There is a familiar script to what happens after an older adult is assessed for fall risk. A clinician designs a home exercise programme — balance drills, sit-to-stand repetitions, stepping sequences. The programme is explained, demonstrated, sometimes written down on a card. The patient nods. The system moves on. And somewhere in the unspoken logic of outpatient rehabilitation sits an assumption: that the exercises will be done. Most of the time, they aren't.
A 2023 prospective observational study by Teng et al., conducted across two major geriatric outpatient clinics in Singapore, followed 68 older adults through a six-week prescribed home exercise programme for falls prevention. The mean home exercise adherence rate was 65%. Only one in five participants completed every prescribed session. And adherence declined steadily, week by week, across the entire study period.
These are not fringe findings. A systematic review by Simek and colleagues found that across falls prevention home exercise programmes, the pooled rate of full adherence was just 21%. The problem has been documented across countries, health systems, and exercise formats. It is consistent, significant, and largely absent from the conversations families have when they bring an older relative home from a falls assessment.
It deserves to be front and centre.
Non-adherence is not a minor inconvenience. Poor home exercise adherence is associated with more frequent falls, greater emergency and inpatient healthcare use following fall-related injuries, and meaningfully worse rehabilitation outcomes overall. The dose requirements for effective falls prevention are already high: the Cochrane review by Sherrington et al. (2019) established that three or more hours of balance-specific training per week is the threshold at which exercise has its greatest impact on reducing falls in older adults at risk. When home exercise adherence is poor, that threshold is never reached — and the intervention fails not because the science is wrong, but because the delivery model assumes something that isn’t reliably there.
This article examines three distinct but deeply connected reasons why home exercise adherence breaks down — including two that consistently surprise both families and clinicians — and what the evidence tells us about what changes things.
The Adherence Numbers Nobody Talks About
Sixty-five per cent sounds passable until you look at what’s behind it.
In the Teng et al. study, only 12 of the 60 participants whose data was analysed — 20% — completed every prescribed session over six weeks. Five participants, roughly 8%, did not attempt the programme at all. The rest were spread across a spectrum of partial completion, and the overall trend was downward. Week one saw the highest engagement. By week six, the number of participants doing little or nothing had grown considerably.
This trajectory is consistent with what the broader literature on home exercise adherence shows. Initial engagement is often reasonable; it is the maintenance of that engagement, without the structure and accountability of supervised appointments, that fails. In clinic or hospital settings, there are fixed times, a therapist observing, a shared expectation of effort. None of those structures transfer automatically into the home. Once the patient is on their own — with a programme sheet, a diary, and the general understanding that they should be exercising — the system relies on internal motivation, formed habits, and available support. None of those can be assumed to be in place.
What the Teng et al. research adds is a granular picture of what this looks like in a real-world multi-ethnic Asian population, following an outpatient pathway that closely mirrors what many older adults in this region actually experience. These were not people who had been discharged without instruction. They were active participants in a physiotherapy programme, attending regular follow-up appointments, with a tailored exercise programme in hand. The adherence gap appeared anyway.
That matters, because it means the solution is not simply better exercise design, or more detailed instruction at the initial appointment. The problem sits elsewhere.
The Three Predictors of Home Exercise Adherence — and Two That Will Surprise You
Rather than documenting the adherence gap and stopping there, the Teng et al. study set out to understand who follows through and who doesn’t. Thirty-one possible predictor variables were tested — covering sociodemographic characteristics, clinical factors, programme specifics, physical performance, and psychosocial measures. Three emerged as significant in the final multivariable model. Two of them challenge the assumptions most people carry about this population.
Number of medications taken
The first counterintuitive finding: participants taking more medications were more likely to adhere to their home exercise programme.
The instinctive assumption runs the other way. A high medication burden suggests greater health complexity, more competing demands on attention and energy, and less capacity to take on another set of requirements. But the Teng et al. researchers propose a more nuanced explanation, drawing on what is known as the Health Belief Model. People carrying a heavier clinical load tend to be more acutely aware of their own vulnerability. They have attended more appointments, had more direct conversations about the consequences of deterioration, and experienced more concretely what poor health costs. For them, the prescribed exercises are not a precautionary suggestion from a clinician they may or may not see again. They are part of a picture they understand to be serious.
The clinical implication reverses the usual pattern of concern. The older adult who seems relatively fit, who hasn’t had a significant fall, who is on few medications — that person may be exactly the one most likely to quietly let the programme lapse. The urgency that drives adherence may simply be lower, because the stakes don’t feel as immediate.
Self-efficacy for exercise
The second finding is equally counterintuitive: higher confidence in one’s ability to exercise predicted lower adherence.
