Physical Exercise for Healthy Older Adults and Those with Frailty: What Exercise Is Best and Is There a Difference? A Systematic Review and Meta-Analyses. (2024)

Author(s): Samaher Alowaydhah (corresponding author) [1,2]; Ishanka Weerasekara [1,3,4]; Sarah Walmsley [1]; Jodie Marquez [1,5]

1. Introduction

In 2019, the number of people aged 65 and over globally was estimated to be 703 million [1]. By 2050, this number is expected to be 1.5 billion, and those aged 80 or over will represent 426 million people [1, 2]. As increased longevity is associated with increased chronic illness and morbidity, hospitalization falls, and increased demand for support and care [3, 4], many older adults are classified as being frail. Although a clear definition has not been established for the term frailty, it is commonly used to define people who are characterized by slow gait speed, weak grip strength, exhaustion, reduced energy expenditure, and weight loss [3, 5]. Some authors also include mental health as an important domain that should be considered when defining frailty [6]. The global incidence of frailty among community-dwelling older adult people is estimated to be 43.4% [7].

The maintenance of health status and functioning with aging has been identified as a critical issue globally critical issue, and as a result, a number of countries have developed programs to facilitate healthy aging [8, 9]. This involves consideration of the complex relationship between individual attributes and behaviours, as well as social, economic, and environmental contexts [10]. Central to this is the need for physical exercise (PE) [11].

There is an extensive body of research investigating the effects of PE across the lifespan; however, the research is disparate regarding types of exercise, exercise settings (independent, supervised, or group), dosage of exercise including frequency and intensity, and specific recommendations for subgroups of older adults such as those who are frail.

The aim of this systematic review and meta-analysis was therefore to synthesize the current evidence regarding the prescription of exercise in healthy, as well as frail, older people in an attempt to understand if the response to exercise is the same and if exercise prescription needs to be further tailored to meet the needs of the frail subgroup. To ensure relevance, articles were restricted to those published within the last 30years and prior to the onset of COVID-19, considering the potential changes in exercise delivery, recruitment, and engagement during this time [12].

Specifically, the objectives of the current systematic review were to establish which types of exercise are most beneficial and whether this differs between those who are healthy and those who are frail.

2. Methods

This review forms part of an overarching review that seeks to establish the benefits of various types of exercise for older adult subgroups. In addition to healthy and frail older adults, this work includes subgroups of those with prevalent conditions in older people such as cognitive, orthopedic, and neurological diseases. These findings will be reported elsewhere. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [13]. The protocol was registered under the registration number CRD42020173465 in an international prospective register of systematic reviews (PROSPERO) on 28 April 2020.

2.1. Search Strategy

The principal electronic search of Medline, Cochrane, Embase, CINAHL, and Scopus was conducted in March 2020. The search strategy was conducted using key terms related to “exercise” and “geriatric.” No methodological filter was used for the study design to maximize detection; however, a time limit for studies published after 1989 was applied to ensure alignment with contemporary exercise implementation practices. For the same reasons, the search did not include research onwards the onset of the COVID pandemic, as many programs were necessarily modified and therefore may not have been heterogenous for meta-analysis with regard to recruitment, implementation, adherence, and outcomes. The search strategy used for MEDLINE is provided in (Sapp1).

2.2. Criteria Used for Selecting Studies

Studies were eligible for inclusion if they met the following criteria: (a) included human adults =65years or older on average and (b) used a PE intervention, as defined below, compared with a control condition. Excluded studies (a) were published prior to the year 1990, (b) were published in languages other than English, (c) investigated cardiac, respiratory, and postsurgery populations, and (d) used study designs such as protocols, systematic reviews, editorials, commentaries, reports, conference abstracts, case studies, and case series.

In the case where there was more than one publication for the same study, for example, an additional publication including longitudinal data, the most recent study only was included to avoid duplication of participants. Both studies were included if different outcomes were reported in each of the publications. The four-stage PICO format (Population, Intervention, Comparison, and Outcome) was used as clarified as follows.

2.3. Population

The population of interest was any adults over the age of 65 who were defined by the original authors as either healthy or frail. In the instance where the study population was of mixed age, studies were included if the average age of the study population was greater than 65years. Studies, where the populations of interest were those with cardiac or respiratory diseases, recent fractures, or patients' postsurgery, were excluded from the review as these subgroups require specific exercise considerations.

2.4. Intervention

We selected studies if they investigated any form of PE intervention as described by the definition of a structured, arranged, and repeated physical activity aimed at enhancing or maintaining one or more health-related factors. This included individual exercise or group settings. Further, physical exercise interventions that were combined with cognitive interventions or dietary interventions were also excluded if an independent exercise comparator group was not included.

