persons-year): 5.9 (walking group), 4.1 (control group); NS
Odds ratio of incident hip fracture during follow up (67)
(95%CI):
Inactive vs. £ 12 Mets physical activity per week: 1.64
(1.24–2.17)
Femoral bone mineral density changes (g ⁄ cm2): (68)
Initial: 0,763 (control group), 0.787 (active group)
Final: 0.764 (control group), 0,791 (active group); p > 0.05
Overall exercise training program effects on bone mineral (69)
density (95%CI) for randomised controlled trial including
postmenopausal women:
Lumbar spine: 0.79 (0.35–1.22)
Femoral neck: 0.89 (0.5–1.29)
Pooled measure of effect: of exercise on bone mineral (70)
density (95%CI):
Spine, impact exercise: 1.6% (1.0–2.2%)
Spine, non-impact exercise: 1.0% (0.4–1.6%)
Femoral neck, impact exercise: 0.9% (0.5–1.3%)
Femoral neck, non-impact exercise: 1.4% (0.2–2.6%)
Changes of bone mineral density at 24-weeks: (72)
Active group: spine L2–L4: + 2% (p > 0.05); femoral neck:
6.8% (p < 0.05)
Control group: spine L2–L4: )2.3% (p < 0.05); femoral
neck: + 1.5% (p > 0.05)
Lumbar bone mineral density changes at 2 years: (73)
In the 2-year exercise group: 0.620 (p < 0.05)
In the 1-year exercise group: 0.632 NS
In the control group: 0.616 NS
RR of hip fracture by metabolic equivalent (MET)-hours per (74)
week of activity (95% CI) < 3 MET ⁄ hours ⁄ week used as
reference:
3–8.9: 0.74 (0.57–0.95)
9–14.9: 0.63 (0.46–0.85)
15–23.9: 0.47 (0.34–0.65)
‡ 24: 0.41 (0.29–0.57)
RR of hip fracture during follow up (95%CI): (75)
Participation in vigorous physical activity: 0.38 (0.16–0.91)
Occasional exercisers: 0.80 (0.41–1.54)
ª 2009 The Authors

These benefits seem to depend on the type of
physical activity. On one hand, some exercises appear
to bring little benefit on the bone structure (swim-
ming) and others seem to slow age-related bone loss
(walking, moderately intense low impact exercise).
On the other hand, others appear to increase bone
density (running and vigorous, high impact, aerobic
exercise). Moreover, the benefit on mineral density
concerns mainly bones that are involved in the exer-
cise (upper limbs and squash, for example) (71). The
effect of physical activity in the case of established
osteoporosis has also been evaluated, especially for
high intensity and high impact exercises, with
favourable benefit after long-term physical activity
exercises (72,73).
It is shown that physical activity reduces the risk
of hip fracture concerning women (74) and men
(75). Recently, Moayyeri assessed the potential cau-
sal association between physical activity and osteo-
porotic fractures from an epidemiological
viewpoint, using a meta analysis of 13 prospective
cohort studies. The author reported that moderate-
to-vigorous physical activity is associated with a hip
fracture risk reduction of 45% (95% CI: 31–56%)
among men and 38% (95% CI: 31–44%) among
women (76). The differential impact of exercises on
muscle strength and mineral bone density is still
debated. The type and intensity of physical activity
that best reduce the fracture risk also remain
unclear (77).
Avoiding falls
Exercises including balance training, strength and
flexibility exercises have been associated with a
reduced risk of falls in older people, especially in a
multidimensional approach (78). Nevertheless, con-
flicting results have been reported, especially in pre-
vention of fall-related injury as seen in several meta
analyses (79–81) (Table 6). Recently, in a multicentre
randomised controlled trial, using a moderate inten-
sity exercise programs Faber et al. (82) did not
observe any positive effect on falls in the frail elderly
people group. The same trend is observed in other
studies (83). In contrast, some randomised con-
trolled trials have reported positive results (84–88).
