Walking and Health Outcomes in Older Adults: A Systematic Review and Meta-Analysis of Longitudinal Studies

Abstract

Objective

We systematically reviewed evidence on the association between habitual walking (regular, non-prescribed walking as part of daily living quantified by duration, distance, step count, frequency and/or volume) and health outcomes among community-dwelling older adults.

Data Source

MEDLINE, Embase, Global Health, and Psych Info databases; searched from inception to 5th September 2025.

Study Inclusion and Exclusion Criteria

Prospective cohort studies on habitual walking and health outcomes among older adults (65+ years) published in English were included.

Data extraction and synthesis

Quality of studies was assessed using the risk of bias in non-randomised studies of exposure (ROBINS-E) tool. A meta-analysis (random effects model) examined the association between daily step count and all-cause mortality.

Results

Of 25 175 records identified, 46 studies (367 843 older adults and 28 unique outcomes) were included. The pooled estimates of walking are based on 19 206 older adults. Older adults who performed an average of 5694 steps/day, had a 13% lower risk of all-cause mortality (HR: 0.87, 0.80-0.95) per additional 1000 steps/day. Benefits remained similar regardless of walking pace. Walking benefits were observed across mortality, disease onset, hospitalisation, cognitive, psychological and functional outcomes.

Conclusion

Walking is a simple, accessible method of physical activity with minimal risk of injury, associated with a lower risk of multiple health outcomes. Public health campaigns and policies should advocate walking to promote healthier ageing.

Keywords

physical activity walking active travel older adults transport walking mortality

Objective

Walking represents “all forms of purposeful or incidental bipedal locomotion”¹ and holds significance in daily routines, be it for transportation, work, leisure or as a form of physical exercise to improve fitness and prevent chronic diseases.^1,2 For most older adults, walking is accessible, affordable, low risk, requires no special training and emerges as a “nearest activity to perfect exercise.” within a supportive environment (conditions that make walking safe, accessible and enjoyable).³

The World Health Organization recommends that older adults (≥65 years) engage in at least 150 minutes of moderate, or 75 minutes of vigorous aerobic physical activity weekly.⁴ However, a substantial proportion of older adults globally does not meet these guidelines.⁵ This is concerning, as engaging in any physical activity offers significant benefits for older adults,⁴ contributing to better health, quality of life, increased independence and longevity.⁶ Habitual walking in particular can help achieve these benefits.⁶

Recent systematic reviews and meta-analyses of cohort studies with age stratified analysis have supported linear association between daily steps and all-cause mortality among older adults.^7,8 However, both reviews focused solely on step count and predominantly examined populations with diseases, disabilities or specific risk factors, limiting generalisability of the findings to healthy community-dwelling older adults. Other reviews have focussed on walking speed and mortality.⁹

A 2022 systematic review of thirteen intervention studies reports on the role of brisk walking in improving cardiorespiratory fitness, muscular strength and body composition in older adults (mean age≥ 60 years).¹⁰ However, the review focussed on a limited set of outcomes, including physical fitness, balance and life satisfaction and focussed on walking interventions.

This narrow scope of the existing literature reviews creates a significant gap in understanding the broader impact of walking on health outcomes relevant to older adults, such as dementia, depression, frailty, cognitive decline, physical function, disability and physical independence. Moreover, there is a growing interest in understanding the effects of day-to-day walking habits, as opposed to structured walking interventions.^11-13 This distinction may be crucial for informing public health policies, designing sustainable programs and built environments that encourage sustainable walking habits, ultimately contributing to longevity and well-being of the ageing population. Additionally, the effect of habitual walking (regular, non-prescribed walking as part of daily living quantified by duration, distance, step count, frequency and/or volume) on health outcomes stemming from epidemiological cohort studies has not been previously summarised for older adults.

Therefore, this study aims to systematically review the evidence of cohort studies on the association between habitual walking and health outcomes among community-dwelling older adults.

Methods

The study protocol was registered with PROSPERO (Registration ID: CDR42023397192) and followed PRISMA guidelines.¹⁴

Inclusion and Exclusion Criteria

Prospective cohort studies written in English language were included if they met Population, Intervention, Comparison and Outcome criteria (Appendix Table 1). Eligible studies were included if they: (i) focused on non-institutionalised, community-dwelling and free of chronic disease adults aged 65 years and over at baseline, (ii) researched the association between habitual walking (non-prescribed walking as part of daily living, quantified by duration, distance, step count, frequency and/or volume) and any health outcomes.

Data Sources and Search Strategy

We searched Medline, Embase, Global Health and PsychInfo from inception to 5th September 2025. This combination of databases was chosen to maximise breadth and depth of coverage across biomedical, public health and behavioural science disciplines. SS developed the search strategy, validated by a senior medical librarian (LR) (Appendix Table 2). Citations were managed with Covidence, which automatically removed duplicates.¹⁵ Additionally, a “snowball search” was performed by examining the reference lists of included articles.

Data Extraction

Two researchers (SS, YC) independently screened titles, abstracts and full texts (Appendix Table 1). Disagreements were resolved through discussion. If consensus could not be reached, a third researcher (DG) was consulted to make the final decision. A data extraction form was developed based on the review objectives and in line with previous evidence.^16,17 SS piloted on a sample of included studies to ensure clarity and consistency. The final data extraction form included information on author, publication year, country/region, sample size, population characteristics (age, sex), follow-up period (years), walking exposure, outcomes, results, conclusion, and covariate adjustment (Appendix Table 3). SS performed the data extraction of all studies, which was cross-checked by YC to verify accuracy and completeness. Any discrepancies were resolved through discussion.

Study Risk of Bias Assessment

The risk of bias in non-randomised studies of exposure [ROBINS-E] tool was used to assess the risk of bias in the included studies.¹⁸ The ROBINS-E tool evaluates bias across 7 domains: (1) confounding, (2) selection of participants into the study, (3) classification of exposures, (4) departures from intended exposures, (5) missing data, (6) measurement of outcomes (7) selection of the reported result.¹⁸ Each domain was addressed using a series of ‘signalling questions’ designed to collect information about the study and its analysis. Responses to these questions (‘yes’ ‘probably yes’ ‘no’ ‘probably no’ and ‘no information’) are interpreted through a structured decision framework that leads to domain level risk of bias judgements. These domain judgements are then combined to determine the overall risk of bias for each study.¹⁸ SS and YC independently assessed the risk of bias and discrepancies were resolved by discussion.