2.5. Comparison

Only studies with a control condition were considered. This included usual care (e.g., occupational therapy or no care), different types of intervention (e.g., cognitive behavioural therapy), or wait-list control. Studies that compared different types of exercise interventions and did not have a nonexercise control condition were excluded because the act of comparing two exercise groups does not provide us with the means to determine the benefit of exercise.

2.6. Outcome Measures

We were interested in the benefits of PE across a broad spectrum of health-related outcomes ranging from impairment measures to quality of life. Studies that only included physiological measures such as brain activity or cellular mediated responses, or frequency of falls, were excluded. For ease of description, we grouped outcomes under broad terms where appropriate, for example, “physical health and function” included and measure of performance of physical tasks such as gait, balance, and strength, and “mental health” included depression and anxiety. Where a study included more than one measure of the same outcome, e.g., both the HADS and Kessler scale to assess mood, the data from the tool with the greatest frequency of use in the selected articles were included in the analysis. For cognition, in the absence of a common tool, the MMSE was prioritised, then the Montreal Cognitive Assessment (MoCA), then the tool that evaluated memory, followed by the tool that was identified by the authors as the primary tool of interest.

2.7. Study Selection Process

Search data were exported to Endnote reference software, and then Covidence software (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia) for screening. After removing duplicates, title/abstracts were independently reviewed by two reviewers (SA, IW) and then full texts were retrieved and screened for eligibility (SA, IW). Disagreements at both levels were resolved by a third reviewer (JM).

2.8. Screening and Data Extraction

Data for assessing study quality, descriptive data, and quantitative data for the calculation of effect size were extracted and recorded by one researcher (SA). A second researcher (IW) cross-checked the extracted data for accuracy. Discrepancies were resolved following discussion with the research team. The methodological quality of the individual-included studies was determined using the Physiotherapy Evidence Database (PEDro) scale [14].

2.9. Data Analysis

A descriptive analysis of the extracted data was undertaken, and the findings were tabulated and graphically presented to answer the research objectives. Where sufficient quantitative data were available, it was pooled and meta-analysis was performed. The Cochrane statistical package, Review Manager 5 (RevMan 5.4), was used for statistical analyses. A fixed effects model was applied if heterogeneity was low as assessed by the I[sup.2] index. If I[sup.2] was >30%, a random-effects model was used to incorporate intertrial heterogeneity [15]. For continuous data, mean difference (MD) was used if the same tool was used. Standard mean difference (SMD) was used when different tools were used to assess the same outcome employing 95% confidence intervals (CIs) to evaluate the effect size. In the instance where a decrease in the score of the tool indicated an improvement (e.g., the timed-up and go test), the inverse of the change score was used so that positive change scores consistently represented performance improvements. This review followed the general practice of interpretation for small, medium, and large effect sizes (0.2, small effect; 0.5, medium effect; 0.8, large effect) [15]. Where there were insufficient data for meta-analyses, or if there were single studies exercise type [16-34], the results were reported narratively.

3. Results

The database search for the overarching study identified 35824 articles. Following the removal of duplicates and abstracts, 2,147 articles were screened for eligibility, of which 92 articles were reviewed for relevance to this substudy. Thirty-five of these articles were excluded with the main reason being for lack of adequate control condition. In total, 57 studies were included; of these, 38 had data available for meta-analysis. Figure 1 describes the flow of studies through the review.

Figure 1: Flow of studies through the review [Please download the PDF to view the image].

3.1. Quality of the Included Studies

The methodological quality of the included 57 studies ranged from low to high with a mean PEDro score of 5.5 out of 10 (SD 1.3, range 3-8). This was relatively consistent between the two samples with the healthy older adult studies having a slightly lower quality on average (mean=5.4, SD=1.3) than the studies with frail participants (mean=5.6, SD=1.3). The majority of studies used randomization (94.7%); however, only 24.6% reported concealed allocation. The worst performing item on the quality assessment was blinding, whereby only two studies (3.5%) reported participant blinding, and no studies reported blinding of the therapists (0%). Sapp 2 details the quality assessment scores.

