Can aerobic exercise really improve factors related to decision-making capacity 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 pressing health challenges of our century. Early cognitive decline usually manifests as problems related to decision-making processes. In this context, aerobic exercise has emerged as a promising strategy for preserving and improving brain health. However, a critical question remains underexplored: whether improvements in executive function (EF) tasks truly reflect enhanced decision-making capacity, or whether they index more circumscribed changes in neural efficiency and network specificity. The heterogeneity of protocols has limited efforts to standardize interventions and evaluate their long-term impact. This narrative review examines studies from the last decade that investigated aerobic and combined physical-cognitive training programs in healthy older adults, focusing on their effects on decision-making and associated neural changes. Evidence shows that chronic interventions (6 months to 2 years) improve EF closely related to decision-making, including cognitive flexibility, task switching, and attentional control. These behavioral gains correlate with neural adaptations in the PFC, including improved cerebral oxygenation and preserved white matter microstructure when exercise is sustained over time. At the molecular level, sustained aerobic activity has been associated with increased VEGFR2 and Cathepsin B, and decreased BDNF expression, suggesting systemic plasticity processes that may contribute to cortical integrity. These findings support the potential of long-term, multimodal interventions that integrate physical, cognitive and social components to promote durable neurobiological adaptations and enhance decision-making. Yet, across the reviewed studies, none directly assessed decision-making under ecologically valid conditions, and the improved performance in real-world decision-making remains largely assumed. We argue that the field must move beyond descriptive summaries of cognitive gains and toward a framework that distinguishes between what has been measured, what has been inferred, and what remains to be proven, particularly regarding the generalizability of exercise-induced neural changes to everyday decision-making.