Data Synthesis

Results were extracted from multivariable models that adjusted for similar confounders across studies. Due to differences in effect metrics and diverse outcome groups with few studies available, quantitative synthesis was possible only for all-cause mortality, which was consistently reported across multiple studies using hazard ratios (HRs) with corresponding 95% confidence intervals. For all other outcomes, where effect estimates were too heterogeneous or data were insufficient, results were reported as a narrative synthesis.

Meta-Analysis

We used the DerSimonian and Laird random effects model, which assumes that the true effect size is not identical across all studies but instead follows a distribution, reflecting both within in-study sampling error and between-study heterogeneity.¹⁹ Statistical heterogeneity was assessed using the Cochran I² statistic, providing an estimate of the amount of variation due to heterogeneity. Results were interpreted according to the Cochrane guidelines (0-40% might not be important; 30-60% moderate heterogeneity; 50-90% substantial heterogeneity; 75-100% considerable heterogeneity).¹⁹

In each case, where possible, we extracted the HRs for the dose-response association for every additional 1000 step/day increment and its effect on all-cause mortality. One study did not provide information on the reference category;²⁰ hence, we assigned the median walking step count as the reference for all studies to standardise the process. For the pooled results we calculated the median step count across the three studies, assigned it to the corresponding HR and arrived at an approximate of 5694 median steps/day ((5094 + 5310 + 6678)/3).^20-22 A similar method of applying median level of walking was used by Zheng et al.²³

To establish robustness of our results, we confirmed our results using a fixed effects model using the inverse variance method, allocating more weightage to studies with smaller variance. We performed additional sensitivity analysis on two studies that examined the effect of walking volume plus intensity on all-cause mortality in this population.

We used Stata version 16²⁴ to pool results from individual studies. Publication bias was not assessed using funnel plots and Eggers test due to a small number of studies included in the meta-analysis.¹⁹

Results

The electronic search of four databases yielded 31 311 studies. After eliminating 6136 duplicates, 25 175 titles and abstracts were screened, excluding of 25 020 studies. Full text review of 155 studies identified 46 studies that met the inclusion criteria (Figure 1).

Figure 1.

PRISMA flow diagram

Risk of Bias

According to the ROBINS-E tool,¹⁸ thirteen studies were rated as low risk of bias, 27 with some concerns and six at high risk. Key sources of bias included limited confounder adjustments (domain 1) and varied walking measurement methods (domain 3), compromising comparability across the studies. (Figure 2; Appendix Table 4).

Figure 2.

Summary of risk of bias across studies assessing individual measures using the ROBINS-E tool. Low risk*‐ applies to studies judged as low risk across all domains except confounding, where some residual bias may remain due to the observational design

Study Characteristics

Forty-six prospective cohort studies were included,^20-22,25-67 involving 467 392 community dwelling older adults engaging in habitual walking (Appendix Table 3). Thirty one studies included both men and women, six included only males^{28,36,38,47,56,57} and nine only females.^{21,25,26,32,40,45,46,59,61} Most studies were conducted in North America,^{21,25-30,32,36,38,40,44,48,51,56,58,59,61,65} followed by fourteen in Asia,^{31,34,37,41-43,49,50,53,57,60,62-64} eight in Europe,^{22,33,39,47,52,54,55,67} and five in Australia.^{20,35,45,46,66} Follow-up periods ranged from two to four years in 13 studies,^{31,33-35,39,41,42,48,50,52,55,63,64} five to 10 years in 25 studies^{20-22,25,27,29,30,32,36-38,40,43-45,49,54,57,58,60-62,65-67} and more than 10 years in 8 studies.^{26,28,46,47,51,53,56,59}

Habitual walking was measured objectively in 19 studies,^{20–22,31,33,34,39,40,42,43,52,53,25–27,60–62,67} while 27 studies assessed it via questionnaires/surveys or recall.^{28-30,32,35-38,41,44-51,54-59,63-66} Walking metrics included distance, step count, duration (daily and weekly), and frequency.

Twenty-eight unique outcomes were identified (Table 1), with eight reporting multiple outcomes.^{22,27,29,30,32,51,56,62} Outcomes included mortality^{20-22,27,30,48,49,51-57,61,62,66} disease onset^{25,27-29,39,40,45,47,64} hospitalisations,^22,30,67 cognitive^{31,32,37,38,63} psychological,^33-36,41,42 and functional.^{26,43,44,46,59,60,62,65}

Table 1.