3.2. Summary of Included Studies

Thirty studies investigated the effects of exercise in 2,370 healthy older adults. The mean age of participants was 74.6years. The majority of studies were conducted with community-dwelling participants, with one study recruiting participants from a retirement village [35] and another from an outpatient clinic [36]. Studies occurred across a range of countries, with the highest frequency occurring in Japan [23, 37-41], and the USA [17, 22, 42-44]. The majority, of 15 studies, implemented multicomponent exercise programs, using various combinations of strength, flexibility/stretching, balance, coordination, and aerobic exercise [22, 35, 38-50]. The remaining studies investigated one specific exercise type, including strength training [18, 42, 46, 51-54], tai chi [37, 55], aerobic or endurance exercise [16, 21, 23], balance [42], inspiratory muscle training [19], yoga [17], dancing [36, 56], flexibility [47], and aquatic exercise [20]. The duration of PE varied from six weeks [17] to 52weeks [21, 37, 41] with 60minutes being the most commonly used across the studies three times per week. Most studies delivered exercise interventions as group classes (19 studies), while nine used individual supervision [16, 20, 23, 43, 47, 48, 52, 54, 55] or independent exercises [19, 50]. Table 1 provides a full description of the included studies.

Table 1: Description of included studies with healthy older adults.

1RM: one-repetition maximum, 400MWT: time to walk 400 meters (seconds), 2MWT: 2-meter walk test, 6MWT: six-minute walk test, 10MWT: 10-meter walk test, BBS: Berg balance scale, BDI: Beck depression inventory, BDI- II: Beck depression inventory II, BMI: body mass index, CDRS: Chinese dementia rating scale, CDSES: chronic disease self-efficacy scales, CDT: clock drawing test, CG: control group, CI: confidence interval, CMMSE: Chinese mini-mental state examination, COAST: cognitive outcome after stroke test, DSST: digit symbol substitution test, EG: exercise group, FBOS: functional base of support, FSST: the four-square step test, GDS: geriatric depression scale, GDSSF-K: geriatric depression scale short form-Korean version, GSES: general self-efficacy scale, HDSR: Hasegawa dementia scale revised, Mini-BEST: balance evaluation system test, MMSE: mini-mental status examination, MoCA: Montreal cognitive assessment, MoCA-K: the Korean version of the Montreal cognitive assessment, NR: not reported, ODI: Oswestry disability index, OSQ: Oviedo sleep questionnaire, PACE: the physician-based assessment and counseling for exercise, PANAS: positive and negative affect schedule, PAS: the physical activity scale, PAQE: the physical activity questionnaire for the elderly, PGCMS: Lawton's PGC morale scale, POMS: profile of mood status, PSQI-K: the Korean version of the Pittsburgh sleep quality index, RCT: randomized controlled trial, RCPM: Raven-colored progressive matrices, RBMT: Rivermead behavioural memory test, SD: standard deviation, SDL: the satisfaction in daily life, SCS: self-control schedule, SF 36: short form health survey, SF-12: the short form health survey, SLST: single leg stance time, SOT: sensory organization test, SPPB: short physical performance battery, STAI: state anxiety inventory, STAXI-2: state anger expression inventory, TMT: trail making test, TUG: timed up and go, VCP-test: visuospatial cognitive performance test, VAS: visual analogue scale, WAIS-III: Weschler adult intelligence scale III, WDST: Weschler digit substitution test, WSM-R: Weschler memory scale-revised, WHOQoL: World Health Organization Quality of Life, WMS-III: wechsler memory scale III. [sup.**]MDC for measure exceeded.

Twenty-seven studies examined the effects of exercise on 3,782 frail older adults. The average age of participants was 80.3years. Eight studies recruited participants from community settings [26, 28, 30-32, 34, 57, 58], 14 involved participants from residential care facilities [24, 25, 27, 33, 59-68], four from hospital and outpatient clinics, and one was not specified [69]. The studies were conducted across the globe with the most common populations being in the USA [30, 34, 57, 62, 69] and Japan [27, 61, 68]. The majority of studies, 14 studies, provided multicomponent PE programs [28-31, 59, 60, 63, 65, 67-72]. Five studies investigated tai chi [25, 27, 34, 57, 61], and the remaining reviewed aerobic exercise [24, 31, 62, 64], balance [26, 33, 34], and strength exercise [31, 32, 58, 63, 66]. The duration of the intervention varied widely across the studies from four weeks [33] to 104weeks [30]. The most prevalent session duration was 45minutes [24-26, 29, 31, 66, 67, 70], with a range from 15minutes [34, 64] to 90minutes [57, 72]. See Table 2 for a full description of the included studies.

Table 2: Description of included studies with frail older adults.