Specific physical activities such as Tai chi, a Chinese
martial art characterised by slow, controlled and pur-
poseful movement have also been evaluated. Authors
report a reduced incidence of falls and an improve-
ment in physical performance and balance. This is
highlighted in a randomised study (89). However,
some literature reviews and randomised controlled
trials do not find these positive effects of Tai chi
(90,93). Nevertheless, Tai chi has great promise as a
primary preventive exercise to maintain function and
ª 2009 The Authors
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Physical activity in older patients 313
as a secondary preventive strategy for older subjects
with poor balance (94).
Cognitive benefit: decreased risk of dementia
Body of evidence supports the role of physical activ-
ity as a tool to maintain cognitive performance. Sev-
eral randomised trials and longitudinal studies have
reported some benefits in various kind of cognitive
outcomes, such as cognitive scales, but without spe-
cific assessment of incident dementia risk and its
leading cause, the Alzheimer’s disease. (95,96). Using
data of the Canadian Study of Health and Aging,
among 4615 subjects free from dementia at baseline,
Laurin et al. (97) reported that high levels of physical
activity is associated with a reduced risk of incidence
of Alzheimer’s disease (OR: 0.50; CI 95%: 0.28–
0.90), after a 5-year follow up. The same trend was
observed by Larson et al. In a prospective cohort
study (1740 persons older than 65 years old) with a
mean follow up of 6.2 years, Larson et al. reported
that the incidence rate of dementia is 13.0 per 1000
person-years for persons who exercised three or
more times per week, compared with 19.7 per 1000
person-years for persons who exercised fewer than
three times per week (hazard ratio for the regular
exercise group: HR:0.62; CI 95%: 0.44–0.86) (98).
Among 2257 physically capable men aged from 71 to
93 years in the Honolulu-Asia Aging Study Abbot
et al. (99) suggested that walking is associated with a
reduced risk of dementia with nearly 7 years of fol-
low up. The relative hazard (RH) of incidences of
Alzheimer’s disease in men who walked < 0.25 mile
per day compared with those who walked more than
2 miles per day is: (RH: 2.21;CI 95%: 1.06–4.57). In
the Cardiovascular Health Study, conducted in the
United States, participants who expended the highest
quartile of energy (calculated at more than
1657 kcal ⁄ week) had a lower risk of Alzheimer’s dis-
ease (adjusted RR 0.55, CI 95%: 0.34–0.88) com-
pared with participants who expended the lowest
quartile of energy (estimated at < 248 kcal ⁄ week)
(100). Nevertheless, some studies have failed to
observe the benefits of physical exercise in preserving
cognitive function as shown by Broe et al. (101)s
using the Sydney Older Persons Study or Wang et al.
(102) with a longitudinal study from the Kungslol-
men Project. More recently, Lautenschlager et al.
(103) reported in a 24-week randomised trial includ-
ing 170 older subjects (68 years old) with subjective
cognitive impairment that a home-based physical
activity programme significantly improves the Alzhei-
mer Disease Assessment Scale Cognitive Subscale
compared with the usual care. Physical activity may
be a surrogate for overall ‘life engagement’ that con-
tributes to develop social network. In fact, a greater
314 Physical activity in older patients
Table 6 physical activity and risk of falls
Population and interventions
20-week randomised controlled trial: 278 frail
institutionalised elderly people (85.6 years old) assigned
to walking programme (n = 66), in balance programme
(n = 80) or control group (n = 92)
Follow up: 52 weeks
Randomised controlled trial: 455 elderly subjects (88 years
old) with history of falls assigned either an exercise group
(n = 217) or a control group (n = 220)
Follow up: 16 months
Randomised, controlled, single-blind 25-week prospective
study: 90 older subjects (79.3 years old) assigned to
either a resistance training (n = 32), an agility training
(n = 34) and a stretching exercises group (n = 32)
Assessment risk of fall using the physiological profile
assessment (PPA)
Randomised controlled trial of 12 months’ duration: 551
older subjects (79.5 years old) assigned to either an
exercise group 1 hour twice weekly (n = 280) and
a control group (n = 271)
Randomised controlled trial: 52 elderly female community
living residents (77 years old) assigned either an exercise
group with home exercises three times a week and a
intervention programme every 2 weeks (n = 28)
and a control group (n = 24)
6 months intervention and 20 months follow up
Randomised controlled trial: 310 community residents
(78 years old) assigned either an exercise programme
(included in a multifaceted-based program; n = 157)
or a control group (n = 153)
Follow up: 14 months
Randomised controlled trial: 163 older community-dwelling
subjects (74 years old) allocated either an exercise group
(n = 83) or a controlled group (n = 80)
Follow up: 12 months
6-month randomised controlled trial: 256 community-
dwelling elderly subjects (77.5 years old) allocated
either a tai chi group (three times per week) or a
control group
Follow up: 6 months
Randomised controlled trial: 110 institutionalised elderly
people assigned to a endurance – resistance group
(n = 37), a tai chi group (n = 38) or a control group
(n = 35)
Follow up: 24 months
Randomised controlled trial: 286 frail institutionalised
elderly people assigned to a tai chi group (n = 145)
or a wellness education group (n = 141)
Follow up: 48 weeks
Randomised controlled trial: 702 older community-dwelling
subjects (69 years old) assigned either a tai chi group
(1 h weekly; n = 353) or a control group (n = 349)
Follow up: 16 weeks
NS, no significant differences; CI, confidence interval.
