Creatine After 60: Sarcopenia, Muscle Strength, Cognition, Dosing, Kidney and Liver Safety, Contraindications, and Clinical Monitoring — A Narrative Review

Ori Scott, M.Sc., Registered Dietitian (Israel)Independent Researcher, New York, NY, USA

Abstract

Background: Aging is associated with progressive reductions in skeletal-muscle strength, mass, and physical resilience that can contribute to sarcopenia, functional limitation, and loss of independence. Creatine monohydrate has been extensively investigated as an adjunct to resistance training, but evidence specifically applicable to adults aged ≥60 years and to medically complex older populations requires careful interpretation.

Objective: To critically synthesize clinically relevant evidence on creatine supplementation after age 60, with emphasis on muscle strength and mass, sarcopenia and frailty, physical function, postmenopausal women, cognition, immobilization and orthopedic rehabilitation, dosing, formulation, kidney and liver safety, cardiovascular considerations, polypharmacy, adverse effects, contraindications, and clinical monitoring.

Methods: This narrative review used a structured evidence-identification approach emphasizing PubMed/MEDLINE-indexed systematic reviews, meta-analyses, randomized controlled trials (RCTs), and clinically relevant prospective studies. Recent literature was prioritized while landmark earlier studies were retained when necessary. Evidence was interpreted according to study design, age, health status, intervention composition, exercise exposure, and direct applicability to adults aged ≥60 years. This review was not designed as a systematic review or meta-analysis and does not claim exhaustive retrieval, duplicate independent screening, review-wide formal risk-of-bias assessment, or independent certainty grading.

Results: Contemporary evidence indicates that creatine added to resistance training can produce a modest additional improvement in muscle strength in adults aged ≥60 years. In the most age-specific meta-analysis, the pooled strength effect was Hedges g=0.31 (95% CI 0.18–0.45), whereas additional effects on muscle mass and physical function were statistically uncertain. Evidence in vulnerable, frail, or sarcopenic adults remains limited. Postmenopausal-women data suggest small improvements in lean mass and strength, particularly when creatine is combined with resistance training, but an overall benefit for bone mineral density has not been established. Evidence for cognitive benefit remains preliminary and does not establish efficacy for cognitive impairment or dementia. Creatine can modestly increase serum creatinine without a corresponding demonstrated reduction in glomerular filtration across pooled studies, potentially complicating creatinine-based kidney-function assessment. Evidence is substantially more limited in advanced chronic kidney disease (CKD), clinically significant liver disease, extensive polypharmacy, and perioperative rehabilitation. Controlled human studies directly evaluating creatine–prescription drug interactions are lacking.

Conclusions: Creatine monohydrate can be considered an adjunct—not a substitute—for resistance training in generally healthy adults aged ≥60 years, with the strongest evidence supporting a modest additional improvement in muscle strength. Evidence is less certain for muscle mass, physical function, frailty, cognition, and postoperative recovery. Creatine monohydrate has the strongest evidence base among formulations. Use in medically complex older adults should incorporate comorbidities, medication review, kidney-function interpretation, hydration and nutritional status, tolerability, and individualized monitoring. Evidence from healthier populations should not be extrapolated as proof of safety in advanced kidney or liver disease or extensive polypharmacy.

Keywords: aging; creatine; creatine monohydrate; sarcopenia; resistance training; muscle strength; frailty; cognition; kidney function; polypharmacy; older adults

1. Introduction

Population aging has increased the clinical importance of maintaining skeletal-muscle strength, mobility, independence, and resilience. Age-related losses of muscle strength and mass can contribute to functional limitation, falls, disability, prolonged recovery from illness or surgery, and loss of independence. Progressive resistance exercise remains a central intervention for preserving and improving neuromuscular function in older adults.

Creatine is a nitrogen-containing compound involved in cellular energy buffering through the creatine–phosphocreatine system. Supplemental creatine increases tissue creatine availability and can enhance adaptations to repeated high-intensity muscular activity. Creatine monohydrate is the formulation used in most clinical research and has a substantially larger evidence base than alternative formulations [1–3].

Interest in creatine after age 60 extends beyond athletic performance. Proposed applications include preservation or improvement of muscle strength and mass, management of sarcopenia or frailty, cognitive support, mitigation of disuse-related muscle loss, and recovery after orthopedic injury or surgery. These proposed applications differ substantially in evidentiary maturity.

Earlier meta-analyses generally suggested that creatine combined with resistance training can augment lean mass and strength in older adults [4,5]. However, definitions of “older adult” varied and some analyses incorporated trials with mean participant ages below 60 years. A 2026 three-level meta-analysis specifically restricted eligibility to adults aged ≥60 years and therefore provides a more directly applicable contemporary estimate [6].

Clinical interpretation becomes more complex in adults with multimorbidity. CKD, hypertension, cardiovascular disease, metabolic disorders, chronic liver disease, and polypharmacy are increasingly prevalent with advancing age. Creatine supplementation can also influence serum creatinine, potentially complicating interpretation of creatinine-based estimated glomerular filtration rate (eGFR).

The objective of this narrative review is therefore not simply to ask whether creatine “works” after age 60, but to distinguish established findings from supportive, indirect, and emerging evidence and to provide a clinically oriented framework for efficacy, dosing, safety, precautions, and monitoring.

