Introduction
The present research paper will critically evaluate the existing literature on the effect of exercise on the wellbeing of senior citizens. Based on the reported findings, the paper will also provide suggestions for how the research findings may be applied in clinical practice, and it will highlight possible areas for additional research in the future.

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Definition of Terms
In this researcher paper, the term “wellbeing” is used broadly to include measures of both physical and mental health. In terms of physical health, the wellbeing of a senior citizen may be characterized by their risk of acute illness, chronic disease, or injury. Wellbeing can also refer to the effectiveness with which an existing physical health condition is managed. In terms of mental health, the term “wellbeing” can refer to general indicators of mental wellness, such as mood and outlook. Wellbeing also encompasses a senior citizen’s ability to cope with mental health disorders, such as depression. In senior citizens, the term can also be used to describe a senior citizen’s cognitive functioning and cognitive decline over time.

Similarly, the term “exercise” is used applied broadly in this research paper. Within the existing literature, there are multiple ways in which the term has been used. Some studies use the term broadly to include any physical activity, while others focus specifically on aerobic exercise, weight training, yoga, or another exercise option. This paper will recognize each as a legitimate form of exercise to include within the analysis. The paper will also acknowledge that the manifestation of “exercise” can vary depending on the physical capacities of the senior citizen.

Finally, ideas about the specific age cutoff for a “senior citizen” can vary depending on the context. The term is sometimes replaced with similar terms within the literature, such as “elderly person” and “older adult.” This analysis will include papers that utilize any of the terms that generally refer to individuals of advanced age.

Literature Review
Effect of Exercise on the Physical Wellbeing of Senior Citizens
For senior citizens, the effects of exercise include both the maintenance of physical health and improvements in existing physical health conditions. First, for older adults, multiple studies show that engagement in regular physical activity can lower the risk of mortality (Bean, Vora, & Frontera, 2004). In one population-based cohort study of over 5,200 senior citizens (age 65 or older) in four counties in the United States, regular physical exercise added an estimated 11 years to a senior citizen’s expected lifespan (Hirsch et al., 2010). The researchers also estimated that the added the number of extra years of life without “impairment in activities of daily living” was over 6 years (Hirsch et al., 2010).

Indeed, physical activity has been shown to lower the risk of physical disability among senior citizens. For instance, in one epidemiological study of over ten thousand senior citizens in three cities in the United States, engagement in regular physical exercise doubled the likelihood that a senior citizen would die without disability, as compared to sedentary individuals (Leveille, Guralnik, Ferrucci, & Langlois, 1999). However, it is important to note that exercise alone may not be sufficient to produce this effect (Buford et al., 2014). The research suggests that additional health behaviors may also be necessary to promote significant effects on disability risk in senior citizens (Buford et al., 2014).

The improvements in mortality rate and disability risk may result from the fact that exercise can reduce the risk of chronic conditions that lead to disability and/or early death (Warburton, Nicol, & Bredin, 2006). Sedentary behavior is one of the most important risk factors for a wide range of common chronic conditions for senior citizens, including cardiovascular disease, diabetes mellitus, some types of cancer (such as colon and breast cancer), obesity, hypertension, osteoarthritis, and osteoporosis (Warburton et al., 2006). The risk that a senior citizen will die from one of these chronic conditions is significantly reduced by regular engagement in physical activity (Bean et al., 2004).

Another way in which exercise may reduce morbidity, mortality, and disability among senior citizens is by preventing falls (Yamazaki, Hayashida, & Yontz, 2017). Some of the effects of regular fitness program – including improvements in balance and musculoskeletal strength – can reduce the risk of falls among senior citizens (Hamar, Coberley, Pope, & Rula, 2013). Not only can fall prevention improve the quality of life for senior citizens, but it can also improve quality of life related to financial burdens for fall-related healthcare (Yamazaki et al, 2017).

Exercise can also produce effects for senior citizens who have already been diagnosed with a chronic condition that affects their physical wellbeing. For instance, exercise can reduce symptoms of osteoarthritis, which is the most common chronic condition among individuals age 65 and older (Bean et al., 2004). In one randomized trial of over 400 senior citizens (60 years or older) with knee osteoarthritis, both an aerobic exercise program and a resistance training program had significantly greater effects on wellbeing than a health education intervention (Ettinger et al., 1997). According to the authors, “modest improvements” were observed for knee pain, performance on strength and conditioning activities, and measures of physical disability (Ettinger et al., 1997).