?: Age range reported instead of mean age, [sup.*]: Median, 1RM: 1 repetition maximum 6MWT: 6-minute walk test, 10MWT: 10 meter walk test, ABC: activity-specific balance confidence scale, ADL: activities of daily living, BAI: beck anxiety inventory, BBS: berg balance scale, BDI: Beck depression inventory, BMI: body mass index, CES-D: center for epidemiological studies-depression, CG: control group, CI: confidence interval, COOP: dartmouth cooperative functional assessment charts, DGI: dynamic gait index, DSST: digital symbol substitution test, EG: exercise group EQ-5D: EuroQoL 5-dimension instrument, FAB: frontal assessment battery, FES-I: falls efficacy scale international, FES: the falls efficacy scale, FIM: functional inventory measure, FTSTS: five timed sit to stand, GDS: geriatric depression scale, GDS-SF: the geriatric depression scale-short form (Chinese version), GP: general practitioners, HADS: hospital anxiety and depression scale, HSPT: high-speed power training, IADL: instrumental activities of daily living, MMSE: mini-mental scale examination, M/S: meters per second, NPI: neuro-psychiatric inventory, NR: not reported, OCQTS: obstacle course quantitative score, OCQLS: obstacle course qualitative score, PGCMS: Philadelphia geriatric center morale scale, POMS-SF: profile of mood states short form, POMA: performance oriented mobility assessment, QLSI: quality of life systemic inventory questionnaire, QoL: quality of life, RCT: randomized controlled trial, SD: standard deviation, SDMT: symbol digit modalities test, SEE: self-efficacy for exercise, SF-12: the health questionnaire 12-item short form survey, SPPB: short physical performance battery, TUG: timed-up-and-go, VAS: visual analogue scale, WAIS: Wechsler adult intelligence scale, WHO: World Health Organization, WHOQoL: World Health Organization Quality of Life. [sup.**]MCD for measure exceeded.

3.2.1. Multicomponent Exercise

(1) Physical Function. PE programs that involved a combination of exercise types improved at least one measure of physical function in seven out of ten studies [22, 35, 38, 42, 45, 48, 50] with healthy participants and six out of nine studies [28, 31, 59, 60, 68, 70] with frail participants. When data were pooled from eight studies with 532 healthy participants, there were no significant effects of multicomponent exercises on physical performance (p=0.22, SMD=0.29, CI=-0.18, 0.76) [35, 38-40, 45, 46, 49, 51] (Figure 2(A)). Physical performance measured by Timed Up and Go (TUG) and Short Physical Performance Battery score (SPPB) was analyzed further separately given that there were adequate data. There was a significant effect of multicomponent exercises on TUG when data from 245 healthy participants were pooled (p=0.006, MD=1.40, CI=0.41, 2.40) [38-40, 48, 50] (Figure 2(B)). There was no significant effect of multicomponent exercises on SPPB when data from 275 healthy participants were pooled together (p=0.30, MD=0.19, CI=-0.17, 0.54) [35, 44, 50] (Figure 2(C)).

Figure 2: The effect of multicomponent exercises on specific outcomes. (A) Physical health and function of healthy subjects. (B) Physical performance as measured by TUG of the healthy subject. (C) Physical performance as measured by SPPB of healthy subjects. (A) Physical health and function of frail subjects. (B) Physical performance as measured by TUG of frail subjects. (C) Physical performance as measured by 6MWT of frail subjects. (c) Cognitive function of healthy subjects. (d) Cognitive function of frail subjects. (e) Depression of healthy subjects. (f) Depression of frail subjects. (g) Quality of life of healthy subjects. (h) Activity of daily living of frail subjects. (i) Mobility of healthy subjects. (j) Mobility of frail subjects [Please download the PDF to view the image].

Data from five studies with 237 frail participants were pooled together for meta-analysis. No significant effect of multicomponent exercises on physical performance was observed (p=0.06, SMD=0.44, CI=-0.01, 0.88) [59, 60, 65, 70, 71] (Figure 2(A)). Functional performance measured by TUG and 6MWT was separately analyzed, given that there were adequate data for subanalysis. There was a significant effect of multicomponent exercises on TUG when data from 141 frail participants were pooled (p<0.0001, MD=-10.85, CI=5.66, 16.04) [70, 71] (Figure 2(B)). Conversely, there was no significant effect of multicomponent exercises on 6MWT when data from 66 frail participants were pooled (p=0.49, MD=20.57, CI=-37.65, 78.79) [59, 65] (Figure 2(C)).

(2) Cognitive Function. The effect of multicomponent exercise on cognitive function was assessed in eight studies, of which five studies reported significant benefit compared to control in healthy older adults [39-41, 47, 48] and four of the eight studies assessed this outcome in the frail [28, 29, 65, 68]. Regarding healthy older adults, data were available for meta-analysis from eight studies [38-41, 43, 46-48]. Pooled data from 435 healthy participants revealed a significant effect of multicomponent exercises on cognitive function in older adults (p=0.003, SMD=0.29, CI=0.10, 0.49) (Figure 2(c)).

