Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR)

Abstract

Aging, a universal and inevitable process, is characterized by a progressive accumulation of physiological alterations and functional decline over time, leading to increased vulnerability to diseases and ultimately mortality as age advances. Lifestyle factors, notably physical activity (PA) and exercise, significantly modulate aging phenotypes. Physical activity and exercise can prevent or ameliorate lifestyle-related diseases, extend health span, enhance physical function, and reduce the burden of non-communicable chronic diseases including cardiometabolic disease, cancer, musculoskeletal and neurological conditions, and chronic respiratory diseases as well as premature mortality. Physical activity influences the cellular and molecular drivers of biological aging, slowing aging rates-a foundational aspect of geroscience. Thus, PA serves both as preventive medicine and therapeutic agent in pathological states. Sub-optimal PA levels correlate with increased disease prevalence in aging populations. Structured exercise prescriptions should therefore be customized and monitored like any other medical treatment, considering the dose-response relationships and specific adaptations necessary for intended outcomes. Current guidelines recommend a multifaceted exercise regimen that includes aerobic, resistance, balance, and flexibility training through structured and incidental (integrated lifestyle) activities. Tailored exercise programs have proven effective in helping older adults maintain their functional capacities, extending their health span, and enhancing their quality of life. Particularly important are anabolic exercises, such as Progressive resistance training (PRT), which are indispensable for maintaining or improving functional capacity in older adults, particularly those with frailty, sarcopenia or osteoporosis, or those hospitalized or in residential aged care. Multicomponent exercise interventions that include cognitive tasks significantly enhance the hallmarks of frailty (low body mass, strength, mobility, PA level, and energy) and cognitive function, thus preventing falls and optimizing functional capacity during aging. Importantly, PA/exercise displays dose-response characteristics and varies between individuals, necessitating personalized modalities tailored to specific medical conditions. Precision in exercise prescriptions remains a significant area of further research, given the global impact of aging and broad effects of PA. Economic analyses underscore the cost benefits of exercise programs, justifying broader integration into health care for older adults. However, despite these benefits, exercise is far from fully integrated into medical practice for older people. Many healthcare professionals, including geriatricians, need more training to incorporate exercise directly into patient care, whether in settings including hospitals, outpatient clinics, or residential care. Education about the use of exercise as isolated or adjunctive treatment for geriatric syndromes and chronic diseases would do much to ease the problems of polypharmacy and widespread prescription of potentially inappropriate medications. This intersection of prescriptive practices and PA/exercise offers a promising approach to enhance the well-being of older adults. An integrated strategy that combines exercise prescriptions with pharmacotherapy would optimize the vitality and functional independence of older people whilst minimizing adverse drug reactions. This consensus provides the rationale for the integration of PA into health promotion, disease prevention, and management strategies for older adults. Guidelines are included for specific modalities and dosages of exercise with proven efficacy in randomized controlled trials. Descriptions of the beneficial physiological changes, attenuation of aging phenotypes, and role of exercise in chronic disease and disability management in older adults are provided. The use of exercise in cardiometabolic disease, cancer, musculoskeletal conditions, frailty, sarcopenia, and neuropsychological health is emphasized. Recommendations to bridge existing knowledge and implementation gaps and fully integrate PA into the mainstream of geriatric care are provided. Particular attention is paid to the need for personalized medicine as it applies to exercise and geroscience, given the inter-individual variability in adaptation to exercise demonstrated in older adult cohorts. Overall, this consensus provides a foundation for applying and extending the current knowledge base of exercise as medicine for an aging population to optimize health span and quality of life.

Graphical abstract

Fig. 1

Evidence shows that being physically active and having a healthy diet (coupled with no smoking and moderate alcohol consumption) are integral to the maintenance of health and well-being at all ages. The left-hand side shows a probable pathway for non-exercisers. These individuals are susceptible to exercise-associated, and diseases not associated with PA. Various pathological processes cause physiological disruption. Exercise as therapy can potentially reverse some declines, but issues related to low cardiorespiratory fitness (VO₂ peak), muscle strength/power/muscle mass and functional capacity values may persist. The right-hand side illustrates the role of PA as preventive medicine, emphasizing the preservation of effective, albeit gradually diminishing, physiological functions. They are partially protected from exercise-associated diseases but are equally prone to diseases unrelated to exercise. Exercise/PA will have no direct effect on those diseases that are not directly exercise dependent. However, there is evidence that exercise has a protective effect in those diseases whose aetiologies are exercise-dependent. Exercise and PA provide immediate benefits to functionality across a wide range of diseases, irrespective of changes in VO₂ peak. While VO₂ peak improvements may contribute to cardiovascular protection, other outcomes of exercise, such as reducing the risk of falls, fractures, and mortality, are not solely dependent on VO₂ peak enhancement. In the very old, this may not play a crucial role, but in many other patients, VO₂ peak values, because of their inextricable link to all-cause mortality, may be crucial. Although changes in handgrip strength are generally associated with frailty, malnutrition, and mortality risk, rather than being a direct outcome or target of exercise therapy, they may serve as a supplementary marker for assessing overall physiological status during exercise interventions. Both cohorts are experiencing constant decremental changes because of the inherent aging process, but at a different rate due to their PA engagement. The center contains the significant moderators of both pathological and physiological processes. PA = Physical Activity, V̇O2 peak = Peak oxygen uptake.

Fig. 2

Sequential exercise programming for individuals with severe frailty should align with the physical requirements necessary for mobility. The process begins with PRT, emphasizing basic movements such as standing up from a seated position or negotiating steps, as these are fundamental for lifting body weight and initiating movement. Following sufficient strength development, the focus shifts to balance exercises to maintain upright positions. Finally, endurance training is introduced to support walking and other daily activities over extended periods. This progression mirrors the natural demands of movement, minimizing the risk of falls and promoting safe ambulation. PRT = progressive resistance training.

Fig. 3

Comparative Efficacy of Exercise and Pharmacological Treatments Across Health Domains. This figure outlines the effectiveness of exercise and drug treatments across various health-related domains, categorized into four primary sections: Optimization of Peak Body Composition and Fitness, Prevention of Risk Factors for Chronic Disease, Treatment of Chronic Disease, and Prevention of Age-Related Changes in Physiology and Function. Each health condition listed under these categories is evaluated for the effectiveness of exercise and available drug treatments, clearly marked to indicate whether exercise, drugs, or both have been found effective. The comparison aims to assist healthcare providers in devising comprehensive, evidence-based treatment plans that integrate physical activity and pharmacological interventions as needed. The presence of two tick marks indicates a higher level of effectiveness, while a single tick mark reflects a lower level of effectiveness. This differentiation is used to visually represent varying degrees of outcome strength.

Fig. 4

Graphical illustration of the considerations for the prescription for secondary and tertiary prevention (disease expression and progression).

Fig. 5

Integrated Management of Exercise, Pharmacotherapy, and Nutritional Interventions in Older adults Care. Adapted from [537].

Fig. 6

Strategies for Modifying Exercise Regimens in Response to Medication-Related Impacts on Patient Engagement and Physiological Adaptations. Adapted from [537].

Fig. 7

Tailoring Exercise Interventions to Counteract Medication-Induced Side Effects in Older Patients. Adapted from [537].