Exercise can also have positive effects for senior citizens with cardiovascular health problems. Heart disease is the leading cause of death around the world, and regular exercise can improve health outcomes for both younger and older adults who have been diagnosed with hypertension and related cardiac conditions (Bean et al., 2004). For instance, there are multiple studies indicating that both aerobic exercise and resistance training can reduce cardiac risk factors associated with coronary artery disease and provide effective rehabilitative therapy for elderly coronary artery disease patients (Bean et al., 2004). Resistance training my also provide functional benefits for disabled older adults with coronary artery disease (Brochu et al., 2002). There is also early evidence suggesting that exercise therapy may improve outcomes for older adults with chronic heart failure (Witham, Struthers, & McMurdo, 2003).

Another significant physical health concern for senior citizens, especially older women, is osteoporosis. The natural loss of bone density, the rate of which significantly increases in advanced age, can lead to fractures among senior citizens (Bean et al., 2004). Not only can exercise in early adulthood increase bone mass and reduce the risk of osteoporosis in later life, but exercise adulthood in old age can also slow the rate of bone mass loss (Nelson, Meredith, Dawson-Hughes, & Evans, 1988). Moreover, exercise has been shown to improve bone mineral density and quality of life measures among elderly patients who have already been diagnosed with osteoporosis (Shanb & Youssef, 2014). Regular resistance training in older adults with osteoporosis or osteopenia has also been shown to improve general physical function and the ability of senior citizens to independently complete activities of daily living (Wilhelm et al., 2012). It is important to note that weight-bearing exercise has significantly stronger effects than non-weight-bearing exercise (Shanb & Youssef, 2014).

Effect of Exercise on the Mental Wellbeing of Senior Citizens
One of the most significant mental health concerns for senior citizens is cognitive decline. Studies have shown that exercise can combat symptoms of cognitive decline in both the short-term and the long-term. For instance, after a single, acute bout of physical activity, seniors perform better on cognitive tasks measuring reaction time, response inhibition, creative thinking, attention, and memory (Hogan, Mata, & Carstensen, 2013). Long-term exercise programs can also improve the well-being of senior citizens by preventing cognitive decline. In one randomized control trial of sedentary senior citizens between the ages of 60 and 79, researchers found that the group who engaged in vigorous exercise three times a week for six months saw significant increases in the volume of gray and white brain matter regions, as compared to a control group that did a stretching routine (Colcombe et al., 2006). This increase in brain has been associated with cognitive performance measures such as task switching (Hogan et al., 2013). Other studies have also suggested that there is an association between regular exercise for senior citizens and executive control processes, including working memory, multitasking, and inhibitory processes (Hogan et al., 2013).

Exercise may also provide benefits for the mental wellbeing of elderly patients who have been diagnosed with an age-related neurodegenerative disorder, such as Alzheimer’s disease or dementia. In one prospective cohort study of 4,615 randomly selected senior citizens (65 years or older) in Canada in the 1990’s, researchers observed that regular physical activity resulted in a significant decrease in the risk of cognitive impairment, Alzheimer’s disease, and any form of dementia (Laurin et al., 2001). More recently, in a randomized controlled pilot trial of patients with early Alzheimer’s disease, Morris et al. (2017) found that a 26-week aerobic exercise program led to slight improvements if functional ability. In addition, there were positive associations between exercise and memory performance (Morris et al., 2017).

Although there is not a clear explanation for the association between exercise and cognitive decline prevention, several hypotheses have been proposed. Some scientists have suggested that exercise can counteract age-related declines in cardiovascular function that contribute to cognitive decline by limiting blood supply to the brain (Lautenschlager, Almeida, Flicker, & Janca, 2004). One population study also showed that among patients carrying a genetic risk factor for Alzheimer’s disease, those who reported less than one hour of physical activity per day had a significantly higher risk of cognitive decline in old age than carriers of the gene who reported at least one hour of physical activity per day (Lautenschlager et al., 2004). For patients with Alzheimer’s disease, the cognitive benefits of exercise may be related to reduced hippocampal atrophy, as regular exercise has been associated with higher bilateral hippocampal volume in patients with early Alzheimer’s disease (Morris et al., 2017).