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Outcomes Reference
Fall incidence rate: 3.3 ± 5.6 (walking (82)
programme), 2.4 ± 4.6 (in balance
programme), 2.5 ± 4.6 (control group): NS
Hazard ratio of falls in the exercise group (83)
compared with the control group during the
study period (95%CI): 0.93 (0.80–1.09)
PPA fall risk score: (84)
Resistance training group: )57.3% (p < 0.01)
Agility training group: )47.5% (p < 0.01)
Stretching exercises group: 20.2 (NS)
Incidence rate ratio of falls (95% CI) comparing (85)
the rate of falls in the exercise group vs. the
control group: 0.78 (0.62–0.99)
Proportion of women with falls in each group: (86)
Before intervention: 16.7% in the control group
and 14.3% in the exercise group had
experienced falls (NS)
At the 20-month follow up: 54.5% women
with falls in the control group and 13.6% in
the exercise group (p = 0.0097)
Relative risk of falls in the exercise group (87)
compared with the control group during the
follow up (95%CI): 0.69 (0.50–0.96)
Incident rate ratio of fall in the exercise group (88)
compared with the control group (95%CI):
0.60 (0.36–0.99)
Number of falls during follow up: 38 (tai chi (89)
group) and 73 (control group); p = 0.007
Rates of falls: 72% (endurance – resistance (91)
group), 58% (tai chi group), 75% (control
group); p = 0.27, NS
Risk ratio of falling (95%CI) in the tai chi (92)
group compared with the wellness education
group: 0.75 (0.52–1.08)
Incident ratio rate of falls in the tai chi group (93)
compared with the control group during the
follow up (95%CI): 0.73 (0.50–1.07)
ª 2009 The Authors

social activity is associated not only with a lower risk
of all-cause mortality but also with lower rate of cog-
nitive decline among older subjects (104,105). As
practising a physical activity can indicate a developed
social environment, it may decrease dementia risk
(106,107).
Numerous studies have reported benefit of physi-
cal activity on cognitive functions of older people
with cognitive impairment or dementia. According
to Heyn et al. (108) in a meta analysis involving 30
randomised trials including 2020 people of over
65 years, exercise training significantly increased
strength, physical fitness, functional performance,
cognitive performance and behaviour. Physical activ-
ity has also been linked to improved quality of life
and mood for Alzheimer’s patients (109). A recent
study suggested that subjects in the early stages of
Alzheimer’s disease are able to participate in a
maximal exercise testing (in terms of peak oxygen
consumption) and have comparable levels of cardio-
respiratory fitness as non-demented subjects (110).
Benefits of physical activity in the very older
people and frail subjects
Concerning very older subjects (80 years and older),
benefits of physical activity are not appreciated in
terms of primary or secondary prevention. Benefits
are considered in terms of strength, muscular func-
tion and more difficult, in terms of disability preven-
tion. As aerobic exercises in endurance are difficult
to perform for elderly people, strength exercise
programs in resistance are often chosen. Physical
activity must be adapted to the physiological ageing
process. The first aim is to improve functional activ-
ity without injuries.
