Exercise in Older Adults and Frailty

Both the UK and WHO recommend that older adults accumulate at least 150 minutes of moderate activity a week, or 75 minutes of vigorous activity, building up gradually, with weight-bearing activity to protect bone. The important difference is in strength and balance. The UK asks for activities that maintain or improve muscle strength, balance and flexibility on at least 2 days a week, which can be combined with aerobic sessions. WHO goes further, recommending varied multicomponent activity that emphasises functional balance and strength on at least 3 days a week specifically to improve function and prevent falls, in addition to strengthening on at least 2 days. For a person who is falling, the WHO emphasis on balance work at least 3 days a week is the more useful target.

Loss of muscle strength is the main limiting factor for independence in later life, and poor balance predicts both falls and cognitive decline, which is why strength and balance receive such prominence in the older-adult guidance. Structured strength and balance programmes reduce the rate and risk of falls and are cost effective, and they can be group based, home based, or embedded in everyday tasks such as sit-to-stands and stair climbing. Practical balance activities include standing on one leg, heel-to-toe and backward walking, and Tai Chi, while resistance can come from weights, bands or body weight. For healthy older adults who like to track steps, around 7,000 to 10,000 steps a day is an approximate optional equivalent for health, with benefit for quality of life seen from about 4,500 to 5,500 steps a day; it is a rough guide rather than a universal target, and is less applicable to frailer people.

Falls are rarely due to a single cause. Current UK guidance recommends that older adults who have had two or more falls in the past year, a fall with loss of consciousness, an injurious fall, or who are frail, receive a comprehensive multifactorial falls assessment and management, with exercise programmes that are progressive, individualised and delivered by appropriately trained professionals. Part of this is a structured, individualised medication review, in which a specific task for the SEM doctor is to look for culprit drugs such as sedatives and hypnotics like benzodiazepines and zopiclone, sedating antidepressants and antipsychotics, and blood pressure lowering medicines that can cause postural hypotension, alongside checking vision, footwear and home hazards.

Two details make the difference between a programme that reduces falls and one that does not. The first is that balance must be genuinely and progressively challenged, by reducing the base of support, shifting the centre of mass or reducing reliance on hand support. Structured home-based approaches such as the Otago programme, and group programmes of similar design, are the models carrying the evidence. Walking alone, however regular, rarely provides enough balance challenge to reduce falls.

The second is that muscle power matters more than maximal strength for falls specifically. Recovering from a trip requires generating force within a fraction of a second, and power declines earlier and faster than maximal strength with age because type II fibres are lost preferentially. That is the rationale for including higher-velocity movement where it is safe and technically competent. Maximal oxygen uptake also falls by roughly ten per cent per decade after the age of about 30, which compounds the loss of functional reserve. Dose matters: effective programmes need multiple sessions weekly sustained over months, with progression, and the benefit declines once training stops, so maintenance should be framed as ongoing rather than as a fixed course.

The same guidance is applied very differently depending on where a person sits on the spectrum of function. Active older adults, who already walk or play sport, gain most from adding resistance, impact and balance work two or more times a week. Those in transition, whose function is declining through inactivity but who remain reasonably healthy, benefit from strategies such as walk and rest for a minute to manage fatigue while building up, with sit-to-stands, stair climbing and home strength and balance exercises to build confidence and stability. For frailer older adults, often with arthritis, dementia or advanced age, the goal is simply to reduce sitting and add any light activity, regular sit-to-stand exercise, short walks, and strength and balance work built into daily tasks, increasing the duration of walking rather than its intensity.

The benefits of activity in older adults are so well established that they can be stated to outweigh the risks, and the safest approach is to start low and build gradually. In older adults with frailty, moderate to severe dementia, or a history of vertebral fractures or repeated falls, it is more appropriate for any new exercises to be supervised initially by a trained professional to ensure they are done safely and effectively. Referral to a structured strength and balance or falls prevention programme is valuable for anyone at risk of falling, and a person with unexplained falls, blackouts or possible cardiac symptoms should be assessed medically first.

• •At least 150 minutes moderate or 75 minutes vigorous a week, built up gradually, with weight-bearing activity for bone.
• •UK: strength, balance and flexibility on at least 2 days; WHO: multicomponent balance and strength on at least 3 days to prevent falls.
• •Strength and balance programmes reduce falls and are cost effective; aim around 7,000 to 10,000 steps a day.
• •Falls need a multifactorial assessment, including review of sedatives, sedating antidepressants and blood pressure drugs causing postural hypotension.
• •Supervise new exercise initially in frailty, moderate to severe dementia, or vertebral fracture or repeated falls.
• •Refer to a falls prevention or strength and balance programme; assess unexplained falls or blackouts first.