2. Methods

This article was designed as a narrative review using a structured evidence-identification approach. PubMed/MEDLINE-indexed literature was emphasized, with bibliographic information additionally checked against publisher records when needed. Systematic reviews, meta-analyses, RCTs, prospective clinical studies, and clinically relevant narrative reviews were considered.

Recent evidence was prioritized, particularly literature published from 2021 through September 2026. Earlier studies were retained when they represented landmark trials, long-term safety observations, or direct evidence for clinically important circumstances.

Evidence selection emphasized relevance to adults aged ≥60 years and to the principal clinical domains addressed in this review: resistance training, muscle strength and mass, sarcopenia and frailty, physical function, sex-specific and postmenopausal outcomes, cognition, immobilization and rehabilitation, orthopedic surgery, dosing, formulation, kidney and liver safety, cardiovascular considerations, polypharmacy, adverse effects, and monitoring.

Particular attention was given to participant age and health status, intervention composition, creatine formulation, dose, duration, resistance-training exposure, clinical outcomes, and whether an intervention contained isolated creatine or multiple nutritional ingredients.

Evidence was interpreted according to study design. RCTs were used for randomized comparisons; observational findings were interpreted as associations; systematic reviews and meta-analyses were interpreted according to the populations and studies included; and mechanistic, younger-adult, or multi-ingredient evidence was not treated as direct proof of isolated creatine efficacy in adults aged ≥60 years.

For synthesis, evidence was conceptually distinguished as direct/established when it directly addressed the population and question; indirect/supportive when derived from related populations or interventions; and emerging/hypothesis-generating when preliminary, mechanistic, exploratory, or otherwise insufficient for firm clinical conclusions.

This was not a systematic review or meta-analysis. Exhaustive literature retrieval, duplicate independent screening and extraction, prospective protocol registration, review-wide formal risk-of-bias assessment, and independent certainty grading were not performed. When certainty ratings are discussed, they refer to assessments performed by the cited systematic review rather than by the present author.

3. Creatine, Resistance Training, and Musculoskeletal Aging

3.1. Muscle Strength

The strongest contemporary evidence supports a modest additional strength benefit when creatine is combined with resistance training after age 60.

The 2026 meta-analysis restricted to adults aged ≥60 years included 11 RCTs comparing creatine plus resistance training with resistance training alone or placebo plus resistance training. Creatine produced a small additional improvement in muscle strength (Hedges g=0.31, 95% CI 0.18–0.45), which the review rated as moderate-certainty evidence [6].

This direction of effect is broadly consistent with earlier meta-analyses [4,5]. Primary trials also provide supporting evidence. Chrusch et al. reported greater improvements in several strength measures when older men received creatine during resistance training [7]. Brose et al. found that creatine supplementation enhanced some strength and body-composition adaptations to strength training in older adults [8]. Other trials have evaluated lower-dose strategies, supplementation timing, and differing resistance-training programs with variable results [9,10].

The totality of evidence therefore supports creatine as a potentially useful adjunct to progressive resistance training for strength. The additional effect should nevertheless be described as modest rather than transformative, and resistance training remains the foundational intervention.

3.2. Muscle Mass and Body Composition

Evidence for an additional effect on muscle mass is less consistent.

Earlier meta-analyses reported greater gains in lean tissue when creatine was combined with resistance training [4,5]. Several primary trials also reported favorable body-composition changes [7–9,11].

However, in the 2026 analysis restricted to adults aged ≥60 years, the pooled effect for muscle mass was g=0.35 with a 95% CI of −0.09 to 0.78, and the evidence was rated low certainty [6]. The confidence interval crossing the null makes an additional muscle-mass effect less secure than the strength effect.

Differences among studies may reflect participant characteristics, baseline creatine status, sex, training program, dose, duration, body-composition methodology, and small sample sizes.

Creatine should therefore not be presented as reliably increasing muscle mass in every adult over 60.

3.3. Physical Function

Physical function is particularly important because increased laboratory strength does not necessarily translate into improved mobility or independence.

In the ≥60 meta-analysis, the pooled estimate for physical function was g=0.47 (95% CI −0.08 to 1.03), with very-low-certainty evidence [6]. A broader systematic review and meta-analysis examining people at risk of functional disability also suggested potentially favorable effects, but the underlying evidence was heterogeneous and generally low or very low certainty [12].

Current evidence therefore does not establish that adding creatine to resistance training reliably improves clinically meaningful physical function beyond resistance training itself.

4. Sarcopenia, Vulnerability, and Frailty

Evidence from healthy older adults should not automatically be extrapolated to individuals with diagnosed sarcopenia, substantial frailty, or major functional impairment.

A randomized trial in vulnerable older women found that creatine combined with resistance training increased appendicular lean mass and improved some strength measures [11]. However, improvement in leg-press strength was not significantly greater than with resistance training alone.

An exploratory trial in frail older adults evaluated creatine and protein supplementation during supervised resistance training. Functional improvements occurred, but adding creatine did not produce clear additional improvements in body composition or muscle function [13].