Physical activity among elderly people and very
elderly people does not slow down the age-related
loss of muscle fibre, but is associated with a strength
gain of between 10% and 180%, comparable to a
‘rejuvenescence’ of 10–20 years (111–114). An
increased strength is noticed. This can be explained
by muscle fibre hypertrophy, (fibres type I and II) of
up to 30% (115,116). An increase in the motor unit
recruitment is also reported. In a randomised con-
trolled trial including 100 frail nursing home resi-
dents (mean age 87.1 years), Fiatarone et al. (117)
observed a significant increase in muscular strength,
gait velocity and cross-sectional thigh-muscle area
after a 10-week period of progressive resistance exer-
cise training. In a randomised controlled trial,
including 136 older subjects (mean age: 75 years)
participating in a both endurance and resistance pro-
gramme for 4–8 weeks, with impairment at least for
one activity of daily living, Meuleman et al. (118)
reported a significant improvement in functional
ª 2009 The Authors
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Physical activity in older patients 315
activity for those who were the most dysfunctional at
enrolment. In contrast, in a multicentre randomised
controlled trial including 268 older subjects of
85 years old, Faber et al. (119) reported positive
effects of a 52-week program on falling and physical
performance in prefrail and not in frail elderly peo-
ple. The same trend was reported by Gill et al. (120)
in a randomised controlled trial including 188 frail
persons 75 years of age living at home who under-
went a 6-month intervention program. Gill et al. do
not find any change concerning disability based on
eight activities of daily living among participants
with severe frailty. Concerning patients with demen-
tia, they benefited from exercise programme. This
effect is shown by Toulotte et al. (121) who observed
in a randomised trial including 20 older demented
patients (81.4 years) an improvement of walking,
mobility, flexibility and static balance after 16 weeks
of training. However, it is less clear whether physical
activity prevents or minimises physical disability as
shown by Latham et al. (122) who do not find any
effect on disability in a systematic review of 41
randomised trials with progressive resistance strength
training. Keysor reported the same trend with incon-
sistent results regarding the beneficial effects of exer-
cise on disability outcomes and showed a divergence
between prospective and experimental studies. A
majority of experimental studies included in that
review did not identify an improvement in disability,
whereas several prospective studies showed a benefi-
cial effect of physical activity on minimizing
disability (123). Although the observational studies
were well designed in this review, some potential bias
could explain this divergence, such as the link
between physical inactivity at baseline and poor
health or functional limitations or the assessment of
physical activity by self-report. The benefit of physi-
cal activity programme on disability (activity of daily
living) of the very elderly people or frail remains
unclear (122,124,125), although some studies
observed encouraging results (126).
Recommendations
Recently, the American College of Sports Medicine
and the American Heart Association published the
recommendations on the type and amounts of physi-
cal activity needed to improve and maintain health
in older subjects (127). Older adults need moderate
intensity aerobic exercise for a minimum of 30 min
on 5 days each week or vigorous intensity aerobic
activity for at least 20 min on 3 days each week
[Classifications of recommendation (COR): I; Levels
of evidence (LOE): A]. Promotion of muscle-
strengthening activity is recommend for a minimum
of 2 days each week (COR: IIa; LOE: A). Older
316 Physical activity in older patients
subjects should perform flexibility activities on at
least 2 days of each week for at least 10 min each
day (COR: IIb; LOE: B). At last, to reduce the risk of
falls, community-dwelling older subjects with sub-
stantial risk of falls should perform exercises that
maintain or improve balance (COR: IIa; LOE: A).
It is essential to note that recommendations con-
cern exclusively ‘older adults’ without any specifica-
tions concerning ‘very elderly’, ‘frail elderly’, older
subjects in nursing homes as well as older subjects
with disability or major chronic conditions such as
Alzheimer’s disease.
Advice from health professionals is an important
part of the solution to the societal problem of inac-
tivity. If no local supervised programme is available,
physicians should encourage patients to be more
active through simple, safe and attractive physical
activities. Physicians should persuade their patients
to integrate physical activity into their everyday life,
for example, walking to the train station or local
shop, walking the dog, using stairs instead of eleva-
tors, spending less time in front of the television or
computer. Finally, when no training programme is
available, older subjects should look for simple ways
to be physically active every day and find activities
they enjoy doing.