This seems logically backwards. The extensive self-efficacy literature in health behaviour generally treats confidence as a predictor of engagement. But the relationship is more conditional than that. Research by Schmidt and DeShon on the self-efficacy–performance relationship has shown that where a task is ambiguous or the demands are unclear, high confidence can actually undermine performance. Highly confident individuals tend to underestimate the resources — effort, external support, structured check-ins — that sustained follow-through requires. They assume they’ll manage. When the programme becomes routine and the novelty fades, there is no scaffolding in place to catch the drop.
There is a second dynamic worth noting. People with lower exercise self-efficacy tend to ask for help more readily. They seek demonstrations, invite family involvement, and accept support when it’s offered. That recruited external scaffolding — precisely what less-confident individuals actively gather — is functionally what drives adherence over time. High confidence, paradoxically, can leave someone exercising alone with no accountability structure at all, which is exactly the condition under which home exercise adherence consistently fails.
The practical implication: an older adult who says “I can manage on my own” is not offering reassurance — or not only reassurance. That statement may warrant closer engagement, not a step back.
Social support for exercise
The third significant predictor aligned with conventional expectation: greater social support for exercising was associated with better home exercise adherence. What was not expected was how low that support turned out to be — and why.
Living With Family Is Not the Same as Being Supported
Nearly 80% of participants in the Teng et al. study lived with a spouse or children. Over a third were in multigenerational households of three or more people. By any surface measure, these were not socially isolated individuals.
And yet social support scores for exercise — measured using a validated tool assessing both family and friend support for exercise behaviours — were strikingly low. Family support averaged 32 out of 100. Friend support averaged 26.
The presence of family in the home had not translated into meaningful support for the one rehabilitative task that mattered most.
This distinction — between physical co-habitation and active, engaged support — is consistently lost in how falls risk is assessed and discussed. When a family member is present, the assumption tends to be that support is in place. But sharing a home does not mean monitoring whether someone has done their exercises today, understanding the purpose of each movement, knowing what correct form looks like, or being attentive enough to notice when engagement starts dropping.
The Teng et al. researchers point specifically to structural pressures in the Singapore family context. Citing research on what has been termed the “sandwiched generation” in East Asia, they note that adult children managing both childcare and elder care responsibilities operate with limited time and depleted attention. Exercise supervision for a parent may be entirely well-intentioned — and consistently deprioritised anyway, because the demands pulling in the other direction are immediate and relentless.
This is not a critique of families. It is a description of a gap that the health system routinely assumes will be filled, without any mechanism to ensure it is.
The research on what effective social support for exercise actually involves distinguishes between several forms: emotional support (encouragement and reassurance), informational support (reminders and guidance), companionship support (exercising alongside), and instrumental support (practical help with setup, timing, or environment). Adherence is most reliably associated with support that is active and specific, not passive and general. Knowing your relative has a programme and wishing them well with it is not the same as being a meaningful part of its delivery.
For families — what the evidence supports:
Be present, not just available. Designate a consistent daily exercise time and, at least several times a week, be in the room. Shared presence changes the dynamic from a private medical obligation to something the household is invested in.
Learn the exercises yourself. Asking to be shown the programme is one of the most practically useful things a family member can do. Understanding what each exercise is designed to achieve — and what correct form looks like — means you can offer informed observation, not just vague encouragement.
Ask specifically, not generally. “Have the exercises been done today?” is more useful than “How are you feeling?” A consistent, specific check-in creates mild accountability without surveillance.
Take high confidence at face value less often. If your relative seems entirely sure they’re managing well and doesn’t need reminding — that is the profile the Teng et al. data flags. Consistent, light-touch engagement from a confident person is a protective factor. Backing off entirely is not.
Treat missed sessions as a conversation cue. When the programme is skipped, the response that supports re-engagement is a brief, non-judgemental conversation, not silence. The longer a lapse continues without acknowledgement, the harder restart becomes.
Why the Unsupervised Exercise Model Has a Built-In Flaw
The adherence problem sits within a broader structural issue that the falls prevention literature has circled for years without fully confronting: the unsupervised home exercise model places the entire burden of delivery on the person least positioned to carry it reliably.
Older adults at risk of falling are managing, by definition, some combination of physical, cognitive, psychosocial, or functional challenge. Prescribing a programme and handing it over at a clinic appointment is efficient from a health system perspective. Whether it is effective depends entirely on what happens in the hours and weeks that follow — and the evidence, consistently, suggests that what happens is not enough.