Overview of the Studies and Outcomes Identified

Author, year, country, years of follow up	Sample size, age, % females	Exposure measurement	Walking units	Outcome
Mortality outcomes
All-cause mortality
Lee et al.²¹	n = 16 741	Objectively measured, accelerometer	Step count	All-cause M*
2019	Mean = 72.0 (±5.7 years)
USA	100%
4.3 years	100%
Manas et al.²²	n = 768	Objectively measured, accelerometer	Step count	All-cause M*
2022	Mean = 78.8 (±4.9) years
Spain	53.9%
5.74 years	53.9%
Oftedal et al.²⁰	n = 204	Objectively measured, accelerometer	Step count	All-cause M*
2019	Mean = 65.4 (±7.1) years
Australia	49.3%
9.6 years	49.3%
Yamamoto et al.⁵³	n = 419	Objectively measured, pedometer	Step count	All-cause M*
2018	71-year-olds
Japan	45.6%
11 years	45.6%
Hamaya et al.²⁷	n = 14 399	Objectively measured	Step count	All-cause M*
2024	Mean = 71.8 (±5.6) years	Objectively measured
USA	48.9%	Accelerometer
9 years	48.9%	Accelerometer
Shimoda et al.⁶²	n = 8664	Objectively measured	Step count	All-cause M*
2025	Median = 74 (71-78) years	Objectively measured
Japan	54%	Accelerometer
5 years	54%	Accelerometer
Klenk et al.⁵²	n = 1271	Objectively measured, accelerometer	Daily duration	All-cause M*
2016	Mean = 75.6 (±6.51) years
Germany	43.6%
4 years	43.6%
Zhao et al.⁵⁷	n = 1239	Self-reported, questionnaire	Daily duration	All-cause M*
2014	65-74-year-olds
Japan	0%
10 years	0%
Landi et al.⁵⁵	n = 248	Self-reported	Daily duration	All-cause M*
2008	Mean age = 85.9 years (±4.9)	Self-reported
Italy	67%	Questionnaire
2 years	67%	Questionnaire
LaCroix et al.²⁴	n = 1645	Self-reported, questionnaire	Weekly duration	All-cause M*
1996	65 years and over
USA	62.7%
5 years	62.7%
Stessman et al.⁴⁹	n = 456	Self-reported, questionnaire	Weekly duration	All-cause M*
2000	70-year- old’s
Israel	43.3%
6 years	43.3%
Patel et al.⁵¹	n = 139 255	Self-reported, questionnaire	Weekly duration	All-cause M*
2018	Mean = 70.7 years
USA	55.4%
13 years	55.4%
Hakim et al.⁴⁸	n = 707	Self-reported, questionnaire	Daily distance	All-cause M*
1998	Mean = 68.9±5.1 years
Hawaii	0%
12 years	0%
Shah et al.⁶⁶	n = 11 539	Self-reported, questionnaire	Weekly frequency	All-cause M*
2024	2024
Australia	Mean = 75.1 (±4.3) years
8.6 years	61.9%
Rakowski et al.⁴⁸	n = 5901	Self-reported, survey	Weekly frequency	All-cause M*
1992	70 years and over
USA	62.3%
4 years	62.3%
Fortes at al.⁵⁴	n = 152	Self-reported, questionnaire	Weekly frequency	All-cause M*
2013	Mean = 80 years
Italy	66.4%
10 years	66.4%
CVD mortality
Patel et al.⁵¹	n = 139 255	Self-reported, questionnaire	Weekly duration	CVD M*
2018	Mean = 70.7 years
USA	55.4%
13 years	55.4%
Cancer mortality
Patel et al.⁵¹	n = 139 255	Self-reported, questionnaire	Weekly duration	Cancer M*
2018	Mean = 70.7 years
USA	55.4%
13 years	55.4%
Hakim et al.⁴⁸	n = 707	Self-reported, questionnaire	Daily duration	Cancer M*
1998	Mean = 68.9±5.1 years
Hawaii	0%
12 years	0%
Cuthberstson et al.⁶¹	n = 22 326	Objectively measured, Accelerometer	Step count	Breast
2024	n = 22 326			Colon
2024	Mean = 73.4 (±6.3)			Endometrial
USA	Mean = 73.4 (±6.3)			Lung
USA	100%			Ovarian
7.9 years				PA-related
7.9 years				Fatal
Respiratory disease mortality
Ikeda et al.⁵⁰	n = 132 448	Self-reported, questionnaire	Daily duration	Pneumonia M*
2020	Mean = 69.2 (±2.9) years
Japan	60.8%
3.4 median years	60.8%
Patel et al.⁵¹	n = 139 255	Self-reported, questionnaire	Weekly duration	RD M*
2018	Mean = 70.7 years
USA	55.4%
13 years	55.4%
Disease onset outcomes
Diabetes
Ballin et al.³⁹	n = 3055	Objectively measured, accelerometer.	Step count	Diabetes
2020	Mean = 77.4 (±4.4) years
Sweden	52%
2.6 years	52%
Garduno et al.⁴⁰	n = 4848	Objectively measured, accelerometer.	Step count	Diabetes
2022	Mean age = 78.9 (±6.7) years
USA	100%
6.9 years	100%
Arthritis
Heesch et al.⁴⁵	n = 3613	Self -reported, questionnaire.	Weekly volume	Arthritis
2008	Mean = 75.28 (±1.44) years
Australia	100%
6 years	100%
Osteoporosis
Yue et al.⁶⁴	n = 24 700	Self -reported, questionnaire	Daily duration	Osteoporosis
2024	Mean = 68.4 (±5.8) years
China	51.9%
3.1 median years	51.9%
Cardiovascular outcomes
Hakim et al.²⁸	n = 2678	Self-reported, questionnaire	Daily distance	CHD
1999	71-93 years olds
Hawaii	0%
12 years	0%
Jefferis et al.⁴⁷	n = 2995	Self-reported, questionnaire	Weekly duration	Stroke
2014	Mean = 68.3 years		Weekly duration
UK	0%		Weekly distance
11 years	0%		Weekly distance
Lamonte al.²⁵	n = 5951	Objectively measured, accelerometer	Step count	Heart failure
2024	Mean = 78.6 (±6.8) years
USA	100%
7.5 years	100%
Hamaya et al.²⁷	n = 14 399	Objectively measured, accelerometer	Step count	CVD*
2024	Mean = 71.8 (±5.6) years
USA	48.9%
9 years	48.9%
Soares-miranda et al.²⁹	n = 4207	Self-reported, questionnaire	Weekly distance	CHD
2016	Mean = 72.5±5.5			Stroke
USA	61%			CVD
10 years	61%			CVD
Hospitalisation Outcomes
Hospitalisations
Manas et al.²²	n = 768	Objectively measured, accelerometer	Step count	H*
2022	Mean = 78.8±4.9 years
Spain	53.9%
5.74 years	53.9%
Ars et al.⁶⁷	n = 657	Objectively measured, accelerometer	Step count	H*
2025	Mean = 73.4 (±9)
Sweden	64.1%
6 years	64.1%
LaCroix et al.²⁴	n = 1645	Self-reported, questionnaire	Weekly duration	CVD H*
1996	65 years and over
USA	62.7%
5 years	62.7%
Cognitive outcomes
Dementia
Wang et al.³²	n = 1249	Self-reported, questionnaire	Daily distance	Dementia
2014	Mean = 83.3±2.8 years
USA	100%
5 years	100%
Abbott et al.³⁸	n = 2257	Self-reported, questionnaire	Daily distance	Dementia
2004	71-93-year old’s
Hawaii	0%
7 years	0%
Tomata et al.³⁷	n = 13 990	Self-reported, questionnaire	Daily duration	Dementia
2018	73.8 (±5.9) years
Japan	55%
5.7 years	55%
Cognitive decline
Chen et al.³¹	n = 274	Objectively measure, accelerometer.	Step count	Cognitive ability
2020	Mean = 74.52±6.1 years
Taiwan	44.6%
2 years	44.6%
Mild cognitive impairment
Wang et al.³²	n = 1249	Self-reported, questionnaire	Daily distance	MCI
2014	Mean = 83.3±2.8 years
USA	100%
5 years	100%
Alzheimer’s
Kim et al.⁶³	n = 151	Self-reported, questionnaire	Weekly duration	Alzheimer’s related brain pathologies
2025	Median = 69.7 (7.4) years
Korea	58.9%
4 years	58.9%
Psychological outcomes
Depression
Hsueh et al.³⁴	n = 274	Objectively measured, accelerometer	Step count	Depressive symptoms
2020	Mean = 74.5 years
Taiwan	54.5%
2 years	54.5%
Chan et al.³⁵	n = 322	Self-reported, questionnaire	Step count	Depressive symptoms
2021	Median = 75.5 (72.3-80.1) years
Australia	62.1%
2 years	62.1%
Raudsepp et al.³³	n = 195	Objectively measured, pedometer	Step count	Depressive symptoms
2017	Mean = 72.1±2.1
Estonia	74.4%
2 years	74.4%
Smith et al.³⁶	n = 1518	Self-reported, questionnaire	Daily distance	Depressive symptoms
2010	79 –100-year-olds
Hawaii	0%
8 years
Julien et al.⁵⁸	n = 498	Self-reported, questionnaire	Weekly frequency	Depressive symptoms
2013	Mean age = 74.64 years
Canada	52.7%
5 years	52.7%
Sleep
Kimura et al.⁴²	n = 855	Objectively measured, wrist band sensor	Step count	Sleep efficiency
2020	Median = 73 (69-78) years			TST
Japan	62.9%			WASO
1 year	62.9%			Nap time
Chen et al.⁴¹	n = 511	Self-reported, questionnaire	Weekly volume	Sleep difficulty
2018	Mean = 73.73 (±5.69) years		Weekly frequency
Taiwan	46%		Weekly duration
2 years	46%		Weekly duration
Functional outcomes
Frailty
Yuki et al.⁴³	n = 401	Objectively measured, accelerometer	Step count	Frailty
2019	Mean = 71.1 (±4.3) years
Japan	44.4%
10 years	44.4%
Disability
Clark et al.⁴⁴	n = 3677	Self-reported, questionnaire	Weekly frequency	LBD
1996	70-99 years
USA	62.3%
6 years	62.3%
Shimoda et al.⁶²	n = 8664	Objectively measured, accelerometer	Step count	Disability
2025	Median = 74 (71-78) years
Japan	54%
5 years	54%
Morikawa et al.⁶⁰	n = 2071	Objectively measured, accelerometer.	Step count	Disability
2024	Median = 75 (72-78) years
Japan	56.5%
5 years	56.5%
Mobility
Field et al.⁴⁶	n = 10 322	Self-reported, questionnaire	Weekly duration	Mobility
2017	Mean = 75.4 years
Australia	100%
12 years	100%
Physical function
Tahmassi et al.⁶⁵	n = 998	Self-reported, questionnaire	Weekly duration	Physical function
2024	Mean = 82.8 (±4.2) years
Mexico	61.9%
9 years	61.9%
Fractures
Liu et al.⁵⁹	n = 9704	Self-reported, questionnaire	Daily distance	Hip fractures
2025	Mean = 71.0 (±4.9 years)			Other fractures
USA	100%
20 years	100%
Falls
Schumacher et al.²⁶	n = 5545	Objectively measured, accelerometer	Step count	Falls
2022	Mean = 78.8 (6.7) years
USA	100%
11.1 months	100%