These studies demonstrate feasibility and provide supportive evidence, but they do not establish creatine as a treatment for frailty or sarcopenia. The ≥60 meta-analysis likewise cautioned that its findings should not automatically be extrapolated to frail, sarcopenic, or functionally limited populations [6].

Future trials should recruit participants using contemporary diagnostic criteria for sarcopenia and frailty and evaluate clinically meaningful outcomes rather than relying primarily on surrogate measures.

5. Postmenopausal Women and Sex-Specific Considerations

Postmenopausal women are an important subgroup because aging and menopause affect muscle, bone, and body composition.

Longer-duration trials have evaluated creatine during resistance training in postmenopausal women and older adults [14]. A two-year randomized trial found that creatine supplementation during exercise did not significantly improve femoral-neck, total-hip, or lumbar-spine bone mineral density compared with placebo, although some bone-geometry measures differed [15].

A 2026 systematic review and meta-analysis of seven RCTs involving 608 postmenopausal women reported a small increase in lean mass and improved leg-press strength. Effects appeared more favorable when creatine doses ≥5 g/day were combined with resistance training [16].

The same evidence does not establish an overall improvement in bone mineral density [15,16]. Creatine therefore should not currently be presented as an osteoporosis treatment.

Sex-specific responses remain an important research area because differences in habitual dietary creatine exposure, muscle characteristics, hormonal status, and baseline tissue creatine could plausibly influence response, but these mechanisms do not establish clinically meaningful sex differences without appropriate comparative trials.

6. Cognition and Brain Health

Creatine participates in cellular energy buffering in the brain as well as skeletal muscle, providing biological plausibility for cognitive effects. Clinical evidence is considerably less mature than the musculoskeletal literature.

A controlled study in elderly individuals reported improvements in selected cognitive outcomes after creatine supplementation [17]. Broader adult evidence has subsequently been synthesized in systematic reviews and meta-analyses.

A 2024 meta-analysis reported possible benefits in selected cognitive domains [18]. However, another systematic review published the same year concluded that the available literature did not convincingly support the proposed theoretical cognitive effects of supplementation [19]. Differences in populations, doses, cognitive tests, baseline creatine status, sleep status, and study quality complicate synthesis.

Most importantly for the present review, a 2026 systematic review specifically examining older adults found only six eligible studies comprising 1,542 participants. Only two were double-blind supplementation studies; the remainder were cross-sectional studies of dietary creatine exposure. Five studies reported some positive relationship with cognition, but only one study was rated good quality [20].

Evidence in dementia is even more preliminary. A 2026 scoping review identified predominantly preclinical evidence and only limited human clinical evidence, without relevant randomized controlled clinical trials establishing efficacy for dementia [21].

Accordingly, creatine should not be described as an established treatment for mild cognitive impairment, Alzheimer disease, or other dementias. Cognitive findings remain promising but hypothesis-generating.

7. Immobilization, Injury, and Rehabilitation

Periods of unloading can accelerate muscle loss and weakness, making creatine attractive as a potential rehabilitation adjunct.

A 2026 review concluded that creatine does not consistently preserve muscle cross-sectional area or strength during strict lower-limb immobilization. Some findings have been more favorable after progressive loading resumes, including accelerated recovery of selected muscle-size or power outcomes [22].

An important limitation is that several foundational immobilization and reloading experiments involved young healthy adults. These studies provide mechanistic or supportive evidence but cannot establish efficacy after fracture, hospitalization, or surgery in adults aged ≥60 years.

Creatine should therefore not be considered a replacement for progressive rehabilitation, adequate protein and energy intake, or treatment of the underlying condition.

8. Orthopedic Surgery

8.1. Total Knee Arthroplasty

Direct randomized evidence following total knee arthroplasty is not favorable.

Roy et al. randomized 37 adults undergoing total knee arthroplasty to creatine or placebo. Creatine was administered at 10 g/day for 10 days before surgery and 5 g/day for 30 days after surgery. Supplementation did not significantly improve postoperative body composition, muscle strength, or functional recovery [23].

Although the trial was small and cannot exclude benefit from different protocols, current direct evidence does not support routine creatine specifically to improve recovery after total knee arthroplasty.

8.2. Hip Fracture

A 2026 double-blind RCT enrolled 80 adults aged ≥60 years after surgery for proximal femoral fracture [24].

Importantly, the intervention was not creatine monotherapy. Participants received a protein supplement enriched with creatine and β-hydroxy-β-methylbutyrate (HMB). Early mobility at one month favored the intervention, whereas mobility did not differ at six months. The study also reported an association with lower six-month mortality [24].

Because protein, creatine, and HMB were administered together, neither the mobility finding nor the mortality finding can be attributed specifically to creatine.

This trial supports further investigation of multimodal nutritional rehabilitation after hip fracture but does not establish isolated creatine efficacy.

8.3. Total Hip Arthroplasty

Direct evidence specifically establishing a benefit from creatine supplementation following total hip arthroplasty is insufficient. Extrapolation from total knee arthroplasty, hip fracture, or younger-adult immobilization studies would not establish efficacy.

This remains an important research gap.

9. Dosing and Loading

Creatine monohydrate can be administered using either a loading strategy or a lower daily dose without loading.

