Evidence summary (Updated 2022)
There is strong evidence to suggest that exercise interventions in at-risk individuals are associated with reduced falls, fall-related injuries and frailty. A systematic review & meta-analysis of exercise as a single intervention (88 trials; 19 478 participants) in older people demonstrated a 21% reduction in falls in older people living in the community (pooled rate ratio 0.79; 95% CI 0.73-0.85; p<0.001). Greatest effect was conveyed by interventions that included both balance training and greater than 3h of physical activity per week . Another meta-analysis of RCTs demonstrated that exercise interventions reduced both fall-related fractures (relative risk 0.604; 95% CI 0.453-0.840; p=0.003) and rate of falls (rate ratio 0.856; 95% CI 0.778-0.941; p=0.001) in older people . This was confirmed again by a single group study of individuals in community senior[’ centres, which demonstrated a 49% reduction in number of falls after implementation of an evidence-based exercise & education falls prevention programme . Evidence from an RCT comparing group- and home-based exercise interventions against standard care demonstrated a significant reduction in falls-related injuries (IRR 0.55; p=0.04). This effect lasted for 12 months after the end of the intervention and there was a significant reduction in total fall rate during this 12-month period (IRR 0.74; p=0.04). A significant reduction in falls incidence persisted in participants of the group-based exercise intervention who maintained levels of 150 minutes of moderate-vigorous physical activity/week at 24 months after the intervention . A recent Systematic review & meta-analysis reported that, compared to controls, practice of Tai Chi was associated with a significant reduction in chance of falling more than once, and rate of falls . No significant difference was demonstrated between eccentric vs. traditional resistance exercises for those >65y with ≥1 fall in the preceding 12 months .
Physical inactivity has been linked to frailty in both mid and later life. A prospective longitudinal cohort (n=6233) study reports that moderate or no physical activity at age 50y is a predictor for frailty . This was confirmed by another birth cohort study which demonstrated that poor performance in physical tests (grip strength, chair rise & standing balance) at age 53y was associated with mobility or personal care disability at age 69y . A positive association has been demonstrated between physical activity in mid-life and both ‘successful ageing’ (no major chronic diseases, no cognitive impairment, physical impairment or mental health limitations) and reduced disability/frailty . Five studies in this systematic review reported a positive association between physical activity in mid-life and physical mobility/physical functioning/reduced disability in later life (1 study observed no significant association). An RCT (n=172; mean participant age 78.3y) demonstrated that implementation of a combined physical activity and nutritional assessment programme in older adults led to a trend towards reduced frailty – 4.9% of the intervention group had progressed to frailty, compared to 15.3% of the control group (odds ratio 0.19; 95% CI 0.08-1.08; p=0.052) .
There continues to be good evidence to suggest that strength and balance exercise in particular can help reduce risk of falls, injury from falls, sarcopenia and frailty and that interventions are generally safe.
The World Health Organisation commissioned a systematic review of the available data. The systematic review analysed data from a large number of people (n, 8714) both male and female and a mix of non-frail and frail patients, the emphasis was on a minimum follow up of 26 weeks and showed that physical activity probably prevented frailty (4 studies; frailty score pooled standardized mean difference, 0.24; 95% confidence interval, 0.04-0.43; P = .017, I2 = 57%, moderate certainty evidence). 
A larger systematic review and meta-analysis of randomised control trials (n=28523) specifically looking at the safety of long term exercise in older individuals found no difference in illness or mortality with long term exercise training but did find significantly reduced number of falls, fall associated injury, physical functioning and cognition (MMSE scores) in the intervention group. 
A large systematic review of the literature (21 studies, n5275 individuals, 33 different interventions) looking at the effectiveness on a variety of interventions in prevention of frailty found that there was some evidence for physical activity intervention, but only when this was delivered in a group setting. The authors conclude that individually tailored interventions had inconsistent results, but that group treatments would seem to be a more economically viable approach in particular with higher levels of frailty in the community particularly given they have been shown to be effective. 
A large systematic review in primary care looked at a large number of studies, (925 studies analysed, 46 studies included, total number of patients 15690). The studies analysed showed significant improvement in frailty with most commonly muscle strength training and protein supplementation as interventions. 
While in the prevention of falls a more detailed analysis of the available literature was undertaken in a network meta-analysis. This showed that the exercises most likely to help in the prevention of falls were those predominantly focused on balance. (exercise with anticipatory control, dynamic stability, functional stability limits, reactive control and flexibility vs no exercise (p-score = 0.95). 