M*- mortality; LBD-lower body disability; MCI- mild cognitive impairment; CVD-cardiovascular disease; CHD-coronary heart disease; RD-respiratory disease; TST-total sleep time; WASO- time awake after sleep onset.

The Association Between Walking and Health Outcomes

Walking and Mortality Outcomes

All-Cause Mortality

Sixteen studies explored the association between walking and all-cause mortality in older adults.^{20-22,27,30,48,49,51-57,62,66} Walking measurements varied, with studies reporting daily step count,^{20-22,27,53,62} weekly walking duration,^{30,49,52,55,57} daily duration,^30,49 distance^51,56 and frequency.^48,54,66 (refer to Table 1). Three studies have explored the association between habitual walking and cause-specific mortality, including pneumonia,⁵⁰ respiratory disease⁵¹ cancer,^51,56 cardiovascular [CVD]⁵¹ and coronary heart disease [CHD].⁵⁶

Step Count

Six studies explored the association between daily step count and all-cause mortality,^{20-22,27,53,62} with three studies (total n = 19 206) included in the meta-analysis. Pooled results of three studies indicate that older adults, who performed an average of 5694 steps/day, had a 13% lower risk of all-cause mortality (HR: 0.87, 95%CI 0.80-0.95, I² = 80.71%) for every additional 1000 steps/day (Figure 3).

Figure 3.

Meta-analysis of evidence on association between step count and all-cause mortality using DerSimonian-Laird random effect model

Sensitivity analyses showed similar results using the inverse variance method with more precise confidence intervals (Appendix Figure 1). In a sensitivity analysis of two studies (n = 17 509 older adults) that adjusted step count and intensity of stepping,^21,22 results indicating pace adjustment did not impact the risk of all-cause mortality (HR: 0.87, 95%CI 0.80-0.95, I² = 80.71%) for every additional 1000 steps/day (Appendix Figures 2 and 3).

Yamamoto et al (n = 419), reported a 54% lower risk of death for adults who accumulated more than 7972 steps/day compared with those who accumulated fewer than 4503 steps/day (HR = 0.46, 95%CI 0.22-0.96)⁵³ Shimoda et al.⁶² (n = 8664) reported a lower risk of all-cause mortality among Japanese older adults who accumulated an optimal 2593 steps/day (HR = 0.63, 95%CI 0.40-0.98) and 3282 steps (HR = 0.77, 95%CI 0.61-0.98). Hamaya et al from the US (n = 14 399) reported that, compared to adults who accumulated 2808 steps/day, those who accumulated 4442 steps/day (HR = 0.70, 95%CI 0.60-0.81), 5995 steps/day (HR = 0.58, 95%CI 0.49, 0.69) and 8551 steps/day (HR = 0.55, 95%CI 0.45, 0.68) had a lower risk of all-cause mortality.²⁷

Weekly Walking Duration

Three studies^30,49,51 explored the association between weekly walking duration and all-cause mortality among older adults. Stessman et al.⁵⁴ reported that, among 456 Israeli older adults, walking at least one hour/day (OR = 0.14, 95%CI 0.04-0.50) or 4 hours weekly (OR = 0.41, 95%CI 0.19-0.91) was associated with reduced odds of 6-year mortality compared with walking less than four hours/week. Conversely, a US study reported no association between weekly walking duration and risk of all-cause mortality.³⁰ Patel et al.⁵¹ reported that inactivity (no walking) was associated with a higher risk of all-cause mortality compared with adults who walked less than two hours/week (HR: 1.26, 95%CI 1.21-1.31).

