Can Aerobic Exercise Really Improve Decision-Making in Aging? What Has Been Measured, What Has Been Assumed, and What Needs to Change.

As populations age globally, cognitive decline has become one of the most pressinghealth challenges of our century. Among the most affected domains is decision making, a coreexecutive function (EF) that is particularly vulnerable to aging. In this context, aerobic exercisehas emerged as a promising strategy for preserving and improving brain health. However, acritical question remains underexplored: whether improvements in executive function tasks trulyreflect enhanced decision-making capacity, or whether they index more circumscribed changesin neural efficiency and network specificity. The heterogeneity of protocols has limited efforts tostandardize interventions and evaluate their long-term impact. This review examines studiesfrom the last decade that investigated aerobic and combined physical-cognitive trainingprograms in healthy older adults, focusing on their effects on decision-making and associatedneural changes. Evidence shows that chronic interventions (6 months to 2 years) improve EFclosely related to decision-making, including cognitive flexibility, task switching, and attentionalcontrol. These behavioral gains correlate with neural adaptations in the PFC, including improvedcerebral oxygenation and preserved white matter microstructure when exercise is sustainedover time. At the molecular level, sustained aerobic activity has been associated with increasedVEGFR2 and Cathepsin B, and decreased BDNF expression, suggesting systemic plasticityprocesses that may contribute to cortical integrity. These findings support the potential of long-term, multimodal interventions that integrate physical, cognitive and social components topromote durable neurobiological adaptations and enhance decision-making. Yet, across thereviewed studies, none directly assessed decision-making under ecologically valid conditions,and the improved performance in real-world decision-making remains assumed. We argue thatthe field must move beyond descriptive summaries of cognitive gains and toward a morerigorous framework that distinguishes between what has been measured, what has beeninferred, and what remains to be proven, particularly regarding the generalizability of exercise-induced neural changes to everyday decision-making.