Key takeaways
- The endpoint after 60 is function and independence, and muscle, bone, balance and cognition decide it.
- Strength predicts outcomes better than muscle mass, which puts resistance training and protein at the top of the list.
- Testosterone therapy in documented, symptomatic hypogonadism improves lean mass — without cognitive or fracture benefit shown.
- Hormone therapy in women is a timing question; local vaginal estrogen is appropriate at any postmenopausal age.
- Most preventable fracture risk is in the fall, not the bone — balance work and a medication review often outrank hormones.
"You're too old for that" is still said in consulting rooms, and it is wrong in both directions. Older adults respond to training and to hormone optimisation, sometimes more visibly than younger ones because they start further from their ceiling. And the goal has changed: at 35 the question is how you look and perform, at 65 it is whether you will still be climbing your own stairs at 85. The variables deciding that are muscle, bone, balance and cognition. Hormones are one input into those — not the main one, and treating them as the main one is how people end up with a good testosterone number and a bad outcome.
What is actually being optimised
The endpoints that matter after 60 are functional, not aesthetic:
- Living independently rather than in assisted care
- Cognitive function preserved well enough to manage your own affairs
- Enough strength to do ordinary daily tasks without planning around them
- Avoiding a hip fracture, which is a mortality event rather than an injury
- Cardiovascular event-free years
- Metabolic health, because diabetes in late life accelerates everything else
Each is shaped by muscle mass, bone density, cardiorespiratory fitness, hormonal status and cognitive reserve — all five at least partly modifiable at 65, 75 and beyond. The list matters because it sets the priority order: interventions that protect muscle and prevent falls sit above interventions that adjust a laboratory value.
Muscle is priority one, and it is not close
Sarcopenia — age-related loss of muscle mass and, more importantly, muscle strength — is the strongest single predictor of late-life functional decline. Modern definitions put strength ahead of mass precisely because strength predicts outcomes better than size does (European consensus on sarcopenia definition and diagnosis). Without intervention, adults lose in the region of 1-2% of muscle per year through the 60s and 70s, and power — force produced quickly — falls faster than strength does. Power is what catches you when you trip.
The countermeasures are unglamorous and they work:
- Resistance training, 2-4 days a week. More important with age, not less. The classic demonstration was in nonagenarians, who gained strength and mobility on a progressive programme (Fiatarone et al., JAMA 1990). If a 90-year-old responds, the argument about being too old ends there. A programme designed for this beats improvising.
- Protein around 1.0-1.2 g per pound of goal body weight, spread across meals. Older muscle is less responsive to a given protein dose — anabolic resistance — so the per-meal amount matters as much as the daily total.
- Enough total energy. Under-eating is common here and accelerates muscle loss faster than almost anything else. Unintentional weight loss after 65 is a warning sign, not a success.
- Creatine, vitamin D and omega-3, all with reasonable evidence in older adults, all cheap.
- Hormone optimisation where indicated, which raises the ceiling training then has to fill.
The ordering is the message: hormones without training produce a laboratory improvement, training without hormones still produces a functional one. Body recomposition after 50 covers how the two interact.
Hormones in late life, stated honestly
Testosterone in men. The Testosterone Trials randomised older men with unequivocally low testosterone and found gains in lean mass, reductions in fat mass, improved sexual function and modest mood benefit (Snyder et al., N Engl J Med 2016). Later cardiovascular safety work in men at elevated risk did not find an increase in major adverse cardiovascular events (Tienforti et al., J Endocrinol Invest 2026). Two things that programme did not show, and which are routinely implied: the cognitive arm found no improvement, and bone mineral density rose without a demonstrated reduction in fractures. Testosterone and cognition and testosterone and bone density cover both in detail. For documented, symptomatic hypogonadism in this age group, treatment is appropriate; as a general anti-ageing measure in men with normal levels, it is not supported.