A rapid review of evidence by Public Health England looking at the data from 20 systematic reviews and metanalyses concluded that there was consistent evidence that preserving strength and power in middle and older age groups was associated with reduced mortality from all causes. The activities identified in the analysis that were most likely to provide benefit were strength and resistance training on two or three occasions per week, with high intensity training giving greater gains. Balance activities three times per week were beneficial at falls reduction. The reviewers conclude that general physical activity alone such as walking or cycling had little evidence at reducing falls or frailty. (16)
Quality of evidence
Grade A – High Quality
Strength of recommendation
Grade 1 – Strong recommendation
There continues to be good evidence to suggest that strength and balance exercise, in particular, can help reduce risk of falls, injury from falls, sarcopenia and frailty.
 Catherine Sherrington Anne Tiedemann, Nicola Fairhall, Jacqueline C T Close, Stephen R Lord (2017) Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017 Dec;51(24):1750-1758. Epub 2016 Oct 4.
 Renqing Zhao , Feifei Feng , Xinzheng Wang. (2017) Exercise interventions and prevention of fall-related fractures in older people: a meta-analysis of randomized controlled trials.Int J Epidemiol. 2017 Feb 1;46(1):149-161.
 Fuzhong Li , Peter Harmer , Kathleen Fitzgerald. (2016) Implementing an Evidence-Based Fall Prevention Intervention in Community Senior Centers. Am J Public Health. 2016 Nov;106(11):2026-2031. Epub 2016 Sep 15.
 S Gawler , D A Skelton , S Dinan-Young 3 T Masud , R W Morris , M Griffin , D Kendrick , S Iliffe , ProAct65+ team. (2016) Reducing falls among older people in general practice: The ProAct65+ exercise intervention trial.Arch Gerontol Geriatr. 2016 Nov-Dec;67:46-54. Epub 2016 Jun 29.
 Zhi-Guan Huang , Yun-Hui Feng , Yu-He Li , Chang-Sheng Lv. (2017). Systematic review and meta-analysis: Tai Chi for preventing falls in older adults. BMJ Open. 2017 Feb 6;7(2):e013661.
 Paul LaStayo , Robin Marcus , Leland Dibble , Bob Wong , Ginette Pepper (2017) Eccentric versus traditional resistance exercise for older adult fallers in the community: a randomized trial within a multi-component fall reduction program.BMC Geriatr. 2017 Jul 17;17(1):149.
 Brunner EJ, Shipley MJ, Ahmadi-Abhari S, Valencia Hernandez C, Abell JG, Singh-Manoux A, Kawachi I, Kivimaki M. Mid life contributors to socioeconomic differences in frailty during later life: a prospective cohort study. Lancet Public Health. 2018 Jun 13. Pii: S2468-2667(18)30079-3.[Epub ahead of print]
 R M Dodds , D Kuh , A A Sayer , R Cooper (2018) Can measures ofphysicalperformance in mid-life improve the clinical prediction of disability in early old age? Findings from a British birth cohort study. Exp Gerontol. 2018 Jun 7;110:118-124. [Epub ahead of print]
 Louise Lafortune , Steven Martin , Sarah Kelly , Isla Kuhn , Olivia Remes , Andy Cowan , Carol Brayne (2016) Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic Review. PloS One. 2016 Feb 4;11(2):e0144405. eCollection 2016.
 M Serra-Prat , X Sist , R Domenich , L Jurado , A Saiz , A Roces , E Palomera , M Tarradelles , M Papiol (2017) Effectiveness of an intervention to prevent frailty in pre-frail community-dwelling older people consulting in primary care: a randomised controlled trial. Age Ageing. 2017 May 1;46(3):401-407
 Oliveira JS, Pinheiro MB, Fairhall N et al. (2020) Evidence on Physical Activity and the Prevention of Frailty and Sarcopenia Among Older People: A Systematic Review to Inform the World Health Organization Physical Activity Guidelines. J Phys Act Health. Aug 11;17(12):1247-1258.
 Hermoso A, Ramirez-Vélez R, Sáez de Asteasu ML et al.(2020)Safety and Effectiveness of Long-Term Exercise Interventions in Older Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Sports Med. Jun;50(6):1095-1106.
 Apóstolo J, Cooke R, Bobrowicz-Campos E et al. (2018) Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: a systematic review. JBI Database System Rev Implement Rep. 2018 Jan;16(1):140-232.
 Travers J, Romero-Ortuno R, Bailey J et al. (2019) Delaying and reversing frailty: a systematic review of primary care interventions. Br J Gen Pract. Jan;69(678):e61-e69.
 Sibley KM, Thomas SM, Veroniki AA et al. (2021) Comparative effectiveness of exercise interventions for preventing falls in older adults: A secondary analysis of a systematic review with network meta-analysis. Exp Gerontol. 2021 Jan;143:111151.
 Public Health England (2018) Muscle and bone strengthening and balance activities for general health benefits in adults and older adults. Summary of a rapid evidence review for the UK Chief Medical Officers’ update of the physical activity guidelines.