Common maintenance approaches in the broader literature include approximately 3–5 g/day, while body-mass-adjusted regimens are also used. A traditional loading strategy typically provides approximately 20 g/day divided into several doses for about 5–7 days before transitioning to a lower maintenance dose [1,2].

Loading is not required for chronic supplementation. Its principal purpose is to increase tissue creatine more rapidly.

A meta-analysis specifically examining ingestion strategies in older adults evaluated doses ≤5 versus >5 g/day, loading versus no loading, and supplementation restricted to training days [5]. Multiple approaches were associated with favorable outcomes, but the evidence did not establish a universally optimal strategy.

The 2026 ≥60 meta-analysis likewise did not identify dose or loading as a stable moderator of the overall treatment effect [6].

For routine use in older adults, a simple daily maintenance regimen may reduce complexity and exposure to large single-day doses. Dosing should nevertheless be individualized according to body size, clinical objective, tolerability, comorbidities, and adherence.

10. Creatine Monohydrate Versus Alternative Formulations

Creatine monohydrate has the most extensive evidence base.

A systematic review evaluating alternative creatine formulations found insufficient evidence that alternative forms consistently produce superior efficacy, bioavailability, or clinical outcomes compared with creatine monohydrate [3].

Claims that creatine ethyl ester, buffered creatine, creatine salts, or proprietary formulations are clinically superior should therefore be interpreted cautiously.

For adults aged ≥60 years, in whom evidence is already limited for several clinical outcomes, use of less-studied formulations introduces additional uncertainty without established benefit.

11. Kidney Function, CKD, and Creatinine Interpretation

Kidney safety is one of the most clinically important aspects of creatine use because creatine metabolism is related to creatinine production and serum creatinine is widely used to estimate kidney function.

A 2025 systematic review and meta-analysis found a modest increase in serum creatinine with creatine supplementation but no statistically significant deterioration in GFR [25]. A subsequent 2026 systematic review and meta-analysis evaluating kidney health included both healthy individuals and patients with CKD and provided additional contemporary evidence [26].

Long-term evidence in an older clinical population is also informative. Bender et al. studied older patients with Parkinson disease receiving creatine or placebo for two years. Serum creatinine increased during creatine supplementation, whereas cystatin C and other assessed renal markers did not indicate corresponding deterioration in kidney function [27].

These findings have an important practical implication: an increase in serum creatinine after starting creatine does not automatically establish kidney injury. Because creatinine is related to creatine metabolism, creatinine-based eGFR may change partly because the biomarker itself has changed.

This principle must not be used to dismiss every creatinine increase. Acute kidney injury, progressive CKD, dehydration, urinary obstruction, medication-related nephrotoxicity, and other renal conditions remain possible.

Evidence in advanced CKD is considerably thinner than evidence in healthy populations. Safety findings in healthy or stable participants therefore should not be generalized indiscriminately to advanced or unstable CKD.

When serum creatinine and the clinical picture are discordant, repeat testing and additional clinical assessment are appropriate. Where clinically indicated, an alternative filtration marker such as cystatin C may assist interpretation.

12. Liver Safety

Available randomized-trial evidence does not demonstrate a consistent hepatotoxicity signal from creatine monohydrate at studied doses.

A large 2026 study-level safety analysis evaluated 684 randomized clinical trials and more than 12,800 participants in creatine and placebo study arms. Reported adverse effects were generally uncommon and no consistent dose- or duration-dependent pattern of serious hepatic toxicity emerged [28].

However, general safety data should not be confused with dedicated evidence in older adults with cirrhosis, decompensated liver disease, or other clinically significant chronic hepatic disorders. Direct evidence in these populations remains insufficient.

Clinically significant liver disease is therefore more appropriately considered a circumstance requiring individualized assessment rather than either an automatically established contraindication or a population in which safety has been conclusively demonstrated.

13. Hypertension and Cardiovascular Considerations

Direct cardiovascular evidence specifically in older adults remains limited.

Short-term randomized research in older men has examined vascular and cardiac responses to creatine, but such brief studies cannot establish long-term cardiovascular efficacy or safety.

Importantly, research examining serum or tissue creatine kinase in relation to hypertension does not evaluate oral creatine supplementation and should not be used as evidence for or against creatine use.

Current evidence does not establish creatine as a treatment for hypertension. Conversely, controlled hypertension by itself has not been established as an absolute contraindication to creatine.

Clinical decisions should instead consider blood-pressure control, cardiovascular stability, kidney function, hydration status, and the individual's medication regimen.

14. Polypharmacy and Potential Drug Interactions

Polypharmacy is defined here as the chronic concurrent use of five or more medications.

Polypharmacy is particularly relevant after age 60 because multimorbidity and multiple medications can affect kidney function, fluid balance, blood pressure, gastrointestinal tolerance, adherence, and interpretation of laboratory results.

A 2026 narrative review and evidence-mapping analysis specifically evaluated potential interactions between creatine and prescription medications. After searching PubMed/MEDLINE, Scopus, and CENTRAL, 132 unique records remained after deduplication, but no controlled human study directly evaluating creatine–prescription drug interactions met eligibility criteria [29].

The investigation also found no clinically established moderate- or high-severity interactions in the major interaction resources evaluated; available concerns were largely minor or theoretical [29].

