Association of frailty and mortality risk in community-dwelling older adults: a systematic review and meta-analysis of 59 international prospective cohort studies

BACKGROUND: The global aging population presents significant health challenges. This study aimed to examine the association between frailty and mortality among community-dwelling older adults. METHODS: We searched five databases up to April 29, 2025, for prospective cohort studies evaluating frailty as a predictor of mortality. Study quality and risk of bias were assessed using the ROBINS-E tool. A random-effects meta-analysis was conducted to estimate pooled mortality risks. RESULTS: A total of 59 studies were included in the systematic review, of which 53 were eligible for meta-analysis, comprising 185,355 participants and over 28,616 deaths. Follow-up periods ranged from 1 to 15 years. Compared to robust individuals, non-robust older adults had a significantly higher risk of all-cause mortality (hazard ratio [HR] = 1.83, 95% confidence interval [CI]: 1.70-1.97). This association was consistent across frailty domains: including physical frailty (HR = 1.74, 95%CI: 1.53-1.99), multidimensional frailty (HR = 2.25, 95%CI: 1.97-2.57), and phenotype-based models accessed frailty (HR = 1.71, 95%CI: 1.48-1.97). Subgroup analyses based on phenotype-based models showed that frail older adults had a higher risk of all-cause mortality (HR = 2.18, 95%CI: 1.72-2.75) than those who were prefrail (HR = 1.51, 95%CI: 1.37-1.67), with a significant difference across frailty levels (Q = 7.88, p < .01). Regarding cause-specific mortality, the risk of death from non-lifestyle-related diseases (e.g., dementia, cancer) (HR = 1.97, 95%CI: 1.36-2.84) was slightly higher than that from lifestyle-related diseases (e.g., cardiovascular and respiratory diseases) (HR = 1.94, 95%CI: 1.52-2.46), though the difference was not statistically significant (Q = 0.008, p > .05). CONCLUSIONS: These findings highlight the need for comprehensive assessment and management of frailty in community-dwelling older adults. Future research and health policy should prioritize targeted strategies according to frailty severity to reduce mortality risk and improve health outcomes.