Data were available for meta-analysis in four studies with 196 frail participants. There was no significant effect of multicomponent exercises on cognitive function (p=0.35, SMD=0.21, CI=-0.24, 0.66) [59, 60, 68, 69] (Figure 2(d)).

(3) Mental Health and Wellbeing. Nine studies investigated the benefits of multicomponent exercise programs on mental health in healthy older adults. Of these, benefits were identified in four studies [35, 45, 47, 49]. Eight studies assessed the effects of multicomponent exercise on depression with 436 frail participants. Seven studies with a total of 392 healthy participants had data available for meta-analysis. No significant improvement in depression, compared to control, was found (p=0.15, SMD=-0.27, CI=-0.10, 0.64) [35, 39, 40, 45-47, 49] (Figure 2(e)).

When data from the eight studies with 436 frail older adults were combined, a significant benefit was revealed (p=0.0002, SMD=-0.37, CI=0.18, 0.56) [59, 60, 65, 67, 68, 70-72] (Figure 2(f)).

One study assessed anxiety using the Beck Anxiety Inventory (BAI), no significant effect of multicomponent exercises on anxiety for frail older adults was observed (p>0.05) [65].

(4) Quality of Life. Quality of life was investigated in three studies with healthy participants, and significant benefits were reported in two of these studies [22, 39]. Meta-analysis of two studies with 103 healthy participants showed no significant effect of multicomponent exercise on quality of life (QOL) (p=0.58, SMD=0.50, CI=-1.28, 2.28) [39, 40] (Figure 2(g)).

One study investigated the effects of a multicomponent of frail older adults on QoL [28]. This study demonstrated that 60-minute exercise sessions over 12weeks resulted in significant improvement in quality of life as measured on the Quality-of-Life Systemic Inventory Questionnaire (p=0.05).

(5) Activities of Daily Living. No studies with healthy older adults evaluated activities of daily living (ADL) as an outcome of interest. Four studies and 208 frail participants were pooled to reveal no significant effect of multicomponent exercises on ADL (p=0.43, MD=0.61, CI=-0.92, 2.15) [60, 68, 70, 71] (Figure 2(h)).

(6) Mobility. Four studies with a total 280 healthy older adults pooled together [35, 39, 42, 44]. No significant improvement was found (p=0.07, MD=-0.23, CI=-0.47, 0.02) (Figure 2(i)).

Data for mobility were pooled together from two studies with 87 frail participants. There was no significant effect of multicomponent exercises on the mobility of the frail older adult (p=0.35, SMD=0.53, CI=-0.57, 1.62) [60-68, 70, 71] (Figure 2(j)).

3.2.2. Tai Chi Exercise

(1) Physical Function. Two studies investigated the effects of tai chi interventions [37, 55]. When 129 healthy participants pooled together, there was a significant effect of tai chi on physical function (p=0.01, MD=0.51, CI=0.12, 0.91) [37, 55] (Sfig 3A).

Three studies investigated the effect of tai chi on physical performance outcomes of frail older adults with all three reporting improvement compared to the control [25, 34, 57] [25]. There were no common data available for meta-analysis.

(2) Cognitive Function. Cognitive function was investigated in one study and 40 healthy participants, whereby significant benefit on healthy older adults was revealed on the Chinese Dementia Rating Scale (p=0.04) but not the MMSE (p=0.36) [55].

No studies with frail older adults measure the effect of tai chi on cognitive function.

(3) Mental Health and Wellbeing. No studies with healthy older adults evaluated mental health as an outcome. Data from two studies with 138 frail participants were pooled [27, 57]. No significant effect of tai chi on depression was found (p=0.59, SMD=-0.31, CI=-0.80, 1.42) (Sfig 3B).

(4) Quality of Life. QoL was not evaluated in any included studies with healthy older adults. One study investigated the effects of tai chi on QoL of frail older adults [61] and reported that 40mins of seated tai chi across 26weeks resulted in significant improvement in QoL as measured by the World Health Organization Quality of Life (WHOQoL) (p=0.03).

(5) Activity of Daily Living. No studies with healthy older adults evaluated ADL as an outcome. Two studies measured the effect of tai chi on ADL in frail older adults [25, 34] with one study reporting a significant benefit [25]. It was not possible to pool the data.

(6) Mobility. There was one study that measured the effect of 60minutes of tai chi for 52weeks on mobility for healthy older adults, and there was a significant improvement (p=0.015) [37]. One study evaluated the mobility as an outcome for frail older adults. Significant improvement was reported for white people by using =0.97m/s or <0.97m/s tool [57].