This finding requires careful interpretation. Absence of an established interaction is not evidence proving that clinically relevant interactions cannot occur.

Direct evidence is particularly sparse in multimorbid adults taking multiple chronic medications.

Polypharmacy itself is therefore not an evidence-based absolute contraindication. Clinical assessment should focus on the actual medication regimen and diseases present, particularly factors affecting renal function, fluid balance, blood pressure, or interpretation of renal biomarkers.

15. Adverse Effects and Tolerability

The large 2026 safety analysis of 684 randomized trials found reported adverse effects to be generally uncommon and mild, without a consistent clinically meaningful relationship between supplementation dose or duration and adverse-event frequency [28].

Longer-term data in older populations are smaller but informative. In the two-year Parkinson-disease study, creatine was generally tolerated, although gastrointestinal complaints occurred [27].

Body mass may increase, particularly during higher-dose loading, partly because creatine increases intracellular water associated with increased tissue creatine storage. Gastrointestinal symptoms may occur, particularly when larger amounts are consumed at once [1,2].

General tolerability findings should not be interpreted as proof of safety in every medically complex older adult.

16. Contraindications and Precautions

The available literature does not support an extensive list of universally established absolute contraindications specific to creatine monohydrate.

It is clinically more appropriate to distinguish situations in which evidence is limited or additional supervision is warranted from proven contraindications.

Additional caution and individualized assessment are reasonable when kidney function is unstable or substantially impaired; an unexplained creatinine elevation is under investigation; an acute illness involves dehydration or major fluid disturbance; significant decompensated hepatic disease is present; or a complex medication regimen creates uncertainty regarding renal function, fluid balance, or laboratory interpretation.

These situations should generally be regarded as precautions requiring individualized clinical assessment, rather than automatically labeled universal contraindications.

17. Clinical Monitoring

No universally validated creatine-monitoring protocol exists specifically for all adults aged ≥60 years. Monitoring should therefore be individualized.

Before supplementation, relevant considerations include the intended clinical objective, current exercise and nutritional program, kidney function, comorbidities, medication and supplement use, hydration status, and history of intolerance.

In medically complex adults, a baseline serum creatinine/eGFR can provide a useful reference. Additional investigations should be driven by existing disease and clinical indication rather than automatically ordered for every healthy individual.

After supplementation begins, stable healthy older adults using conventional doses may not require intensive laboratory surveillance. Individuals with CKD, multimorbidity, recent acute illness, extensive polypharmacy, or unexpected laboratory changes warrant closer assessment.

A rise in serum creatinine should not automatically be classified as creatine-induced nephrotoxicity. When creatinine-based eGFR appears inconsistent with the overall clinical picture, alternative kidney-function assessment, including cystatin C when appropriate, may improve interpretation [25–27].

Supplementation should be reassessed if progressive unexplained renal deterioration, clinically significant intolerance, dehydration, major acute illness, or another clinically relevant concern develops.

18. Duration, Long-Term Use, and Discontinuation

Many resistance-training trials in older adults are relatively short, limiting conclusions about multi-year supplementation.

Nevertheless, controlled data extending to approximately two years exist in postmenopausal women and older patients with Parkinson disease [15,27]. These studies provide useful long-term information but cannot establish safety for every multimorbid older population.

Current evidence does not establish a clinical requirement to cycle creatine on and off. Continued supplementation should depend on clinical objectives, tolerability, comorbidities, and whether a meaningful rationale for continued use remains.

Research examining cessation after supplementation and resistance training suggests that stopping creatine does not produce a recognized clinical withdrawal syndrome [30]. Tissue creatine stores gradually return toward baseline after supplementation is discontinued.

19. Cost and Cost-Effectiveness

Creatine monohydrate is generally a comparatively simple nutritional intervention, although product cost varies by country, manufacturer, purity testing, and dose.

Formal cost-effectiveness evidence specifically evaluating creatine for prevention or treatment of sarcopenia, disability, cognitive decline, fracture rehabilitation, or long-term-care outcomes in adults aged ≥60 years is insufficient.

Consequently, describing creatine as clinically “cost-effective” for these outcomes would exceed the current evidence.

Economic evaluation would become particularly valuable if future trials demonstrate meaningful reductions in falls, rehabilitation duration, hospitalization, institutionalization, or loss of independence.

20. Practical Clinical Interpretation

The available evidence supports a hierarchy of clinical conclusions.

The most defensible application after age 60 is creatine monohydrate as an adjunct to progressive resistance training for a modest additional improvement in muscle strength in generally healthy older adults [6]. Resistance training remains the foundational intervention.

Evidence for additional increases in muscle mass is mixed, while evidence for improvement in physical function is uncertain [6,12]. Limited studies in vulnerable and frail populations do not establish creatine as a treatment for sarcopenia or frailty [11,13].

Postmenopausal women may experience small improvements in lean mass and strength, particularly when supplementation accompanies resistance training, but creatine is not an established osteoporosis treatment [15,16].

Cognitive findings remain preliminary and inconsistent. Creatine should not currently be presented as an evidence-based treatment for cognitive impairment or dementia [18–21].

