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Bushman, Barbara Ph.D., FACSM; Goddard, Stacy DHEd, MCHES

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ACSM's Health & Fitness Journal 24(5):p 46-55, 9/10 2020. | DOI: 10.1249/FIT.0000000000000607
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• Incorporating balance and mobility exercises, in addition to muscular strength, aerobic activities, and flexibility, is needed to prevent falls among older adults.

• Functional activities can be added into any phase of a workout for older adults from warm-up to cool-down.

• Adequately addressing barriers while emphasizing motivators is key in promoting physical activity and well-being.

• Health and fitness professionals are in a pivotal position to take a holistic approach to wellness with well-designed programs that are physically and mentally stimulating.


The use of the term “older adult” by the American College of Sports Medicine (ACSM) includes people who are 65 years of age or older as well as those who are 50 to 64 years of age with clinical conditions or physical limitations affecting movement, fitness, or physical activity (PA) (1). Older adults vary in fitness and physical abilities, with some engaging in competitive athletic endeavors whereas others are limited by effects of chronic diseases or inactivity (2). Given the differences in physical capabilities within this age range, responses to exercise by those of the same chronological age may differ greatly, although the effect of chronological aging and deconditioning are often intertwined (1). Lacking discovery of a means to turn back time, chronological aging is inevitable; however, avoiding the effect of age-related declines by promoting PA is key to promoting health and wellness throughout the life span (2).

Lacking discovery of a means to turn back time, chronological aging is inevitable; however, avoiding the effect of age-related declines by promoting PA is key to promoting health and wellness throughout the life span.

Chronological aging brings about physiological changes in body systems due to the actual passage of time (3). Examples include declines in maximal aerobic capacity, decreases in muscular strength, and changes in body composition (3). Contributing to age-related responses are potential genetic factors and lifestyle behaviors (3). Regular PA is one lifestyle factor that appears to promote “successful aging” in a myriad of ways, including preservation of functional capacity and risk reduction for several chronic diseases (3).


According to the National Council on Aging, approximately 80% of older adults have at least one chronic disease, and 77% have at least two with the most common being heart disease, stroke, diabetes, and cancer (4). Regular PA has the potential to reduce the risk of developing cardiovascular disease (including heart attack, stroke, and heart failure), type 2 diabetes, and several cancers (including bladder, breast, colon, endometrium, esophagus, kidney, lung, and stomach) (2). In addition, physical health provides more resilience when health problems arise (e.g., exercise-based cardiac rehabilitation programs have been found to reduce the risk of cardiovascular mortality [5], and regular exercise can improve many aspects of both physical and mental health during cancer treatment [6]). See Box 1 for an encouraging list of benefits for older adults that can result from regular PA (2).

Box 1: Benefits of regular PA.

The Physical Activity Guidelines for Americans, 2nd edition, provides insight into the wide-ranging benefits of regular PA for older adults, including (2):

  • lower risk of all-cause mortality and cardiovascular disease mortality
  • lower risk of many diseases and conditions including cardiovascular disease, hypertension, type 2 diabetes, adverse blood lipid profile, and many cancers
  • improved cognition and reduced risk of dementia (including Alzheimer’s disease)
  • improved quality of life
  • reduced anxiety and reduced risk of depression
  • improved sleep
  • slowed or reduced weight gain; weight loss, particularly when combined with reduced calorie intake; prevention of weight regain following initial weight loss
  • improved bone health
  • improved physical function
  • lower risk of falls and fall-related injuries

Although life expectancy is increasing (see Box 2), most older adults are living with chronic disease(s) (4). Two concerning challenges related to this are the fiscal shortfall in health and social security programs and the rising costs of medical care (7). Currently, people 65 years and older account for one-third of total health care expenditures in the United States, with this proportion expected to increase in the next 25 years as the older adult population grows (7). Leisure-time PA data merged with health care expenditure data revealed that 11% ($117 billion per year) of annual total health care expenditures resulted from inadequate PA levels (8). As this themed journal issue shows, being and staying active throughout the life span is a lifestyle choice with significant potential effect on well-being.

Box 2: Older adult population snapshot: number, life expectancy, and workforce and retirement.

In the United States, the older adult population is projected to more than double by 2060, from 48 million (2015 status) to 98 million (17). Part of the growth in the older adult population is due to the increase in life expectancy from 68 in 1950 to 78.7 years old in 2018 (17,36). The gender gap in life expectancy is approximately 5 years with life expectancy of males at 76.2 years and females at 81.2 years as of 2018 (36).