Conclusion
Keeping in mind the numerous adverse effects of a
sedentary lifestyle and the benefits of a modest
increase in activity, physical inactivity remains a
major health challenge for the older age group even
in the frailest and the most vulnerable one (Table 7).
Walking (at least 30 min per day preferentially all
days of the week) appears as the exercise of choice
among older subjects, because of its benign nature,
lack of need of supervision and universal availability.
Nevertheless, less vigorous levels of activity and spe-
cific types of exercises may be more appropriate for
more frail and disabled persons (128). Risks associ-
ated with exercise practice, essentially musculoskele-
tal injury, are avoidable with appropriate caution.
Despite evidence documenting that exercise is ben-
eficial for older subjects even for the oldest, many
old patients do not achieve the recommended levels
of physical activity. Promoting physical activity at an
individual-level and ⁄ or at community-level is still a
matter of debate, especially regarding concerns about
efficacy in long-term (129).
Improving collaboration between physicians and
other healthcare workers is essential. The heterogene-
ity of the older people in terms of cardiovascular fit-
ness, muscle strength, performance in activities of
daily living, medical comorbidities, psychosocial
Journal compilation ª 2009 Blackwell Publishing Ltd Int J Clin Pract February 2009, 63, 2, 303–320
Table 7 health benefits of physical activity
Health benefits of physical activity
among older subjects
Reduction in total mortality rate
Primary prevention of coronary heart disease
Benefit on lipid profile
Modification of body composition with reduction in
both body fat and age-related sarcopenia
Primary and secondary prevention of type 2 diabetes
Primary prevention of stroke
Lowering blood pressure with prevention and control
of hypertension
Reduction in peak oxygen consumption (V02max)
age-related decline
Primary prevention of colon cancer and breast cancer
Primary prevention of hip fracture
Prevention of falls (in a multidimensional approach)
Possible cognitive benefit with reduction in dementia
incidence
Benefits on strength and muscular function among
very old people, and frail older subjects
needs and desires must be taken into account to pre-
scribe individualised and appropriate physical activi-
ties. Lack of financial incentives stands in the way of
the promotion of physical activity (130).
In the geriatric department of the University Hos-
pital of Strasbourg, we have been able to convince
two health insurance companies, one public (Mutua-
lité Sociale Agricole) and another private (Mutuelle
Générale de l’Éducation Nationale), to cosubsidise an
exercise programme in elderly people (131). This
intermittent work exercise training was adapted from
a 2-month personalised interval training programme
on ergocycle and involved 18 sessions (three per
week) of alternating 30 min of aerobic and anaerobic
activities. Preliminary data show a 30–100%
improvement in the cardio-respiratory endurance
pattern of these elderly patients; all of them were
convinced that it was beneficial and asked to con-
tinue the programme (132,133). The cost of this
6-week endurance programme is 972 euros including
two cycle incremental exercise tests, one transtho-
racic echocardiography, 18 training sessions on ergo-
cycle and two outpatient consultations. In recent
months, demented older subjects (Alzheimer’s dis-
ease) and the respective caregiver (often spouse) have
been included in this intermittent work exercise
training with encouraging early results in terms of
feasibility and efficacy.
Further studies are needed to understand better,
on a population level, the optimal activity-promoting
interventions in the older patient group and particu-
ª 2009 The Authors

larly for the frail elderly people and the institutiona-
lised older persons (134).
Author contributions
Thomas Vogel, Pierre-Henri Brechat, Pierre-Marie
Leprêtre contributed to the conception of the
study, internet search and interpretation of data.
Thomas Vogel and Jean Lonsdorfer contributed to
additional analysis of data. Thomas Vogel, Marc
Berthel and Georges Kaltenbach contributed to
drafting and critical revisions of the manuscript.
All authors gave final approval of the manuscript
submitted.
Acknowledgement
Acknowledgement to Caroline Djenani for her writ-
ing assistance.
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Paper received June 2008, accepted October 2008
ª 2009 The Authors