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, PsycINFO, 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 der Simonian 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; 4,420 participants; RR 0.88; 95% CI 0.79 to 0.98) and injurious falls (9 RTCs; 4,481 participants; RR 0.74; 95% CI 0.62 to 0.88), and tended to reduce the risk of fractures (19 RTCs; 8,410 participants; RR 0.84; 95% CI 0.71 to 1.00; p = 0.05). Exercise did not significantly diminish the risk of multiple falls (13 RTCs; 3,060 participants), hospitalization (12 RTCs; 5,639 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 to 1.00; p = 0.047). 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.

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