Many older adults are still active in the workforce (37). Participation rates in the work force by 2024 are estimated to be 29.9% for those 65 to 74 years of age and 10.6% for those 75 and older (38). Overall, 8.2% of the workforce is anticipated to be 65 years or older by 2024 (38). Potential contributors to this increased growth rate in the workforce for older adults include better health and longer life expectancy, higher education levels, changes in social security and pensions, and the need to save more for retirement (37). According to the Center for Retirement Research, the average age of retirement is 65 years for men and 63 years for women (as of 2016) (39).

More than merely saving fiscally or extending longevity, quality of life (QOL) can be improved with an ongoing PA plan. QOL reflects overall wellness, including many factors: physical (the main focus within this article), intellectual or cognitive, vocational, social, spiritual, emotional, and environmental (9) (see Figure 1). Wellness has been defined as the “ability to understand, accept and act upon our capacity to lead a purpose-filled and engaged life” and the various dimensions of wellness overlap, allowing for individuals to “pursue and optimize life’s possibilities” (9). A physically active lifestyle can benefit many other areas; for example, regular PA may decrease risk of dementia (cognitive dimension), provide opportunity for interactions with family and group PA (social), allow for leisure activity in outdoors (spiritual and environmental), and enhance mood and self-esteem (emotional and vocational). See Table 1 for examples of how PA intertwines other dimensions of wellness.

Figure 1:
Dimensions of wellness. Used with permission by the International Council on Active Aging®,
Interaction between Physical Activity and Other Dimensions of Wellness


Given the importance of PA throughout the life span, ACSM recommends older adults engage in aerobic, resistance, and flexibility exercises to reach or maintain optimal health. A regular aerobic exercise routine provides many potential benefits, including reduced blood pressure, improved insulin sensitivity, lower triglycerides and total cholesterol, and slower development of disability (3). Resistance training benefits include attenuating age-related changes in muscle (i.e., atrophy), improving mobility, and promoting the ability to continue to do activities of daily living (ADL) independently (11). The effect of flexibility exercises has not been studied to the same extent as aerobic and muscular exercises, although evidence does support improvements in flexibility with activities that focus on range of motion (3). Neuromotor exercises may be considered for those who are frequent fallers or who have mobility limitations (1), and when dynamic balance and functional training are coupled with dynamic resistance training, older adults can potentially ward off functional decline (11). See Box 3 for specific recommendations for older adults (1). For those with chronic health conditions that limit ability to reach these recommendations, ACSM encourages PA as tolerated to avoid being inactive (1). Some activity is better than none so older adults who are deconditioned should be encouraged to be as active as appropriate based on individual health conditions and current fitness status (1).

Box 3: Recommended exercise components for older adults.

Older adults are encouraged to develop a complete exercise program, including (1)

  • Aerobic exercise
    • ○ Moderate-intensity aerobic activity should be included 5 or more days per week (30–60 minutes per day) or vigorous intensity 3 or more days per week (20–30 minutes per day) or a combination of moderate and vigorous activity.
      • ▪ Intensity is defined on a 10-point relative scale from 0 (i.e., sitting) to 10 (i.e., all-out effort); moderate intensity is considered a level 5 or 6 and vigorous intensity is considered a level 7 or above.
    • ○ Activities should not be of excessive orthopedic stress. A common activity is walking; water or aquatic exercise and stationary cycling are examples of activities for those with concerns related to weight-bearing activities.
  • Resistance exercise
    • ○ On 2 or more days per week, include 8 to 10 exercises for the major muscle groups, 1 to 3 sets, 8–12 repetitions (note: for older adults, consider starting with 10–15 repetitions); also include power training (e.g., light to moderate loading for 6–10 repetitions with high velocity) to address the typical decline in power with aging.
    • ○ Light intensity for beginners with progression to moderate to vigorous (same relative scale can be used as noted for aerobic activity; moderate 5 or 6, and vigorous 7 or 8).
    • ○ Exercises should target the major muscles and can include a variety of activities, for example, traditional weight-training, weight-bearing calisthenics, or stair climbing.
  • Flexibility
    • ○ On 2 or more days per week, include stretching activities.
    • ○ Activities to improve flexibility include slow movements that end in a static stretch (i.e., hold in a position of feeling tightness or slight discomfort) of 30–60 seconds.
  • Neuromotor exercises
    • ○ Activities that include balance, agility, and proprioception have been found to reduce and prevent falls. Although no specific recommendations have been established, to promote reduction and prevention of falls, 2 to 3 days per week have been found to be effective. (For more on neuromotor exercises, see the article “Wouldn’t You Like to Know: Neuromotor Exercise Training” (12); for additional insights into the value of functional movements within a resistance training program, see the Position Statement from the National Strength and Conditioning Association “Resistance Training for Older Adults” [11]).