Daily Walking Duration

Klenk et al,⁵² Zhao et al.⁵⁷ and Landi et al⁵⁵ examined the association between daily walking duration and risk of all-cause mortality. In 1271 German older adults, walking 101.2 to 128.4 minutes/day was associated with a lower risk of death (HR = 0.30, 95%CI 0.14-0.66) compared to those walking less than 76.1 minutes/day.⁵⁷ In 1239 Japanese older men there was a lower risk of all-cause mortality with walking two or more hours/day (HR = 0.52, 95%CI 0.30-0.88) compared to walking less than 0.5 hours/day.⁵² Similarly, a study from Italy on 248 older persons reported that adults walking one hour or more/day had a lower risk of all-cause mortality (RR = 0.36, 95%CI 0.12-0.98) compared to adults walking less than one hour/day.⁵⁵

Daily Walking Distance

A Hawaiian study⁵⁶ on 707 older men reported that those walking less than one mile/day had a higher mortality risk compared to men walking more than two miles/day (RR = 1.8, 95%CI 1.2-2.7).

Weekly Walking Frequency

Rakowski et al.⁴⁸ observed that US older adults (n = 5901) who walked less than a mile once a week or never had a 54% higher risk of all-cause mortality compared to those who walked one mile or more on four or more days/week (OR = 1.54, 95%CI 1.24-1.92). An Italian study of 152 older adults reported a 47% lower risk of mortality for older adults who walked for at least 15 minutes at open air four times/week compared to those who walked at open air less than four times/week (RR = 0.53, 95%CI 0.32-0.88).⁵⁴ An Australian study (n = 11 539) reported that, compared to older adults never walking for transport, those walking for transport rarely/once a week (HR = 0.73, 95%CI 0.56-0.96), more than once a week (HR = 0.76, 95%CI 0.59-0.99) and every day (HR = 0.74, 95%CI 0.57-0.96) had a lower risk of all-cause mortality.⁶⁶

Cardiovascular Disease Mortality

Weekly Duration

Patel et al.⁵¹ (n = 139 255), reported a 24% lower risk of CVD mortality (HR = 0.76, 95%CI 0.71-0.82) for US older adults who walked more than six hours/week compared to those who did no walking.

Cancer Mortality

Daily Walking Distance

Another US study involving 707 retired men,⁵⁶ reported that men who walked less than one mile/day had a higher risk of cancer mortality (RR = 2.4, 95%CI 1.1-5.4) and CHD mortality (RR = 2.6, 95%CI 0.7-10.3) compared to adults who walked 2.1 to 8 miles/day.

Weekly Duration

Patel et al.⁵¹ (n = 139 255), reported a 7% lower risk of cancer mortality (HR = 0.93, 95%CI 0.87-1.00) for US older adults who walked more than six hours/week compared to those who did no walking.

Step Count

Cuthberstson⁶¹ (n = 22 326), reported no association between daily steps and site specific cancers (breast, colon, endometrial, lung, ovarian, physical activity related and fatal cancers).

Respiratory Disease Mortality

Weekly Duration

Patel et al.⁵¹ (n = 139 255), reported a 35% (HR = 0.65, 95%CI 0.57-0.74) lower risk of respiratory disease mortality) for US older adults who walked more than six hours/week compared to those who did no walking.

Daily Duration

A Japanese study⁵⁰ on 132 448 older individuals reported that daily walking (more than one hour/day) was associated with a lower risk of pneumonia-related mortality compared to those that did not walk for more than one hour/day (sub-hazard ratios [sHR] = 0.58, 95%CI 0.39-0.86).

Walking and Disease Onset Outcomes

Diabetes was assessed in two studies.^39,40 Five studies explored the association between overall walking and cardiovascular outcomes including stroke,^29,47 CVD,^27,29 heart failure²⁵ and CHD.¹⁶ (refer to Table 1).

Diabetes

Step Count

A Swedish study with 3055 older adults, reported a 59% lower risk of diabetes for those walking 4500 or more steps/day compared to those walking less than 4500 steps/day (HR = 0.41, 95%CI 0.25-0.66).³⁹ An American study on 4838 females reported that an increment of 2000 steps/day was associated with a 12% lower risk of diabetes (HR = 0.88, 95%CI 0.78-1.00).⁴⁰

Arthritis

Weekly Volume

An Australian study⁴⁵ including 3613 older women reported that women who walked weekly at a high intensity level (between 600 to 1200 MET minutes/week) were 31% (OR = 0.69, 95%CI 0.57-0.83) less likely to report arthritis compared to those walking less than 40 MET minutes/week.

Osteoporosis

Daily Duration

A Chinese study (n = 24 700) reported, compared to no walking, older adults with high genetic risk who walked ≤30min/day (HR = 0.95, 95%CI 0.87-1.03), >30 to ≤60 minutes/day (HR = 0.80, 0.73-0.88) and >60 minutes/day (HR = 0.54, 0.41-0.70) had a lower osteoporosis risk.

Cardiovascular Disease

Weekly Distance

A study from Hawaii²⁸ on 2678 older men reported a higher risk of CHD among men who walked less than 0.25 miles/day compared to those who walked more than 1.5 miles/day (RR: 2.3, 95%CI 1.3-4.1). Soares-Miranda et al.²⁹ (n = 4207) observed a lower risk of stroke (HR = 0.46 95%CI 0.35-0.62), CVD (HR = 0.53, 95%CI 0.44-0.65) and CHD (HR = 0.64, 95%CI 0.50-0.83) in older adults who walked 49 or more blocks/week compared to those walking up to five blocks/week.²⁹

Daily Distance

Jefferis et al.^28,47 studied 2995 older men in the UK and reported a lower risk of fatal or non-fatal stroke for men who walked more than 22 hours/week compared to those walking up to three hours/week (HR: 0.36, 95%CI 0.14-0.91); they reported no association between the number of miles walked and stroke.

