Why Older Adults Abandon the Exercises That Keep Them Steady

For millions of older people, the world does not simply look or feel stable. Vertigo, dizziness, and balance disorders—collectively known in the clinical literature as VDB—affect an estimated 15 to 35 percent of adults at some point in their lives, and the burden climbs steeply with age. Roughly 30 percent of people over 60 experience these conditions, and among the very old the figure approaches half, with reported rates of 45 to 51 percent in those aged 88 to 90. The consequences are far from trivial: dizziness erodes mobility, restricts everyday activities, and sharply increases the risk of falls, which remain one of the leading causes of injury and loss of independence in later life. Yet the most effective treatments for many of these disorders are not pills or procedures but exercises and lifestyle changes that patients must carry out on their own, day after day, often without supervision. A new study now offers one of the most detailed longitudinal pictures yet of whether older patients actually keep doing what their doctors recommend—and the answer reveals a striking divergence between two very different kinds of advice.

The research, published in the Journal of Neurology, comes from the MobilE-TRA 2 cohort, a prospective observational study run at the German Center for Vertigo and Balance Disorders in Munich, a tertiary referral centre that sees more than 3,000 patients a year. The team, led by Sophia P. Schulze and Ralf Strobl of Ludwig-Maximilians-Universität München, followed 337 adults aged 60 and over who had been newly assessed for a vertigo, dizziness, or balance disorder. Just over half were women, and the average age was 71. Each participant underwent a full interdisciplinary work-up—structured medical history, neurological, ocular-motor, and neuro-otological examinations, and where clinically indicated, caloric testing, video head impulse testing, vestibular-evoked myogenic potentials, posturography, and audiometry. Then, at three and twelve months after receiving their individualised treatment recommendations, patients filled in postal questionnaires reporting how often they had actually implemented what had been prescribed. Follow-up rates were impressively high: 88.7 percent at three months and 87.2 percent at twelve.

The researchers drew a deliberate distinction between two categories of non-pharmacological recommendation. The first was specific exercises—balance, gait, or habituation exercises prescribed as part of vestibular rehabilitation, the standard therapy for many vestibular disorders. The second was lifestyle-related recommendations, a composite covering physical activity, general everyday movement, and weight control. This distinction matters because the two types demand different patterns of behaviour. Specific exercises need not be performed daily to be effective, whereas lifestyle changes depend on frequent, near-continuous implementation. Accordingly, the team applied different cut-offs on a five-point self-reported frequency scale, defining adherence to exercises as a score of two or higher and adherence to lifestyle recommendations as three or higher. The framework guiding the analysis was the World Health Organization’s multidimensional model of adherence, which sees the phenomenon as shaped by interacting social and economic, health system-related, condition-related, therapy-related, and patient-related factors.

The headline numbers look reassuring at first glance. Around 80 percent of participants were classified as adherent to each recommendation type at least once during follow-up—79.6 percent for specific exercises among the 216 who reported receiving them, and 80.4 percent for lifestyle recommendations among the 270 who received those. But the longitudinal analysis, using logistic generalised linear mixed-effects models with random intercepts to account for repeated measurements within each person, told a more nuanced story. Adherence to specific exercises dropped markedly between the three-month and twelve-month assessments, with an odds ratio of 0.28 (95 percent confidence interval 0.12 to 0.67). In plain terms, the odds of a patient still performing their prescribed vestibular exercises a year after their initial assessment were less than a third of the odds at three months. Adherence to lifestyle recommendations, by contrast, remained statistically stable over the same period.

Why do the exercises fall away while the lifestyle changes persist? The authors are careful not to interpret the decline as simple failure. In vestibular rehabilitation, symptoms often improve or resolve with treatment, and a patient whose dizziness has faded may genuinely need less practice. Previous research has also documented persistent barriers: symptom provocation during the exercises themselves—which can temporarily make people feel worse—along with time constraints, coexisting impairments, and insufficient guidance or feedback. People with vestibular disorders also report higher fear-avoidance beliefs and lower confidence during balance activities than healthy adults, which can make unsupervised home exercise feel risky. The decline may therefore reflect a mixture of successful recovery, waning motivation, and the well-known difficulty of sustaining self-managed home exercise that has been observed across physiotherapy and chronic disease populations more broadly.

One of the study’s most intriguing findings concerns who stuck with the exercises. Patients with greater perceived dizziness-related handicap at baseline—measured with the validated 25-item Dizziness Handicap Inventory, which scores the functional, physical, and emotional impact of dizziness from 0 to 100—were more likely to adhere to specific exercises, with an odds ratio of 1.03 per point (95 percent CI 1.00 to 1.06). This seems counterintuitive until one considers the psychology of symptom-driven motivation. People whose dizziness seriously disrupts their lives have a powerful, immediate reason to work at their rehabilitation. Those with mild or rapidly improving symptoms, on the other hand, may simply lose the incentive to continue. The same symptom burden can cut both ways, however: in other vestibulopathy subgroups, symptoms provoked by the exercises have been identified as a barrier to adherence. Symptom burden, the authors conclude, appears to influence adherence in ways that are highly context-specific.