For those who may have been inactive, or insufficiently active, during adulthood, initiating an exercise program, even later in life, can be beneficial. Findings from a recent cohort study reveal benefits of starting to exercise regardless of age (13). For older adults who increased their level of moderate to vigorous PA to more than three to four times per week, the risk of cardiovascular disease was lower compared with those who remained inactive. Those who have been active throughout adulthood should be encouraged to continue. In the same cohort study, risk of cardiovascular disease events was found to increase in those who decreased frequency of PA compared with those who were consistently active more than five times per week (13) (see Figure 2).

Figure 2:
Effect of PA in older adults. (Kim K, Choi S, Hwang SE, Son JS, Lee J-K, Oh J, Park SM. Changes in exercise frequency and cardiovascular outcomes in older adults. Eur Heart J 2020;41(15):1490–9, by permission of Oxford University Press [13].)

Although the benefits of initiating and maintaining PA are well established (1), unfortunately when compared with the recommendations, participation rates in PA are far from ideal. The levels of aerobic and muscle-strengthening activities decrease over the life span, with very low participation among older adults (14). Only 15.7% of adults between 65 and 74 years of age engage in both aerobic and muscle-strengthening activity, and the percentage drops to 8.5% for those 75 years of age and above (14). In response, health and fitness professionals can foster programs that engage and promote PA in the older adult population. A sample beginner exercise program is shown in Table 2, and Box 4 provides a sample week of activities for an established exerciser (15). An excellent handout from Exercise is Medicine® summarizing PA recommendations for older adults is available (16).

Sample Beginner Exercise Program for Older Adultsa

Box 4: Sample 1-week schedule for an established exercise program.

Based on ACSM recommendations, a sample exercise program is shown below (1,15). Depending on a health status and physical ability, modifications should be considered where appropriate. For example, for athletic clients, consider shifting intensity to be more vigorous with jogging or running for aerobic conditioning; for clients with mobility limitations, consider replacing on-land walking with stationary cycling, shallow water walking, or other aquatic exercise; if balance or joint issues preclude traditional resistance training, consider seated use of exercise bands or webbed gloves in a pool for muscular strengthening.


5-minute slow pace walk to warm-up

45-minute walk at a moderate pace

5-minute slow pace walk to cool-down

10 minutes of stretching activities


5- to 10-minute warm-up

30-minute resistance training session (if at gym, could include machines, free weights; if at home, could include resistance bands and body weight activities). Select one exercise for each of the following body areas: hips and legs, chest, back, shoulders, low back, abdominal muscles, quadriceps, hamstrings, biceps, and triceps.

5- to 10-minute cool-down


5- to 10-minute slow pace walk to warm-up

30-minute walk at a moderate to vigorous pace (every 4 minutes, include 1 minute at a more brisk pace)

5- to 10-minute slow pace walk to cool-down

20 minutes of neuromotor exercises (e.g., tai chi)


5-minute slow pace walk to warm-up

45-minute walk at a moderate pace

5-minute slow pace walk to cool-down

10 minutes of stretching activities


5- to 10-minute warm-up

30-minute resistance training session (see Monday’s workout—consider alternative activities targeting given muscle groups)

5- to 10-minute cool-down


5- to 10-minute slow pace walk to warm-up

30-minute walk at a moderate to vigorous pace (every 4 minutes, include 1 minute at a more brisk pace)

5- to 10-minute slow pace walk to cool-down

20 minutes of neuromotor exercises (including activities for balance, agility, and proprioception)


5-minute slow pace walk to warm-up

45-minute walk at a moderate pace

5-minute slow pace walk to cool-down

10 minutes of stretching activities


Beyond reduced disease risk, a physically active lifestyle allows for ADL to be handled with greater ease (2). Maintaining independence not only is highly desired by older adults but also allows adults to age in place, which is much more cost effective compared with aging in a nursing home. In 2017, 1.2 million people 65 years and older needed nursing home care, and this number is projected to increase to 1.9 million by 2030 (17). Active life expectancy has been defined as the number of expected years of physical, emotional, and intellectual vigor or functional well-being (18). Increasing active life expectancy will decrease health care expenditures, improve the QOL of older adults, and be beneficial to the overall population.