Exercise can help senior citizens maintain their general mental wellness as they get older. Exercise has been shown to improve mood and increase positive affective responses in older adults (Hogan, et al., 2013). It is also associated with improved sleep quality (Singh et al., 2005). At the same time, multiple studies have shown that regular aerobic exercise can help ward of depressive symptoms in patients who are not clinically depressed (Sjosten & Kivela, 2006). In laboratory studies, exercise is also associated with lower levels of anger, tension, and confusion (Hogan et al., 2013). For senior citizens with physical health conditions that are commonly associated with “adverse psychological reactions,” such as hypertension, regular exercise can significantly improve mental health measures of depression, anxiety, hositility, paranoia, interpersonal sensitivity, compulsions, and somatization (Wenxin, Li, & Yao, 2016).

At the same time, studies also indicate that exercise can promote the mental wellbeing of senior citizens suffering from psychological disorders, such as clinical depression. Some senior citizens have struggled with depression throughout their lives, but over half of depression cases among older adults are late-onset cases (Fiske, Wetherell, & Gatz, 2009). Although it is not entirely clear how exercise aids in the management of depression among senior citizens, one hypothesis is that it decreases the secretion of cortisol, a key stress hormone (Fiske et al., 2009). Among patients with clinical depression, multiple studies indicate that aerobic exercise can help ameliorate symptoms (Sjosten & Kivela, 2006). A randomized control trial has also shown that in clinically depressed patients, weight training led to statistically significant improvements in multiple quality of life indicators, with high-intensity weight-training being more effective than low-intensity weight training (Singh et al., 2005). Exercise may also be as effective or even more effective than traditional antidepressant medication for clinically depressed senior citizens (Fiske et al., 2009). The benefits of exercise have also been noted in senior citizens who have been diagnosed with various subtypes of clinical depression, including major depression, medication-resistant depression, and post-stroke depression (Fiske et al., 2009).

Limitations to the Effect of Exercise on the Wellbeing of Senior Citizens
It is clear from the literature that exercise has a positive effect on the wellbeing of senior citizens, in terms of both physical and mental health. However, one limitation is that the size of the effect may diminish with increasing age (Netz, Wu, Becker & Tenenbaum, 2005). Some observations suggest that the effect of exercise on the wellbeing of senior citizens is greater for individuals who are between 65 and 75 years old, as compared to those who are 76 years old or older (Hogan et al., 2013). This has been observed for measures of both physical wellbeing (such as cardiovascular status, strength, and functional capacity) and mental wellbeing (such as self-efficacy) (Netz et al., 2005).

Conclusion
Clinical Recommendations
Based on the literature relating to the effect of exercise on the wellbeing of senior citizens, it is possible to make clinical recommendations for older adults (Chase et al., 2015). For healthy senior citizens, exercise should be recommended as a strategy to promote physical and mental health maintenance for the long-term. Similarly, exercise can be recommended for older adults with a wide range of chronic health issues, including both physical and mental health problems (Bean et al., 2004).

Future Research
While the positive effects of exercise on the physical and mental wellbeing of seniors is clear, one of the most significant questions that remains to be answered is the ideal exercise intervention for senior citizens (Chase et al., 2015). There are a variety of physical activity interventions that may be implemented for senior citizens, but for many patient populations, the ideal modality, volume, and intensity of exercise is not yet clear (Bean et al., 2004; Warburton et al., 2006). Although it is clearly important for seniors to exercise regularly, it is important to acknowledge that some types of exercise may be more effective for promoting wellbeing than others. Injury risk must also be considered when determining an appropriate exercise training plan for senior citizens (Warburton et al., 2006). The effectiveness of different types of exercise may be studied directly through clinical trials or by further exploring the poorly understood mechanisms through which exercise exerts positive effects on certain elderly populations.

Finally, it is also important for researchers to dedicate future research to finding ways to improve exercise adherence among older adults (Chao, Foy, & Farmer, 2000). There are a variety of reasons that have been proposed as barriers to exercise among older adults, including misperceptions about the effects of exercise on wellbeing (Bean et al., 2004). Further research into this topic can highlight some of the strategies that can be used to promote exercise among senior citizens so that they may experience the associated effects on physical and mental health and wellbeing.

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