The dose issue compounds this. Sherrington et al.’s Cochrane review found the greatest falls reduction in programmes delivering three or more hours of balance training per week. Sustaining that volume unsupervised — while motivation wanes, the programme isn’t progressing, and no one is monitoring quality — is a significant ask. Without oversight, there is also the question of whether the exercises are actually being performed correctly. An older adult who pushes through discomfort without clinical input is not always making progress. In some cases, they may be compensating rather than improving, continuing exercises that should have been modified, or — in the worst case — sustaining a programme that is no longer appropriate for their current level of function.
The Teng et al. study adds an important dimension here. Better home exercise adherence was associated with higher average daily step counts at six weeks — measured by accelerometer, not self-report. This suggests that adherence to a prescribed programme and broader physical activity levels track together. The person who follows through on their exercises tends, at six weeks, to also be moving more across their daily life. The relationship cannot be read as causal from this study design, but the direction is meaningful: home exercise adherence is not just about completing a checklist. It appears connected to how functionally active someone is becoming in the real world.
That link — between the quality of rehabilitation delivery and real-world functional improvement — is the clinical argument for supervised, in-home rehabilitation. Not as an elevated option for those who can afford better, but as the delivery model that actually closes the gap the unsupervised prescription leaves open.
What an Occupational Therapist Actually Does
The OT’s role in falls prevention tends to be summarised in terms of home modification — grab rails, removing floor rugs, rearranging kitchen cupboards. That work matters. But it represents a fraction of what an occupational therapist contributes in a home rehabilitation context, and it is not where the most clinically significant contribution often lies.
The Teng et al. findings effectively describe the profile of an older adult at high risk of home exercise non-adherence: living with family who are stretched across competing obligations; confident enough to decline offered support; without the active, engaged exercise-specific network that the data identifies as the operative predictor of follow-through. An OT working in the home is positioned to identify this profile — not through a questionnaire completed in a clinic waiting room, but through direct observation and assessment in the environment where rehabilitation either happens or doesn’t.
A 2025 systematic review of OT-based falls prevention interventions across 17 studies, published in Rehabilitation, confirmed that occupational therapy approaches — ranging from exercise-based programmes to cognitive and behavioural components — contribute meaningfully to functional independence, balance, and psychological outcomes related to fall risk. The added value of the OT in the home setting is that all of those contributions are delivered in context, where the real barriers to follow-through become visible.
Assessment as the first intervention
Before any exercise is attempted or progressed, a home visit creates the opportunity to assess the conditions that will determine whether the prescribed programme has a realistic chance of being sustained. Who else is in the household, and when are they present? What does the daily routine look like, and where does exercise fit naturally within it? Is the physical environment suitable for the prescribed programme — or are there spatial, safety, or logistical factors that will quietly work against compliance? Is there anyone in the household who could plausibly become an active support, and what would that need to look like given their own pressures?
These are not administrative questions. They are the clinical basis for a programme that is genuinely tailored to real life. The predictors the Teng et al. study identified — medication burden, self-efficacy, and social support — are all variables that a thorough home assessment can surface and address before they become the reasons the programme fails.
Family coaching as a clinical priority
Given what the Teng et al. data shows about the gap between family presence and meaningful exercise support, engaging family members directly is not supplementary — it is, for many patients, a primary determinant of whether the programme succeeds beyond the first couple of weeks.
An OT working in the home can speak with family members about the programme in specific, practical terms: what each exercise is designed to achieve, what correct form looks like, how to encourage without taking over, and how to notice early signs of flagging engagement. This is more targeted than an information sheet and more durable than a general explanation at a clinic appointment. It accounts for the specific household dynamic, the specific person most likely to engage, and the specific competing demands they are navigating.
Monitoring, adjusting, and re-motivating over time
The Teng et al. data shows home exercise adherence declining across all six weeks of the study — not as a sudden drop but as a steady erosion. A programme that was designed at baseline and has not changed by week four is already working against the patient’s engagement. Regular in-home follow-up creates the opportunity to observe how the programme is actually being performed — not how it is being recalled in a diary — and to modify it in response. Exercises can be progressed when capacity has improved, simplified when confidence has dropped, or completely reconfigured when life circumstances have shifted.
Re-motivation matters distinctly here. A near-fall, a viral illness, a change in family routine — any of these can interrupt a programme and make restart harder the longer the gap extends. An in-home visit that catches the interruption early and addresses it directly is a qualitatively different intervention from a patient quietly abandoning the programme and presenting months later with a fall.
What This Means in Practice: Steps You Can Take Now
Whether professional support is part of the picture right now or not, the evidence points to practical, specific actions that make a measurable difference.