Being physically active goes beyond just decreasing chronic disease risks to actually slowing down or preventing the disablement process often seen in aging (19). For example, in a study of community-dwelling older adults, those who participated in a multicomponent exercise intervention reversed frailty measures (improved functional measurements and physical performance tests); improved cognitive, social networking, and emotional components (Mini-Mental State Examination, Geriatric Depression Scale, and EuroQol quality-of-life scale); and had fewer visits to their primary care physician than the control group (20).

One of the greatest threats to older adults losing their independence is from falling. One in four adults over the age of 65 years falls each year, equating to an older adult being treated in the emergency room every 11 seconds and a death every 19 minutes due to a fall (21). In 2015, injuries from falls cost $50 billion with 75% of the cost being covered by Medicare and Medicaid (22). Beyond the medical costs, falls often result in a decreased QOL and fear of falling. A fear of falling can lead to older adults limiting their activities and social engagements, which then results in a decline in their physical, mental, emotional, and social wellness (21).

Although maintaining muscular strength, aerobic capacity, and flexibility is beneficial for performance of ADL and recreation activities for everyone, incorporating balance and mobility exercises that challenge the sensory, motor, and cognitive systems is needed to prevent falls (7). Fall risk for older adults increases because of declines in hearing, vision (i.e., peripheral and depth perception), reflexes, as well as somatosensory inputs (i.e., touch and proprioception) (23). Another potential aspect that may contribute to risk of falls is medication use. Prescription drug use is reported by nearly 9 of 10 older adults and more than half report taking four or more prescription drugs (24). Exercise professionals need to be aware of medications that may increase risk of falling (e.g., changes in heart rate or blood pressure that might result in dizziness). For more information on medications, see “What You Need to Know: Basic Pharmacology for Health Fitness Practitioners” (25).

Within an exercise plan, health and fitness professionals can include activities to reduce fall risk. Functional balance activities can be added into a workout for an older adult in any phase of the workout from the warm-up to cool-down. Incorporating exercises that manipulate the environment in which the client is exercising to mimic real-life situations will challenge the sensory system and improve balance and mobility (e.g., type of surfaces, lighting). Motor system changes such as time required to plan and execute a movement, over- or underresponding when balance is unexpectedly disrupted, or having an inappropriate postural response with a decreased base of support also can lead to falls (7). Stressing these systems during a workout such as completing tasks while moving or reducing the base of support can efficiently challenge the motor system. The reduced ability to perform multiple tasks at once while maintaining speed, postural stability, and accuracy of movement also declines with age (7). Complex movements involving both balance and mobility exercises during the workout will decrease not only the risk of falling but also a fear of falling in older adult clients. Health and fitness professionals also can encourage activity beyond the structured fitness class by suggesting simple exercises (through the mail, or by social media) that can be done at home. Exercises such as sit-to-stand, standing on one leg, and heel-to-toe walking can build self-confidence, decrease the fear of falling, and improve balance in seniors. See Table 3 for examples of neuromotor exercises ranging from simpler to more challenging (15). See Box 5 for information related to fitness assessments, including insights into potential fall risk, that can be used with older adults (26,27).

Examples of Neuromotor Exercises

Box 5: Fitness assessments for older adults.

Simple field-based assessments that can be used with limited space and equipment are beneficial in assessing areas an older adult may be lacking in health-related fitness components as well as assessing for potential fall risk. Assessments such as these are potential motivators for PA to improve in areas of difficulty or to maintain in areas of strength. The Senior Fitness Test (SFT) developed by Jones and Rikli consists of seven tests to measure an older adult’s functional fitness. The seven tests are the 30-second chair stand, arm curl, 6-minute walk, 2-minute step test, chair sit-and-reach, back scratch, and 8-foot up-and-go (26). Conducting the SFT allows the health and fitness professional to determine what physiological parameters (i.e., strength, endurance, flexibility, and balance) an older adult may lack by using functional movements (i.e., bending, stepping, walking, and reaching) that will affect ADL (26). The Fullerton Advanced Balance (FAB) scale is another field-based assessment with minimal equipment requirements that helps health and fitness professionals determine whether older adult clients are at an increased fall risk. The FAB scale consists of 10 test items that measure different dimensions of balance such as somatosensory inputs, dynamic balance, balance with a reduced base of support, vestibular inputs, and reactive postural control (27).