3.2.3. Strengthening Exercises

(1) Physical Function. Strength training was beneficial for physical function in all four studies with healthy adults that evaluated this outcome [42, 51-53]. Data were pooled from two studies with 85 healthy participants [51, 52]. Both intervention groups (high-speed and low-speed training) of Yoon et al. were considered in the meta-analysis [51]. There was no significant improvement in strength training demonstrated (p=0.14, MD=0.80, CI=-0.26, 1.86) (Sfig 4A). Four studies evaluated the benefit of strength training on physical function in frail older adults [31, 58, 63, 66]. All four reported benefits of strength training compared to control. No data were available for meta-analysis.

(2) Cognitive Function. Improvements in cognitive function were found in four studies evaluating this outcome in healthy participants [18, 46, 51, 53], and four included studies with frail participants [32, 58, 63, 66]. Three studies had data available from 129 healthy participants for meta-analysis [46, 51, 53]. Both intervention groups of Yoon et al. were included [51]. A significant effect of strengthening exercises on the cognitive function of older adults was revealed (p=0.04, SMD=0.86, CI=0.03, 1.68) (Sfig 4B).

For studies of frail adults, data were available for meta-analysis from three studies with 120 participants. No significant improvement was observed (p=0.14, SMD=0.99, CI=-0.34, 2.31) [58, 63, 66] (Sfig 4C).

(3) Mental Health and Wellbeing. The data from two studies, with 179 healthy participants, were pooled for meta-analysis [46, 54]. The three intervention groups (resistance 1, 2, and 3) of Kekalainen 2018 were included. No significant benefit of PE was revealed (p=0.32, MD=0.47, CI=-0.45, 1.39) (Sfig 4D). No studies with frail older adults evaluated mental health as an outcome.

(4) Quality of Life. Three studies evaluated the effect of strengthening exercise on QOL for healthy older adults with two studies reporting significant benefits [18, 54]. No data were available for meta-analysis. One study evaluated the effect of strengthening exercise on the quality of life of frail older adults. Following 12weeks of resistance training for 60minutes, twice a week, a significant benefit was reported (p<0.001) [63].

(5) Activities of Daily Living. No studies with healthy older adults evaluated ADL as an outcome. ADL was assessed using the Barthel Index (BI) in two studies with frail older adults [63, 66]. When the data for these 77 participants were pooled, a significant benefit for strength training was demonstrated (p=0.0003, MD=15.78, CI=7.28, 24.28) (Sfig 4E).

(6) Mobility. Two studies measured the effect of strength on the mobility of healthy older adults [42, 52]. When the studies were pooled together, a nonsignificant improvement was demonstrated (p=0.56, MD=-0.25, CI=-1.08, 0.59) (Sfig 4F).

One study assessed the effect of strength on the mobility of frail older adults and demonstrated a significant improvement (p=0.027) [58].

3.2.4. Aerobic Exercises

(1) Physical Function. In healthy older adults, aerobic exercise did not lead to a significant benefit in physical function in the one study that evaluated this outcome using the Physical Health and Function test (p=0.13) [23]. In frail older adults, aerobic training was beneficial for physical function in two out of three studies [31, 62]. Data from two studies with 70 participants were pooled together for meta-analysis where the TUG was used to measure physical performance. No significant effect of aerobic exercises on physical performance was found (p=0.36, MD=2.25, CI=-2.52, 7.02) [62, 64] (Sfig 5).

(2) Cognitive Function. With regard to cognition, in healthy older adults, two studies evaluated this outcome and reported significant benefits compared to the control [21, 23]. There were insufficient data for meta-analysis. Conversely, in the frail, no significant benefit was revealed in cognitive function in the one study that assessed this outcome [64].

(3) Mental Health. One study of healthy older adults evaluated mental health following aerobic exercise programs and reported significant benefits as measured with the BDI (p=0.01) [16]. Two studies evaluated the effect of aerobic exercise on mental health in frail older adults, with neither reporting significant benefit [24, 62].

(4) Quality of Life. There was no reported benefit of aerobic exercise on QoL in the one included study with healthy participants [23] (p=0.42) nor the study with frail older adults [62].

(5) Mobility. No study measured the effect of aerobic exercise on the mobility of healthy older adults. There was one study that evaluated mobility as an outcome of frail older adults; a nonsignificant improvement was reported [62]. No data are available.