Hormone therapy in women. The timing window favours starting within about ten years of menopause or before 60. A woman already established on therapy can typically continue with periodic review — the arbitrary stop at 65 that was standard practice for years is not evidence-based. Starting fresh in the late 60s or beyond is a different conversation, with more careful evaluation and a strong preference for transdermal over oral preparations because of the first-pass effect on clotting factors. When to start HRT covers the decision.
Local vaginal estrogen sits outside all of that. Systemic exposure is negligible, benefit for genitourinary symptoms and recurrent urinary infections is substantial, and age is not a barrier — see why it is so underused. It is probably the highest benefit-to-risk hormonal intervention available to a woman in her 70s.
DHEA is typically very low by this decade. Evidence for supplementation is modest and largely limited to women and to people with adrenal insufficiency; the DHEA article covers what is and is not established.
Protecting cognition
No hormone has been shown to preserve cognition. The interventions that have the best evidence are the ones that also happen to be good for everything else on this page:
- Cardiorespiratory fitness, which is the modifiable variable with the strongest association with late-life outcomes generally — VO2 max as a mortality predictor covers why
- Resistance training, with its own independent cognitive signal
- Sleep, adequate in duration and screened for apnoea
- Blood pressure and metabolic control through midlife and beyond
- A Mediterranean-pattern diet
- Hearing aids where hearing loss is present — one of the larger modifiable contributors to dementia risk, and one of the most neglected
- Social engagement and genuine cognitive challenge — something difficult rather than something familiar
Falls, which is where the outcomes actually turn
Hip fracture in older adults carries roughly 25-30% one-year mortality (Haentjens et al., Ann Intern Med 2010). That reframes everything above it. A fracture requires two things: a bone that breaks and a fall that breaks it. Most attention goes to the first; most of the preventable risk lives in the second.
- Strength, balance and power training, which addresses both halves at once
- Bone-directed treatment where indicated — established osteoporosis medications, not testosterone, are the drugs with fracture-reduction evidence
- Vitamin D adequacy
- Vision and hearing checked, both of which feed balance
- Medication review — sedatives, anticholinergics and antihypertensives causing postural drops. Frequently the highest-yield item here
- Home modification: lighting, rugs, stair rails, bathroom grab bars
What to monitor, and how often
Comprehensive panels roughly twice a year, with attention to:
- Hormones — total and free testosterone, sensitive estradiol, DHEA-S, a full thyroid panel
- Metabolic — fasting insulin and HbA1c, not glucose alone
- Cardiovascular — ApoB and hs-CRP
- Bone-relevant — vitamin D, calcium, alkaline phosphatase
- Anaemia screening and renal function, both of which change quietly with age
- Haematocrit, if on testosterone therapy, at every panel
- Age-appropriate cancer screening, and DEXA every two years
Add two things no blood test provides: grip strength and gait speed. Both predict late-life outcomes well, take under a minute, and catch decline earlier than any laboratory value. The 60-second assessment routes the medical side to a physician.
The principle: the "too old to start" position has been refuted repeatedly, but the correction is not that hormones are the answer at 70. It is that the response to training, protein and metabolic intervention remains intact at 70, and hormone optimisation is one supporting input into that — appropriate when there is documented deficiency and symptoms, and not a substitute for the work.
Bottom line
Optimisation after 60 is a functional project: muscle, bone, balance and cognition, with independence as the endpoint. Resistance training, adequate protein and enough total food have the largest effect and the least controversy, and they work at any age. Testosterone therapy for documented, symptomatic hypogonadism produces real gains in lean mass and body composition, without demonstrated cognitive or fracture benefit — worth saying plainly. Hormone therapy in women is largely a timing question; local vaginal estrogen is appropriate at any postmenopausal age. Falls prevention and a medication review often outperform any hormonal adjustment. All of it belongs with a physician who monitors rather than prescribes and hopes.
Educational content, not medical advice. Laboratory interpretation and any treatment decision are made by a licensed physician after individual evaluation. Individual results vary.