Although physical benefits from participating in PA for people of all ages are well established, the connection of PA with social health is less understood in older adults. Social isolation has been shown to increase both morbidity and mortality in older adults (28). By contrast, PA has been shown to improve the social environment of older adults (7). Older adults who were physically active were found to have better emotional support from others as well as more involvement in social activities (29). Other research has shown that physically active older adults also were more content with their relationships with their friends, family, and neighbors as well as more likely to engage in social groups within the community (30). There have been mixed results related to older adults’ preferences for group or individual PA programs with some preferring group-based exercise classes with others of similar age (31) whereas others prefer exercising on their own (32). Health and fitness professionals should tailor exercise programs to reflect preferences and may consider encouraging group exercise classes when social isolation is a risk for individual older adult clients. Asking clients about typical daily routines can clarify potential isolation, for example, watching television alone all day compared with regularly engaging in hobbies with others or volunteering with civic or community groups. A group exercise class can be a way to promote social connections while also improving physical conditioning.


An understanding of motivators and barriers to participation in PA can help health and fitness professionals in implementing effective programs which promote wellness. One review revealed key motivators for older adults to include peer encouragement/support and having fun, the social aspect of PA, and support from health professionals (33). Tapping into this desire for connection, health and fitness professionals can include opportunities for clients to interact with one another by linking individuals as exercise buddies or suggesting group exercise classes. Including activities such as “high fives” within a class is a simple way to provide opportunity for interaction and connection. Programs with peers can be effective; one example is SilverSneakers, a fitness program that is a benefit within many Medicare plans and includes programs specifically for adults 65 years and older (34).

An understanding of motivators and barriers to participation in PA can help health and fitness professionals in implementing effective programs which promote wellness.

Barriers include lack of family support, lack of belief in the capacity to be active, environment (e.g., cost, weather, and facilities), fears about safety or of falling, and lack of guidance from health care professionals (33). Encouraging interaction with exercise partners for support, providing clear instructions and demonstrations, and developing adaptations for activities that allow for full participation in classes (e.g., seated activities when standing may be too challenging) are all ways to lower obstacles to participation. Conducting fitness assessments and talking with clients about the types of activities they enjoy or new activities they would like to try will allow health and fitness professionals to help older clients set attainable goals and design individualized programs to reach their goals. In this way, exercise programs that address barriers while emphasizing motivation will help to support older adults in their pursuit of health and wellness.

A recent review supports the connection of PA with other dimensions of wellness. The review explored what PA means to older adults. Although older adults are aware of health benefits of activity, other aspects may be more powerful drivers for PA, including “desiring a sense of purpose and feeling needed by and connected to others.” (35). Transitional events, such as retirement, may affect individual self-worth and identity (35). Older adults can be encouraged to pursue various physical activities that are challenging while also providing social connections (35). For example, leadership opportunities can be presented in leading exercise classes (i.e., peer-lead), mentoring others who may be just beginning an exercise program, or assisting with organization of health-related events such as blood pressure checks for a mall-walking group. Given the effect that PA can have on each dimension of wellness, health and fitness professionals are in a key position to take a holistic approach to wellness when developing exercise programs for older adults. Older adults who participate in well-designed exercise programs (e.g., physically and mentally stimulating activities in a group environment to promote social interactions) will greatly benefit not only in their physical health but also in each component of their overall wellness.


Regular PA can minimize changes in physiological systems due to aging and can decrease the risk for many chronic diseases. A complete exercise program includes aerobic, resistance, and flexibility exercises, along with neuromotor activities for those at risk of falls. With an ongoing commitment to a physically active lifestyle, older adults can experience “successful aging” and continue to lead a life full of purpose and meaning.



Although age-related physiological changes will occur, regular PA is one lifestyle factor that enhances preservation of functional capacity and reduces risk for several chronic diseases. Physical activity recommendations for older adults include regular participation in aerobic, resistance, and flexibility exercises as well as neuromotor exercises for those at risk of falling. Physical activity promotes enhanced QOL and wellness in all its dimensions, including physical, cognitive, vocational, social, spiritual, emotional, and environmental. Health and fitness professionals are ideally positioned to provide creative programs that reflect the dimensions of wellness, encouraging older adults to continue to strive for goals and engage fully in life.


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Older Adults; Wellness; Physical Activity; Fall Prevention; Aging

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