For older adults:
Treat prescribed sessions as fixed appointments in the day, not tasks to fit in when convenient. Consistency of timing is one of the most reliable predictors of whether a new behaviour persists. A programme that shifts to “whenever I get a chance” has already begun the drift toward abandonment.
If confidence in managing the exercises is high, use that confidence to build in external accountability — not to justify doing it entirely alone. A simple daily log, a family member checking in, or a text to a therapist at the two-week mark counteracts what the Teng et al. data suggests about confident patients quietly under-committing.
If the exercises have become easy or repetitive, contact your therapist about advancing the programme. A programme that is no longer challenging is no longer delivering the training stimulus that underpins the benefit.
For family members:
Active support means scheduled, specific engagement — not goodwill from a distance. Being present for sessions several times a week, knowing what the exercises should look like, and asking specifically whether today’s session has been done are the forms of support the research associates with better home exercise adherence. General encouragement, offered occasionally, is far less effective.
Watch the pattern over weeks, not just individual days. Adherence to home exercise tends to erode gradually rather than drop suddenly. A brief fortnightly check-in on how the programme is going is more clinically useful than waiting for a visible problem.
For those making decisions about rehabilitation:
Ask explicitly what follow-up after prescription looks like, and how often. A programme handed over without any mechanism for in-home monitoring relies entirely on patient self-management — which the evidence, consistently, shows most people will not sustain alone for the required duration.
Ask whether the patient’s home environment and social circumstances have been assessed, not just their physical function. The predictors the Teng et al. study identified are psychosocial. A purely physical assessment leaves them invisible.
The evidence across home rehabilitation contexts is gathered in the Lifeweavers Knowledge Bank for families working through these decisions.
Frequently Asked Questions About Home Exercise Adherence and Falls Prevention
Why do so many older adults not follow through on their home exercise programme?
The reasons are more varied than most people expect. The Teng et al. (2023) study, which followed older Singaporean adults through a six-week prescribed home exercise programme for falls prevention, found that adherence was not reliably predicted by age, fitness level, or physical function. The significant predictors were psychosocial: medication burden, self-efficacy for exercise, and social support for exercising. Physical difficulty is rarely the primary reason programmes are abandoned — the absence of structured support, and the psychosocial conditions in the home, are more consistently implicated.
Does having family at home improve home exercise adherence?
Not automatically. Despite nearly 80% of participants in the Teng et al. study living with a spouse or children, social support scores for exercise averaged only 32% from family members and 26% from friends. Shared living arrangements do not reliably translate into the kind of active, specific, exercise-focused support that predicts adherence. Meaningful support involves being present, informed about the programme, and consistently attentive — not simply being in the same household.
What does an occupational therapist do for falls prevention beyond environmental modifications?
An OT working in the home setting can assess the psychosocial and environmental conditions that determine whether a prescribed rehabilitation programme will actually be sustained. This includes evaluating daily routines, social support structures, self-efficacy patterns, and the physical suitability of the home environment. They can coach family members directly, monitor and progress exercises over time, address declining engagement before it becomes programme abandonment, and adjust the plan as the patient’s circumstances and capacity evolve. The contribution is as much about delivery conditions as it is about programme content.
How much exercise do older adults need for meaningful falls prevention?
The 2019 Cochrane review by Sherrington and colleagues identified that the greatest falls rate reductions came from programmes delivering three or more hours of balance-specific training per week. This is a substantial volume, particularly for older adults managing multiple health conditions — which is why home exercise adherence is not a secondary concern. The clinical benefit the research demonstrates depends on the dose actually being reached and sustained.
Is high confidence about exercising a reliable predictor of follow-through?
Counterintuitively, no. The Teng et al. study found that higher self-efficacy for exercise was associated with lower adherence. One explanation is that highly confident individuals tend to underestimate the external resources — support, monitoring, accountability — that sustained performance over weeks actually requires. Those with lower confidence tend to seek and accept more help, and it is that recruited support that drives follow-through. This does not make confidence unhelpful, but it does mean that an older adult’s confidence in managing independently should not be treated as a reason to reduce engagement or follow-up.
What should I look for in a home rehabilitation programme for falls prevention?
Beyond the qualifications of the treating therapist, the relevant questions are whether the programme includes structured in-home follow-up — not just an initial prescription; whether the patient’s social environment and daily routine have been assessed as part of the plan; whether family members are given specific guidance on how to actively support the programme; and whether there is a mechanism for monitoring and adjusting the exercises as capacity and circumstances change. A programme that relies entirely on patient self-management, with no in-home follow-up component, is asking the patient to carry the full burden of delivery — which the research consistently shows most will not sustain alone.