During strict immobilization, benefit is inconsistent; a role during active reloading remains plausible but incompletely established in older adults [22]. Direct evidence after total knee arthroplasty is negative [23]. Positive hip-fracture findings derive from a multi-ingredient intervention and cannot be assigned specifically to creatine [24].

Creatine monohydrate remains the preferred evidence-based formulation because alternative formulations have not demonstrated consistent clinical superiority [3].

Kidney-function interpretation deserves particular attention. Creatine can increase serum creatinine without corresponding evidence of impaired filtration, potentially complicating creatinine-based eGFR interpretation [25–27]. This phenomenon does not eliminate the possibility of genuine renal disease.

Finally, polypharmacy alone is not an established contraindication, but controlled human creatine–prescription drug interaction studies are absent [29]. Individual medication review and clinical judgment therefore remain necessary.

21. Research Gaps and Future Directions

Several clinically important evidence gaps remain.

Larger RCTs should enroll adults with objectively diagnosed sarcopenia and frailty rather than predominantly healthy community-dwelling participants. Outcomes should include gait speed, falls, activities of daily living, hospitalization, rehabilitation success, quality of life, institutionalization, and independence.

Dedicated studies are also needed in CKD populations stratified by stage, particularly advanced CKD, and should incorporate filtration markers less directly influenced by creatine metabolism.

Clinically significant liver disease remains poorly studied, as do older populations with substantial multimorbidity and polypharmacy.

Cognitive research requires adequately powered randomized trials in adults aged ≥60 years with standardized cognitive outcomes and careful distinction between cognitively healthy participants, mild cognitive impairment, and diagnosed dementia.

Perioperative studies should distinguish isolated creatine supplementation from multi-ingredient nutritional interventions and evaluate total hip and knee arthroplasty, hip-fracture rehabilitation, and recovery following hospitalization.

Future dosing studies should directly compare maintenance-only regimens with loading strategies in older adults rather than relying primarily on indirect subgroup comparisons.

Finally, formal economic evaluations are needed before cost-effectiveness claims can be made.

22. Strengths and Limitations

A principal strength of this review is its specific clinical focus on adults aged ≥60 years and its distinction between direct older-adult evidence and indirect evidence derived from younger populations, broader age definitions, mechanistic studies, or multi-ingredient interventions.

The review also integrates efficacy with practical safety issues, including interpretation of serum creatinine, CKD, polypharmacy, liver disease, cardiovascular considerations, and monitoring. Positive findings were interpreted alongside null and negative trials rather than treating the literature as uniformly favorable.

Important limitations remain. This is a narrative review rather than a systematic review. Literature retrieval was structured but not exhaustive, and duplicate independent screening and data extraction were not performed. No independent review-wide risk-of-bias assessment or certainty grading was conducted.

The underlying evidence is heterogeneous in age definitions, health status, sex, creatine dose, exercise exposure, intervention duration, and outcome measurement. Several clinically important populations—including adults with advanced CKD, significant liver disease, extensive polypharmacy, and severe frailty—remain underrepresented.

These limitations constrain the certainty of clinical conclusions and reinforce the importance of individualized interpretation.

23. Conclusions

Creatine monohydrate is among the better-studied nutritional supplements for skeletal-muscle performance, but the evidence becomes narrower when clinical questions are restricted specifically to adults aged ≥60 years.

The strongest current evidence supports creatine as an adjunct to progressive resistance training for a modest additional improvement in muscle strength in generally healthy older adults. Additional effects on muscle mass and physical function are less certain. Evidence is insufficient to describe creatine as an established treatment for sarcopenia, frailty, cognitive impairment, dementia, osteoporosis, or postoperative disability.

Creatine monohydrate should remain the reference formulation because alternative formulations have not demonstrated sufficient clinical superiority. Loading is optional rather than obligatory, and no single dosing strategy has been established as universally optimal for adults aged ≥60 years.

Available evidence is generally reassuring regarding tolerability and kidney function at studied doses, but creatine can increase serum creatinine and thereby complicate creatinine-based eGFR interpretation. Evidence is substantially more limited in advanced CKD, clinically significant liver disease, severe frailty, and extensive polypharmacy.

For clinical practice, the relevant question is therefore not simply whether creatine is “safe” or “effective” after age 60. Decisions should integrate the intended outcome, resistance-training exposure, nutritional status, comorbidities, medication regimen, kidney-function interpretation, tolerability, and the strength and directness of evidence for the specific clinical setting.

Declarations

Funding

This work received no external funding. No third party provided financial or commercial support for the preparation of this review.

Conflicts of Interest

The author is the founder of Healthy Habits Coaching, a nutrition and healthy-habits coaching and educational platform through which the author provides coaching services and publishes health and nutrition educational content, including narrative reviews. Some subject areas addressed by Healthy Habits Coaching may overlap with topics discussed in this article.

Healthy Habits Coaching did not provide external sponsorship for this review, and no third party provided financial or commercial support for its preparation. The author's relationship with Healthy Habits Coaching is disclosed for transparency as a potential commercial and/or non-financial interest. The author reports no other conflicts of interest relevant to this article.

Author Contributions

Ori Scott: Conceptualization; Methodology; Investigation; Validation; Writing—review and editing; Project administration.