3.2.5. Dancing

Two studies investigated the effects of dancing on physical function in healthy older adults [36, 56]. When the data were pooled from 91 healthy participants, no significant effect was revealed (p=0.94 MD=4.95, CI=-135.34, 145.25) (Sfig 6). One study reported the benefit of dancing on cognitive function as measured on the MoCA (p=0.003) and in mental health as measured on the GDS (p=0.01) [56]. Another showed a benefit in QoL for healthy older adults as measured on the 36-Item Short Form Survey (SF36) (p<0.05) [36]. No studies investigated the effects of dancing in frail older participants.

3.2.6. Balance Exercise

One study found that balance exercises were beneficial for the physical health and function of healthy older adults (p<0.05) [42].

For frail older adults, balance training improved physical health and function outcomes in the three studies which evaluated this [26, 33, 34]. These studies also assessed the effect of balance on mental health [26, 33, 34], and none found a significant benefit. No included studies evaluated the effect of balance exercise on cognitive function.

3.2.7. Single Study Exercise Types

Additional types of exercise were investigated in single studies to identify the effect of PE on healthy older adults. These were yoga, inspiratory muscle training, aquatic therapy, and flexibility. Bonura et al. 2014 concluded that six weeks of yoga resulted in improved anger control/mood than both routine exercise and control participants (Cohen's d=0.89 for yoga versus exercise and 0.90 for yoga versus control [17]). Ferraro et al. 2019 used a program of twice-daily inspiratory muscle training over eight weeks to demonstrate significant improvements in functional performance as measured by the TUG compared to the control group (p=0.03) [19]. One study investigated supervised, individual aquatic exercises provided three times per week over 12weeks. There were statistically significant improvements in depression (p=0.03) and fatigue (p=0.01) following the intervention, compared to the control [20]. Brown et al. 2009 reported that one hour twice a week of flexibility and relaxation techniques had significant effects on mental health measured by GDS (p<0.01) [47]. There were no studies with frail participants that investigated these types of PE. Table 3 describes the results of each study type and their outcomes. A visual representation of all meta-analyses conducted and the outcomes are presented in Sfig 7.

Table 3: Summary of results: number of studies in each category with references.

[sup.a]follow-up data collection varied from 1month to 24months; [sup.b]significant improvement was reported at the first follow-up for each study.

4. Discussion

This is the first systematic review and meta-analysis to comprehensively synthesize the current evidence regarding the prescription of exercise in both healthy and frail older people. It provides an understanding of the types of exercise programs which are most effective in these groups which may assist clinicians in the selection of appropriate interventions. The positive impacts of physical activity on various facets of health are widely recognized and accepted by all adults [73]. Health organizations worldwide have formulated guidelines outlining exercise recommendations, encompassing specific types of exercises, and suggesting intensity levels for engaging in these activities [74]. While some attention is given to healthy older adults, a considerable portion faces the challenge of frailty, which can hinder their ability to remain physically active. Therefore, it is important to tailor guidelines to maximize compliance and benefit and to provide overall better QoL with a less economic burden to communities in this subgroup. This systematic review has integrated the research findings from these two subgroups of the population to offer valuable insights into the best types of exercise that are associated with the greatest benefits in specific health-related outcomes and the difference between them.

Multicomponent exercise programs are the most widely investigated, and the evidence suggests that this form of exercise is beneficial for improving physical function in both healthy and frail older adults. In the healthy, it may have the added benefit of improving cognitive function, whereas in the frail, it may contribute to improved mood. Tai chi may also improve physical performance in the healthy aged; however, this benefit was not demonstrated in the frail population. Strengthening exercise programs may lead to improvements in cognition in healthy older adults and ADL performance in the frail. Drawing conclusions about other forms of exercise and other health-related outcomes is challenging due to the limited and heterogenous literature and inconsistent findings.

Our findings align with previous reviews exploring the advantages of exercise in healthy older adults [75]. Plummer et al. 2016 focused on the effects of PE on dual-task performance while walking among healthy older adults and revealed a notable increase in single-task gait speed [75]. This improved physical performance which was also observed in our review following multicomponent exercises and tai chi.

Several systematic reviews have specifically focused on the benefits of exercise in frail older adults with reference to specific outcomes [76-78]. Cadore et al. 2013 evaluated the effect of exercise on functional capacity in frail older adults, concluding that multicomponent interventions appear to be the most effective approach for improving these outcomes [76]. As well as concurring with our analysis, this may have implications for reducing fall-related morbidity, the decline in independence, and subsequent economic sequelae. Some previous authors have also evaluated the effects of physical exercise on physical function in addition to quality of life and activities of daily living [77, 78].