Step Count

A study from the USA (n = 5951) reported that, compared to <2164 steps/day, females who took 2164 to 3210 steps/day (HR = 0.72, 95%CI 0.56-0.93), 3211 to 4541 steps/day (HR = 0.60, 95%CI 0.44-0.81) and >4541 steps/day (HR = 0.54, 95%CI 0.36-0.79) had a lower risk of heart failure. Another study from the USA (n = 14 399) reported no association between step count and CVD.²⁷

Walking and Hospitalisation Outcomes

Three studies explored the association between walking and hospitalisations.^30,32,67 (refer to Table 1).

Weekly Duration

La Croix et al³⁰ researched 1645 USA older adults and reported that walking more than four hours/week was associated with a lower risk of CVD hospitalisations compared to walking less than one hour/week (RR = 0.74, 95%CI 0.56-0.98).

Step Count

Manas et al.²² examined data of 768 Spanish older adults and observed that a higher step count was associated with a 5% lower risk of hospitalisation (HR = 0.95, 95%CI 0.90-1.00 per additional 1000 steps). A Swedish study (n = 657) observed that each additional 1000 steps/day was associated with a reduced risk of unplanned hospital admissions (HR = 0.95, 95%CI 0.91-0.99).⁶⁷

Walking and Cognitive Outcomes

Three studies explored the association between walking and dementia,^32,37,38 while one study each examined cognitive decline,³¹ mild cognitive impairment³² and Alzheimer’s disease.⁶³ (refer to Table 1).

Dementia

Daily Distance

A study from the USA on 1249 older women reported no association between blocks walked/day and risk of mild cognitive impairment but observed a lower risk of dementia for women who walked 138.9 blocks/day compared to those who walked 7.1 blocks/day on average.³² In a Hawaiian study (n = 2257), older men who walked less than 0.25 miles/day had a 93% higher risk of dementia compared to men walking more than two miles/day (Relative Hazard [RH] = 1.93, 95%CI 1.11-3.34).³⁸

Daily Duration

A Japanese study (n = 13 990) reported a 28% lower risk of incident dementia (HR = 0.72, 95%CI 0.62-0.84) for older adults walking one or more hours daily compared to those walking less than half an hour daily.³⁷

Cognitive Decline

Step Count

A study from Taiwan (n = 274) reported that, compared to older adults taking less than 3500 steps daily, those who accumulated more than ≥7000 steps daily had a lower rate of cognitive decline (rate ratio RR = 0.43, 95%CI 0.23-0.82).³¹

Alzheimer’s Disease

Weekly Duration

A study from Korea (n = 151) reported that, compared with no walking, long-duration walking (>360 min/week) was associated with lower Aβ-beta amyloid deposition over four years (β = −0.310, P=<0.001). No associations were observed between walking and tau deposition, neurodegeneration, or white matter hyperintensity volume.⁶³

Walking and Psychological Outcomes

Five studies have assessed the association between walking and depressive symptoms^33-36,58 (Table 1). Sleep outcomes were assessed in two studies^41,42 (refer to Table 1).

Depression

Step Count

A study on walking from Estonia³³ involving 195 older adults reported a negative correlation between walking and depressive symptoms over three yearly assessments (T1 = baseline, T2 = interim and T3 = follow-up). Path coefficients from depressive symptoms at baseline to interim and follow-up were negative (β = −0.24, P < 0.01; β-0.21, <0.01), as were coefficients from walking to depressive symptoms (β = −0.17, P < 0.01; β-0.20, <0.01). An Australian study (n = 322)³⁵ reported that older adults with a lower step count per day (OR = 1.31, 95%CI 1.03-1.68) and the shortest walking bouts (OR = 2.52, 95%CI 1.67-3.81) had higher odds of developing depressive symptoms compared to those with higher daily step counts and longest walking bouts. In contrast, a Taiwanese study (n = 274)³⁴ reported that older adults taking 7000 or more steps daily had a 29% lower risk of depressive symptoms than those taking less than 3500 steps daily (RR = 0.71, 95%CI 0.55-0.92).

Daily Distance

A study from Hawaii including 1518 men reported that, compared with walking <0.25 miles/day, both intermediate (0.25-1.5 miles/day) and higher (≥1.5 miles/day) walking levels were associated with lower odds of incident depressive symptoms over 8 years (OR 0.52, 95%CI 0.32-0.83; and OR 0.61, 95%CI 0.39-0.97, respectively).³⁶

Weekly Frequency

A Canadian study (n = 498) reported no association between walking frequency and depressive symptoms.⁵⁸

Sleep Outcomes

Step Count

A Japanese study⁴² of 855 older adults reported a positive correlation between daily steps and sleep efficiency (β = 0.098, 95%CI 0.034-0.162) and an inverse correlation with total sleep time (β = −0.001, 95%CI -0.066 - 0.065), time awake after sleep onset (β = −0.107, 95%CI -0.172, −0.04), awakening time count (average number of minutes awake after sleep onset and frequency of awakening per day) (β = −0.105, 95%CI -0.17, −0.04) and duration of nap time (β = −0.31, 95%CI -0.371 to −0.249).

Weekly: Volume, Frequency, Duration

A study from Taiwan studied 511 older adults and identified that participants with low walking volume (≤4.5 MET-h/week) (IRR = 1.61, 95%CI 1.16-2.22), low walking frequency (≤3 days/week) (IRR = 1.10, 95%CI 0.81-1.51) and low walking duration (≤20 minutes) (IRR = 1.40, 95%CI 0.98-2.00) had a higher level of sleep difficulty compared to those with high walking volume (>10 MET-h/week), frequency (7 days/week), and duration (>40 minutes).⁴¹

Walking and Functional Outcomes

Three studies examined the association between walking and disability,^44,60,62 while one study each investigated frailty,⁴³ mobility,⁴⁶ physical function,⁶⁵ fractures⁵⁹ and falls.²⁶

Frailty

Step Count

A Japanese study of 401 older adults⁴³ reported that those walking less than 5000 steps/day had higher odds of developing frailty compared to those walking 5000 or more steps/day (OR = 1.85, 95%CI 1.10-3.11) (refer to Table 1).