Ori Scott conceived the review topic and scope, defined the research questions and evidence-selection framework, evaluated the scientific relevance of the literature and the interpretation of the evidence, critically revised the article, and approved the final version. The author accepts full responsibility for the integrity and final content of the work.

Ethics Statement

Ethics approval was not required because this narrative review is based exclusively on previously published literature and involved no recruitment of human participants, collection of identifiable personal information, or original research involving human participants or animals.

Patient Consent

Not applicable. The article contains no original participant data, identifiable patient information, or clinical images requiring patient consent.

Consent for Publication

Not applicable.

Data Availability

No original participant-level data or research dataset was generated for this narrative review. The evidence discussed in the article is derived from published literature cited in the reference list.

Acknowledgements

None.

Artificial Intelligence Disclosure

OpenAI ChatGPT (GPT-5.6 Sol) was used as an assistive tool during article preparation for organization, drafting, language refinement, revision, and presentation of material. AI-generated output was reviewed and edited by the author and was not treated as an independent scientific source or author.

The author determined the review question and scope, evaluated the scientific relevance of the literature, assessed the interpretation and limitations of the evidence presented, critically revised the article, and approved the final version. The author retains full responsibility for the accuracy, integrity, references, scientific interpretation, and content of the article.

Publication Statement

This narrative review was prepared for publication by Healthy Habits Coaching as independent health and nutrition educational content. It has not undergone external journal peer review unless explicitly stated otherwise.

References

1. Antonio J, Candow DG, Forbes SC, Gualano B, Jagim AR, Kreider RB, et al. Common questions and misconceptions about creatine supplementation: what does the scientific evidence really show? J Int Soc Sports Nutr. 2021;18(1):13. doi:10.1186/s12970-021-00412-w. PMID:33557850.

2. Kreider RB, Kalman DS, Antonio J, Ziegenfuss TN, Wildman R, Collins R, et al. International Society of Sports Nutrition position stand: safety and efficacy of creatine supplementation in exercise, sport, and medicine. J Int Soc Sports Nutr. 2017;14:18. doi:10.1186/s12970-017-0173-z. PMID:28615996.

3. Fazio C, Elder CL, Harris MM. Efficacy of alternative forms of creatine supplementation on improving performance and body composition in healthy subjects: a systematic review. J Strength Cond Res. 2022;36(9):2663–2670. doi:10.1519/JSC.0000000000003873. PMID:36000773.

4. Devries MC, Phillips SM. Creatine supplementation during resistance training in older adults—a meta-analysis. Med Sci Sports Exerc. 2014. doi:10.1249/MSS.0000000000000220. PMID:24576864.

5. Forbes SC, Candow DG, Ostojic SM, Roberts MD, Chilibeck PD. Meta-analysis examining the importance of creatine ingestion strategies on lean tissue mass and strength in older adults. Nutrients. 2021;13(6):1912. doi:10.3390/nu13061912. PMID:34199420.

6. Yao L, Yang D, Gao J. Effects of resistance training combined with creatine supplementation on muscle strength, physical function, and muscle mass in older adults: a systematic review and three-level meta-analysis. Front Nutr. 2026;13:1919884. doi:10.3389/fnut.2026.1919884. PMID:42712402.

7. Chrusch MJ, Chilibeck PD, Chad KE, Davison KS, Burke DG. Creatine supplementation combined with resistance training in older men. Med Sci Sports Exerc. 2001;33:2111–2117. doi:10.1097/00005768-200112000-00021. PMID:11740307.

8. Brose A, Parise G, Tarnopolsky MA. Creatine supplementation enhances isometric strength and body composition improvements following strength exercise training in older adults. J Gerontol A Biol Sci Med Sci. 2003;58–B19. doi:10.1093/gerona/58.1.B11. PMID:12560406.

9. Candow DG, Little JP, Chilibeck PD, Abeysekara S, Zello GA, Kazachkov M, et al. Low-dose creatine combined with protein during resistance training in older men. Med Sci Sports Exerc. 2008;40:1645–1652. doi:10.1249/MSS.0b013e318176b310. PMID:18685526.

10. Candow DG, Zello GA, Ling B, Farthing JP, Chilibeck PD, McLeod K, et al. Comparison of creatine supplementation before versus after supervised resistance training in healthy older adults. Res Sports Med. 2014;22:61–74. doi:10.1080/15438627.2013.852088. PMID:24392772.

11. Gualano B, Macedo AR, Alves CRR, Roschel H, Benatti FB, Takayama L, et al. Creatine supplementation and resistance training in vulnerable older women: a randomized double-blind placebo-controlled clinical trial. Exp Gerontol. 2014;53:7–15. doi:10.1016/j.exger.2014.02.003. PMID:24530883.

12. Davies TW, Watson N, Pilkington JJ, et al. Creatine supplementation for optimization of physical function in the patient at risk of functional disability: a systematic review and meta-analysis. JPEN J Parenter Enteral Nutr. 2024;48:389–405. doi:10.1002/jpen.2607. PMID:38417175.

13. Collins J, Longhurst G, Roschel H, Gualano B. Resistance training and co-supplementation with creatine and protein in older subjects with frailty. J Frailty Aging. 2016;5:126–134. doi:10.14283/jfa.2016.85. PMID:27224505.

