Cognitive frailty independently predicts hip fracture risk in older Chinese adults: a 10-year prospective analysis

Hip fractures represent a significant public health burden among aging populations, particularly in China, where they are driven by osteoporosis and falls. Cognitive frailty- defined as the coexistence of physical frailty and mild cognitive impairment in the absence of dementia has been associated with increased fall risk; however, its relationship with hip fractures remains poorly understood. This study aimed to investigate the association between cognitive frailty and hip fractures risk among older Chinese adults. Data were derived from the China Health and Retirement Longitudinal Study (CHARLS), a nationally representative cohort. The cross-sectional study included 3,870 participants aged ≥ 60 years, while 3,797 participants were followed longitudinally over 10 years (2011–2020). Cognitive frailty was operationally defined as concurrent presence of cognitive impairment -assessed through word recall, the telephone interview for cognitive status (TICS-10), and figure drawing and physical frailty, defined by (Fried Frailty Phenotype (FFP) score ≥ 3. Logistics regression and cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs), adjusting for sociodemographic and health-related covariates. Sensitivity analyses and subgroup analyses were conducted to validate the robustness of the findings. The mean age of the cohort was 66.89 years, and 172 participants (4.53%) developed incident hip fractures during follow-up. Both cross-sectional and longitudinal analyses demonstrated a significant association between cognitive frailty and an increased risk of hip fracture. In the fully adjusted logistic regression model, cognitive frailty was associated with a higher likelihood of hip fracture (OR = 3.67, 95% CI: 1.47–9.13). In the cohort analysis, cognitive frailty remained an independent predictor of incident hip fracture (adjusted HR = 2.13, 95% CI: 1.10–4.11). Subgroup analyses showed generally consistent associations across different strata. In addition, sensitivity analyses using alternative frailty index thresholds (FI > 0.20 and FI > 0.25) and analyses with imputed data confirmed the robustness of these findings. Cognitive frailty is independently associated with a significantly increases elevated risk of hip fractures in older Chinese older adults, highlighting it as a clinically important and modifiable risk factor. These findings underscore the need for integrated screening protocols that simultaneously assess both cognitive and physical frailty in geriatric care settings.