Disability

Step Count

A Japanese study of 2071 older adults⁶⁰ reported that those taking ≥5235 median steps/day had a lower risk of disability (HR = 0.58, 95%CI 0.40-0.85) compared to those taking <5325 median steps/day in the non-social isolation group. Similarly, in the social isolation group, taking ≥4936 steps was associated with a lower risk of disability (HR = 0.62 95%CI 0.43-0.89) compared to taking <4936 steps.

Shimoda et al.⁶² (n = 8664) reported a nonlinear association between daily step count and incident disability in Japanese older adults. A lower risk was observed at 2168 steps/day in frail (HR = 0.74 95%CI 0.56-0.98) and 7459 steps/day in non-frail participants (HR = 0.86 95%CI (0.74-0.99). Similar patterns were observed by age, with optimal thresholds of 6,066 steps/day (>75 years; HR 0.83, 95%CI 0.72-0.99) and 8,573 steps/day (<75 years; HR 0.77, 95%CI 0.59-0.99).

Weekly Frequency

A US study⁴⁴ on 3677 older adults reported that, compared to never walking 1 mile or more/week, walking 1 mile or more for 4-7 days/week was associated with a lower risk of disability onset (Whites: OR = 0.66, 95%CI 0.56-0.77; Blacks: OR: 0.37, 95%CI 0.22-0.64).

Weekly Duration

An Australian study⁴⁶ involving 10 322 females concluded that compared to non-walkers (<10 min/week), those who walked at sufficient levels (≥150 min/week) had higher mean mobility scores (Coefficient = 0.21, 95%CI 0.20-0.22) and were less likely to use mobility aid (β = −0.82, 95%CI -1.00, −0.64).

Fractures

Daily Distance

A US study⁵⁹ involving 9704 women reported that, compared to no engagement in walking for exercise, walking for exercise was associated with a lower risk of hip fracture (HR = 0.86, 95%CI 0.76-0.98). Each additional block (1/12 mile) walked for exercise per day was associated with a lower risk of hip fracture (HR = 0.98 95%CI 0.98-0.99). There was no association between walking for exercise and other fractures. Walking for routine activities showed no association with fractures.

Physical Function

Weekly Duration

A Mexican study (n = 998)⁶⁵ reported that, compared to no walking, older adults who walked <150 min/week (HR = 0.66, 95%CI 0.51-0.86) and ≥150 min/week (HR = 0.54, (0.41-0.71) had a lower risk of low physical function.

Falls

Step Count

A US study (n = 5545) reported that, compared with women in the lowest step quartile (<2184 steps/day), those in the highest quartile (>4597 steps/day) had a lower risk of falls (HR = 0.71 95%CI 0.54- 0.95). However, this association was attenuated and no longer statistically significant after further adjustment for physical function.²⁶

Discussion

We systematically reviewed the association between habitual walking and 28 unique health outcomes among community-dwelling adults aged 65 years and over. Our pooled analysis of three prospective cohort studies suggests a graded, dose-response relationship between step count and mortality. Specifically, older adults whose median daily step count was approximately 5694 steps (derived from study-level medians across three studies), had a 13% lower risk of all-cause mortality for every additional 1000 steps/day. This implies that even the modest increases in daily steps may yield meaningful health benefits for older adults. However, these findings should not be interpreted as causal given the observational nature of included studies, small number of studies and high heterogeneity. Irrespective of walking metrics (eg, step count, duration, distance, frequency), stratification approaches and health outcomes examined, habitual walking has been consistently associated with a lower risk of adverse health outcomes. Notable exceptions included one study reporting no association between self-reported walking frequency and depression,⁵⁸ and several studies reporting no associations between walking and all-cause mortality,²⁴ CVD hospitalisations,³⁰ CVD incidence²⁷ mild cognitive impairment,³² cancer,⁶¹ depressive symptoms⁵⁸ and fractures other than hip fractures.⁵⁹ The risk of bias across the studies ranged from low to high; thus, some results should be interpreted with caution.

Walking may influence health outcomes through interconnected physiological and psychosocial mechanisms.^1,68 Regular walking improves cardiovascular fitness, lowers blood pressure, thereby reducing CVD risk^13,69 and contributing to lower all-cause mortality. Psychological benefits include reduced depressive symptoms through neurochemical pathways, better sleep and opportunities of social interaction.⁷⁰ Collectively, these multisystem benefits highlight walking as a simple and multifaceted strategy to promote healthy ageing. Additionally, it is established that regular physical activity helps preserve muscle strength, balance and progression of basic activities of daily living which are known to slow the onset of functional decline and reduce disability.⁷¹

Our results align with an umbrella review and meta-analysis⁸ reporting lower risk of all-cause mortality with each additional 1000 steps/day in adults ≥70 years (HR = 0.85, 95%CI (0.81-0.90; n = 6). The smaller effect reported for adults 60-69 years likely reflects the younger healthier cohorts and small number of studies (HR = 0.96, 95%CI 0.4-0.97; n = 2). A more recent systematic review⁷ highlights a linear relationship between daily steps and all-cause mortality among older adults (n = 6), though mostly in populations with existing conditions, disability or risk factors.

Our findings on overall walking and all-cause mortality also align with previous studies on middle aged adults.^12,13,72-74 Additionally, greater walking improves cardiovascular fitness risk factors,^69,75 mental well-being,^12,76 weight maintenance^69,77 and reduces the risk of depression,⁷⁸ hypertension,⁶⁹ and cardiovascular disease^10,62,79 consistent with our study results. We extend the available evidence by providing pooled evidence on the role of habitual walking and all-cause mortality among community-dwelling older adults and provide a narrative synthesis on a broad range of other unique health outcomes relevant to older adults.

Limitations

Few studies controlled for other physical activities, despite this being previously highlighted as an important confounder among middle-aged adults.¹² Socio-economic status, another key confounder was often not adjusted for.^80,81 Few studies reported on the validity and reliability of walking assessment methods, with many relying on self-reported measures susceptible to recall bias and misclassification.⁸²

A further limitation relates to the bidirectional relationship between walking and health or functional status. While our review suggests that habitual walking is associated with favourable health outcomes, declining cognitive or physical function may also reduce an individual’s capacity to walk, thereby contributing to the observed associations. Although some included studies adjusted for baseline health status, many did not, or did so incompletely, which may have resulted in residual confounding and limited comparability across studies. Future research should employ repeated measures and longitudinal modelling approaches to better capture temporal dynamics and help disentangle causal direction.

