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de Souto Barreto P, Rolland Y, Vellas B, et al. Association of Long-term Exercise Training With Risk of Falls, Fractures, Hospitalizations, and Mortality in Older Adults: A Systematic Review and Meta-analysis. JAMA Intern Med. 2018 Dec 28. pii: 2719424. doi: 10.1001/jamainternmed.2018.5406.
Area Score
Public Health
Physical Medicine and Rehabilitation
Family Medicine (FM)/General Practice (GP)
General Internal Medicine-Primary Care(US)

Importance: Long-term exercise benefits on prevalent adverse events in older populations, such as falls, fractures, or hospitalizations, are not yet established or known.

Objective: To systematically review and investigate the association of long-term exercise interventions (=1 year) with the risk of falls, injurious falls, multiple falls, fractures, hospitalization, and mortality in older adults.

Data Sources: PubMed, Cochrane Central Register of Controlled Trials, SportDiscus, PsychInfo, and Ageline were searched through March 2018.

Study Selection: Exercise randomized clinical trials (RCTs) with intervention length of 1 year or longer, performed among participants 60 years or older.

Data Extraction and Synthesis: Two raters independently screened articles, abstracted the data, and assessed the risk of bias. Data were combined with risk ratios (RRs) using DerSimonian and Laird's random-effects model (Mantel-Haenszel method).

Main Outcomes and Measures: Six binary outcomes for the risk of falls, injurious falls, multiple falls (=2 falls), fractures, hospitalization, and mortality.

Results: Forty-six studies (22?709 participants) were included in the review and 40 (21?868 participants) in the meta-analyses (mean [SD] age, 73.1 [7.1] years; 15?054 [66.3%] of participants were women). The most used exercise was a multicomponent training (eg, aerobic plus strength plus balance); mean frequency was 3 times per week, about 50 minutes per session, at a moderate intensity. Comparator groups were often active controls. Exercise significantly decreased the risk of falls (n = 20 RCTs; 4420 participants; RR, 0.88; 95% CI, 0.79-0.98) and injurious falls (9 RTCs; 4481 participants; RR, 0.74; 95% CI, 0.62-0.88), and tended to reduce the risk of fractures (19 RTCs; 8410 participants; RR, 0.84; 95% CI, 0.71-1.00; P = .05). Exercise did not significantly diminish the risk of multiple falls (13 RTCs; 3060 participants), hospitalization (12 RTCs; 5639 participants), and mortality (29 RTCs; 11?441 participants). Sensitivity analyses provided similar findings, except the fixed-effect meta-analysis for the risk of fracture, which showed a significant effect favoring exercisers (RR, 0.84; 95% CI, 0.70-1.00; P = .047). Meta-regressions on mortality and falls suggest that 2 to 3 times per week would be the optimal exercise frequency.

Conclusions and Relevance: Long-term exercise is associated with a reduction in falls, injurious falls, and probably fractures in older adults, including people with cardiometabolic and neurological diseases.

Comments from MORE raters

General Internal Medicine-Primary Care(US) rater

Well done systematic review supporting recommendations to exercise. The reductions in falls and hospitalizations are relevant to hospitalists like me, but the suggestions need to begin in the ambulatory sector.

Geriatrics rater

This meta-analysis involving nearly 22,000 participants reaffirms what has been known since the FICSIT randomized multi-center, multi-intervention trial over 25 years ago; viz a viz, that exercise significantly reduces fall risk. It also shows that exercise (aerobic or strength training with balance training) reduces the risk for injurious falls. Like the LIFE program, there was no statistically significant impact on hospitalizations or mortality. A major limitation of this meta-analysis is that it does not assess the impact of exercise on quality-of-life or physical functioning. The LIFE study showed that exercise, even in the obese, improved mobility. The conclusion that exercise should not be done > 3 x per week is misleading. A person who exercises more may be healthier overall and, with exercise, may undertake activities that may increase the risk for falls (e.g., playing sports or outdoor games with grandchildren). A colleague who is 74 quipped to me that on Sunday he fell multiple times... while playing soccer in an adult league.

Physical Medicine and Rehabilitation rater

Good article.

Public Health rater

This review supports recommendations for exercise in older adults for a variety of health benefits including fall prevention.