This study has a number of notable strengths as well as some limitations. Previous reviews have focused on singular exercise types or restricted outcomes which may limit their clinical application. This is the first systematic review to collate evidence, allowing comparisons across all forms of exercise and all available health-related outcomes in both healthy and frail older populations. We restricted inclusion to controlled trials with primarily good to excellent quality to minimize bias and allow for between-group comparisons. However, the review is constrained by the incongruity of the available evidence. Meta-analysis was limited by unusable data, a lack of studies investigating certain types of exercise such as yoga, and inconsistent use of outcome measures across studies. Where data were not available for meta-analysis, the findings were reported narratively. Given that the majority of studies were not powered (20 of the 57 included studies were powered) and failed to correct for multiple comparisons, caution must be taken in interpreting these findings as they are prone to type I and type II errors. Similarly, despite pooling the data, several of the meta-analyses contain samples with less than 90 participants; therefore, we are limited in the conclusion that can be drawn from these analyses. In some instances, the outcome tools used to evaluate change have not been validated and may not be responsive to change in this population, and care must be taken when interpreting these results. These tools include the Loss of Balance test, Sensory Organization test, muscle strength tests, Weschler Scale, COWAT, Satisfaction in Daily Life, and the Quality-of-Life Systemic Inventory. Further, some studies included subanalysis of their sample according to the presence or severity of symptoms such as the degree of cognitive impairment. It was beyond the scope of this review to incorporate such subgroup findings into our analysis. We relied on the definition and categorization of the sample as being either “healthy” or “frail” as provided by the original authors. However, the definition of frailty is not consistently reported nor uniformly applied, potentially leading to variations in how frailty was defined across the studies. Moreover, our review is restricted to studies published prior to 2020, due to the effects of COVID which may have impacted traditional exercise delivery. This may have resulted in missing out on some relevant studies.

In the future, it will be essential for researchers to adopt standardized approaches when it comes to exercise type, dosage, and the collection of outcomes to enable meaningful conclusions to be drawn. In some instances, it may be that the dosage of the intervention or the mode of the delivery was not targeted to achieve the measured outcomes' given current evidence. When considering all of the outcomes reported in this SR, there were a total of 30 reports of nonsignificant effects of these, and six studies did not report exercise adherence (37, 56, 54, 65, 70, 72) and a further three reported less than 80% adherence (40, 35, 59). Therefore, for these studies, it is not known whether failure to respond was due to inadequate adherence to the exercise and consequently insufficient dosage of the intervention. A further consideration is that our study included study samples that were predominantly female and despite this being representative of the older population, it may limit the generalizability to male populations. Lastly, this review may have overlooked relevant studies published in other languages because the searches were limited to English.

Despite the reported importance of physical exercise [79], there is a dearth of comprehensive, methodologically sound research investigating its effects on older adults. This deficit limits both clinical application as well as evidence-based policy direction. Essentially, our study demonstrates that physical exercise has a positive impact on both healthy and frail older adults in several domains. However, the specific benefits may vary depending on the type of exercise prescribed and the participants' health. As a result, we strongly urge clinicians to consider the particular population and the desired outcome when prescribing exercise in these populations to achieve the most relevant benefits. Further, we propose that our findings may assist in informing evidence-based guidelines and policies that will reduce the economic and social burden associated with inactivity in the older population.

Acknowledgments

The authors thank Debbie Booth (Librarian), The University of Newcastle, Australia, for her assistance in the database. This work was supported by PhD scholarship funding provided by Jouf University, Saudi Arabia. Open access publishing facilitated by The University of Newcastle, as part of the Wiley - The University of Newcastle agreement via the Council of Australian University Librarians.

Supplementary materials

Supplementary Materials: Sapp 1: Example search engine terms as used in MEDLINE. Sapp 2: Quality assessment of the included studies using the PEDRO scale. Sfig 3: The effect of tai chi on specific outcomes. Sfig 4: The effect of strength training on specific outcomes. Sfig 5: The effect of aerobic exercise on the physical health and function of frail older adults. Sfig 6: The effect of dancing on physical health and function of healthy older adults. Sfig 7: Visual representation of the meta-analysis findings.

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Author Affiliation(s):

[1] College of Health, Medicine and Wellbeing, The University of Newcastle, Newcastle, Australia

[2] College of Applied Medical Science, Jouf University, Sakakah, Saudi Arabia

[3] Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen 5063, Norway

[4] School of Allied Health Science and Practice, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia

[5] Hunter Medical Research Institute, New Lambton, Australia

Author(s) Email: Samaher Alowaydhah - [emailprotected]; Ishanka Weerasekara - [emailprotected]; Sarah Walmsley - [emailprotected]; Jodie Marquez - [emailprotected]

DOI: 10.1155/2024/5639004