14. Candow DG, Chilibeck PD, Gordon J, et al. Effect of 12 months of creatine supplementation and whole-body resistance training on measures of bone, muscle and strength in older males. Nutr Health. 2021;27:151–159. doi:10.1177/0260106020975247. PMID:33234019.

15. Chilibeck PD, Candow DG, Gordon JJ, Duff WRD, Mason R, Shaw K, et al. A 2-yr randomized controlled trial on creatine supplementation during exercise for postmenopausal bone health. Med Sci Sports Exerc. 2023;55:1750–1760. doi:10.1249/MSS.0000000000003202. PMID:37144634.

16. Naddafha S, Antonio J, Kreider RB, Stout JR. Creatine monohydrate for lean mass, strength, and bone density in postmenopausal women: a systematic review and meta-analysis. J Int Soc Sports Nutr. 2026;23:2668435. PMID:42141930.

17. McMorris T, Mielcarz G, Harris RC, Swain JP, Howard A. Creatine supplementation and cognitive performance in elderly individuals. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn. 2007;14:517–528. doi:10.1080/13825580600788100. PMID:17828627.

18. Xu C, Bi M, Zhang C, Luo L. The effects of creatine supplementation on cognitive function in adults: a systematic review and meta-analysis. Front Nutr. 2024;11:1424972. doi:10.3389/fnut.2024.1424972. PMID:39070254.

19. McMorris T, Hale BJ, Pine BS, Williams TB. Creatine supplementation research fails to support the theoretical basis for an effect on cognition: evidence from a systematic review. Behav Brain Res. 2024:114982. doi:10.1016/j.bbr.2024.114982. PMID:38582412.

20. Marshall S, Kitzan A, Wright J, Bocicariu L, Nagamatsu LS. Creatine and cognition in aging: a systematic review of evidence in older adults. Nutr Rev. 2026;84:333–344. doi:10.1093/nutrit/nuaf135. PMID:40971619.

21. Whitford T, Donlon C, Pech A, Goldberg C, Whiteson H, Etienne M. The cognitive effects of creatine supplementation in older adults and preclinical models of dementia: a scoping review. Ageing Res Rev. 2026;122:103317. doi:10.1016/j.arr.2026.103317. PMID:42668123.

22. Stout JR, Pabian PS. Creatine monohydrate supplementation for recovery from muscle disuse: timing matters. Sports Med Health Sci. 2026;8:495–500. doi:10.1016/j.smhs.2026.05.006. PMID:42539704.

23. Roy BD, de Beer J, Harvey D, Tarnopolsky MA. Creatine monohydrate supplementation does not improve functional recovery after total knee arthroplasty. Arch Phys Med Rehabil. 2005;86:1293–1298. doi:10.1016/j.apmr.2005.01.005. PMID:16003653.

24. Kalantar SH, Poursalehian M, Donyazad M, Shafie H, Zebardast J, Khalooeifard R, et al. Protein supplementation for hip fracture recovery in elderly patients: a randomized controlled trial. J Orthop Trauma. 2026;40:286–293. doi:10.1097/BOT.0000000000003158. PMID:41665352.

25. Kabiri Naeini E, Eskandari M, Mortazavi M, Gholaminejad A, Karevan N. Effect of creatine supplementation on kidney function: a systematic review and meta-analysis. BMC Nephrol. 2025;26:622. doi:10.1186/s12882-025-04558-6. PMID:41199218.

26. de Souza Almeida A, Dias da Silva LO, Takahasi BNA, et al. Impact of creatine supplementation on kidney health: a systematic review and meta-analysis. Int Urol Nephrol. 2026. doi:10.1007/s11255-026-05287-x. PMID:42507286.

27. Bender A, Samtleben W, Elstner M, Klopstock T. Long-term creatine supplementation is safe in aged patients with Parkinson disease. Nutr Res. 2008;28:172–178. doi:10.1016/j.nutres.2008.01.001. PMID:19083405.

28. Gonzalez DE, Dickerson BL, Hines K, Chun J, Gil A, Forbes SC, et al. Creatine supplementation dose and duration are not associated with increased side effects: a structured review and study-level dose-response analysis of randomized controlled trials. Sports (Basel). 2026;14:137. doi:10.3390/sports14040137. PMID:42043069.

29. Ostojic SM. Potential interactions between creatine supplementation and prescription drugs: a narrative review and evidence-mapping perspective. Curr Ther Res Clin Exp. 2026;105:100844. doi:10.1016/j.curtheres.2026.100844. PMID:42757020.

30. Candow DG, Chilibeck PD, Chad KE, Chrusch MJ, Davison KS, Burke DG. Effect of ceasing creatine supplementation while maintaining resistance training in older men. J Aging Phys Act. 2004;12(3):219–231. doi:10.1123/japa.12.3.219. PMID:15263100.

31. Chilibeck PD, Kaviani M, Candow DG, Zello GA. Effect of creatine supplementation during resistance training on lean tissue mass and muscular strength in older adults: a meta-analysis. Open Access J Sports Med. 2017;8:213–226. doi:10.2147/OAJSM.S123529. PMID:29138605.