Included studies are predominantly from high-income countries, limiting generalisability to low and middle-income regions where environmental and social factors may differ.^83-85 Variation in exposure assessment methods across studies further challenged comparability of findings. Additionally, the meta-analysis results should be interpreted with caution due to the small number of included studies and substantial heterogeneity, likely driven by differences in walking measurement, sample size and follow-up duration. Sensitivity analyses using a fixed-effects inverse-variance model yielded pooled estimates similar to the primary analyses, with narrower confidence intervals, supporting robustness of the findings (Appendix Figure 1). Lastly, the small number of studies precluded formal assessment of publication bias, which remains a potential limitation, as it may have contributed to an overrepresentation of favourable findings.

The risk of bias assessment indicated that 13 studies were rated as low risk, while most were judged to have some concerns (n = 27) or high risk of bias (n = 6). In particular, limited adjustment for key confounders and heterogeneity in walking measurement methods may have introduced bias and reduced comparability across studies. Therefore, although our findings suggest an association, the conclusions should be interpreted with caution. Future studies employing more rigorous designs, consistent exposure measurements, and comprehensive confounder adjustment are needed to strengthen the evidence base.

Implications for Practice, Policy and Future Research

Our findings underscore the importance of promoting walking to improve health outcomes and reduce mortality risk among community-dwelling older adults. At the individual level, health professionals should encourage older adults to incorporate regular walking into their daily routine, emphasising its wide-ranging benefits. At the populational level, educational programs and walking interventions⁸⁶ are essential to support and empower older adults to adopt walking as a regular and safe activity.

While the WHO guidelines provide general recommendations for older adults, they do not fully account for age-related factors such as functional limitations, comorbidities and varying capacities. Tailoring recommendations to the needs of older adults is therefore essential to ensure they are both realistic and achievable.

Walking is of particular relevance to the population health of older adults as it is convenient, accessible and carries a low risk of injury.⁶⁹ Additionally, it appears to be a preferred activity among sedentary individuals taking up PA.⁶⁹ As such, walking may represent an important cornerstone for promoting PA and enhancing health among older adults.

To facilitate walking in older adults, ensuring safe and supportive environments is crucial. The built environment, including urban design and land use, can be facilitators or act as barriers to walking.⁸⁷ Key factors include access to destinations and amenities (eg, shops, restaurants, libraries), safety features (eg, lighting, crime deterrents, cross walks) and quality of infrastructure (eg, footpaths, surface conditions, availability of benches, noise, odour and openness).^83,87,88 These environmental features may help explain variation in walking behaviour and related outcomes, as supportive environments are likely to promote higher levels of walking. Social support from family members also plays an importnat role in encouraging activity among older adults.⁸⁹ Additionally, weather conditions are a common environmental barrier influencing engagement in walking.⁹⁰ Among middle-aged adults, cultural factors and social responsibilities have shown to limit women’s participation in physical activity⁹¹ and these factors may also persist in older age.

Future research should explore dose-response patterns of walking across key subgroups, including gender, socioeconomic status, geographic region, socioeconomic status, and ethnicity, to better inform policy and intervention design. The current lack of stratified evidence limits subgroup-specific conclusions, and should be addressed in future studies. Expanding research in low- and middle-income countries is also important to enhance global applicability of findings. Methodological challenges in assessing walking behaviours, such as varied measurement units, should be addressed by incorporating objective, device-based measures (eg, accelerometers) using standardised metrics. A more nuanced understanding of the determinants influencing walking behaviour is needed to inform policies and targeted interventions.

There was insufficient evidence to draw conclusions regarding the purpose of walking, as few studies compared or indicated the purpose. Greater understanding of the context and purpose of walking is needed. Few studies have examined the role of transport walking (walking to get to places/destinations) on health in older adults.^92,93 Future research should prioritise this domain, as transport walking is common among older adults and can be a practical approach to increasing activity levels in this age group. Walking groups and social support have been identified as effective strategies to support walking adherence⁹⁴ and leisure time activity,⁸⁹ suggesting promising interventions to promote walking among older adults.

Conclusion

Our systematic review and meta-analysis demonstrate that overall walking is associated with favourable health outcomes among community-dwelling older adults, and that even small increases in daily step count are associated with a lower all-cause mortality risk, reinforcing the value of promoting walking in this population. Given its affordability,⁹⁵ high adherence,⁹⁶ and low risk of injury,⁹⁶ walking represents a practical and accessible strategy to improve health in older age. Public health policies and programs that promote walking should therefore be supported, alongside further research to better understand the associations.

So What?

What is Already Known on This Topic?

Walking is a common and accessible form of physical activity for older adults and has been linked to lower mortality risk and improved health. Previous reviews have primarily focused on step count, walking speed, or intervention studies, often in populations with existing disease or disability, and have examined a limited range of health outcomes.

What This Study Adds

This systematic review synthesises longitudinal evidence from 46 cohort studies of community-dwelling older adults, examining habitual walking across multiple metrics and 28 health outcomes. The meta-analysis showed that older adults with a median daily step count of approximately 5700 steps/day had a 13% lower risk of all-cause mortality per additional 1000 steps/day. Walking was also consistently associated with favourable cognitive, psychological, functional, and disease outcomes.

How This Study Might Affect Research, Practice, or Policy: These findings support walking as a low-risk, scalable strategy for healthy ageing, reinforcing its inclusion in public health guidelines and age-friendly urban planning, while highlighting the need for longitudinal research with standardised exposure measures.

Supplemental Material

Supplemental Material - Walking and Health Outcomes in Older Adults: A Systematic Review and Meta-Analysis of Longitudinal Studies

Supplemental Material for Walking and Health Outcomes in Older Adults: A Systematic Review and Meta-Analysis of Longitudinal Studies by Shivangi Shah, Yang Chen, Alice Owen, Christina Ekegren, Stella Talic, Dragan Ilic, Danijela Gasevic, MD, PhD in American Journal of Health Promotion.

Footnotes

ORCID iDs

Shivangi Shah

Yang Chen

Stella Talic

Dragan Ilic

Danijela Gasevic

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data available on request.*

Registration & Protocol

This review has been registered in the international prospective register of systematic reviews under the registration number (Registration ID: CDR42023397192).

Supplemental Material

Supplemental material for this article is available online.

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