The lifestyle recommendations obeyed a different logic altogether. Here, the strongest predictor was self-efficacy—a person’s belief in their own ability to perform specific behaviours, assessed with a three-item General Self-Efficacy Short Scale. Higher self-efficacy was associated with higher adherence (OR 1.65; 95 percent CI 1.02 to 2.66), while male gender was associated with lower adherence (OR 0.37; 95 percent CI 0.16 to 0.88). The self-efficacy finding aligns neatly with systematic reviews in physiotherapy, where low self-efficacy is consistently described as a barrier to home exercise, and with broader behavioural evidence linking confidence to health behaviour change. It also echoes earlier results from the same cohort, in which self-efficacy predicted functioning after specialised care. In a condition where patients must manage dizziness and unsteadiness while simultaneously changing daily habits, the belief that one can cope with difficult situations may be precisely the resource that sustains behaviour over time.

Perhaps the most methodologically interesting part of the study is what did not predict adherence. Drawing on behavioural economics, the team measured two further patient-related traits: time preferences, meaning how much people value future benefits relative to immediate rewards, and health-related risk attitudes, meaning willingness to take risks in health contexts. Both have been linked to health behaviours such as smoking, alcohol consumption, exercise, and diabetes self-management in previous research. Yet in this cohort, neither showed a statistically significant association with adherence to either recommendation type. The finding suggests that the psychological machinery behind keeping up vestibular exercises or lifestyle changes may differ from that behind other preventive health behaviours—or simply that the single-item measures used here lacked the sensitivity to detect weaker effects. Either way, it tempers the assumption that present-oriented, risk-tolerant patients are inevitably the ones who drift away from their treatment plans.

The study has honest limitations that shape how its results should be read. Adherence was self-reported and therefore vulnerable to recall and social desirability bias; the authors emphasise that the figures represent perceived implementation rather than objectively measured behaviour. Adherence measurement in VDB has never been standardised, and the category of specific exercises may have encompassed different exercise types across diagnostic subtypes, which ranged from benign paroxysmal positional vertigo and persistent postural-perceptual dizziness to Menière’s disease, vestibular migraine, and bilateral vestibulopathy. Diagnostic subtype could not be included in the multivariable models because several groups were too small, leaving open the possibility of residual confounding. Sensitivity analyses with alternative cut-offs shifted some estimates—for instance, under a stricter exercise cut-off, multimorbidity emerged as a barrier and self-efficacy as a stronger facilitator—so individual effect estimates warrant caution. Recruitment during the SARS-CoV-2 pandemic, when healthcare access was disrupted, may also have selected a more severely affected population, limiting transferability to primary care.

Even with those caveats, the practical message is clear and potentially actionable. Adherence in older adults with vertigo, dizziness, and balance disorders is not a single behaviour but at least two, with different time courses and different drivers. Exercises decay over the year after prescription, particularly among those whose symptoms were mild to begin with, while lifestyle changes persist—especially in patients with high self-efficacy, and less so in men. For clinicians, that argues against a one-size-fits-all follow-up schedule: patients with low self-efficacy, mild symptoms, or a recent exercise prescription may benefit most from booster contacts, feedback, and structured support in the months after their initial assessment, precisely when the data show adherence beginning to slip. For researchers, the study opens a direct question that it could not answer: why do patients stop? Larger cohorts, objective adherence measures, and primary-care replication will be needed to turn these observational patterns into interventions that keep older people steady on their feet.

Subject of Research: Adherence to non-pharmacological treatment recommendations in older adults with vertigo, dizziness, and balance disorders

Article Title: Adherence to treatment recommendations in older adults with vertigo, dizziness, and balance disorders: the MobilE-TRA 2 cohort study

Article References: Schulze, S. P., Katzenberger, B., Koller, D., Huppert, D., Grill, E., & Strobl, R. (2026). Adherence to treatment recommendations in older adults with vertigo, dizziness, and balance disorders: the MobilE-TRA 2 cohort study. Journal of Neurology, 273(10), Article 649. https://doi.org/10.1007/s00415-026-14195-0

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14195-0

Keywords: vertigo, dizziness, balance disorders, vestibular rehabilitation, treatment adherence, older adults, self-efficacy, geriatrics, cohort study, lifestyle modification, Dizziness Handicap Inventory, neurology