Cognitive Frailty as a Predictor of Future Falls in Older Adults: A Systematic Review and Meta-analysis

Published:November 21, 2022DOI:



      To examine the association between cognitive frailty and the risk of future falls among older adults.


      Systematic review and meta-analysis.

      Setting and Participants

      Older people aged ≥60 years with cognitive frailty from community, hospital, or both.


      PubMed, EMBASE, Web of Science, the Cochrane Library, Wanfang Database, China Knowledge Resource Integrated Database (CNKI), Weipu Database (VIP), and Chinese Biomedical Database (CBM) were searched for relevant studies published from the inception of the database until June 14, 2022. Stata 16.0 software was used to perform the meta-analysis. A random effects model was used to pool the prevalence of falls in older adults over age 60 years with cognitive frailty and the strength of the association between cognitive frailty and falls [odds ratios (ORs) and 95% CIs]. Quality assessment, heterogeneity, and sensitivity analyses were also conducted. A study protocol was registered in PROSPERO (CRD42022331323).


      The review included 18 studies in qualitative synthesis, 14 of which were in meta-analysis. Eleven sets of cross-sectional data involving 23,025 participants and 5 sets of longitudinal data involving 11,924 participants were used in the meta-analysis. The results showed that the overall prevalence of falls in 1742 people with cognitive frailty was 36.3% (95% CI 27.9-44.8, I2 = 93.4%). Longitudinal study results showed that cognitively frail individuals had a higher risk of falls (OR 3.02, 95% CI 2.11-4.32, I2 = 0.0%, P = .406), compared to robust participants without cognitive impairment; physically frail people (alone) had a moderate risk of falls (OR 2.16, 95% CI 1.42-3.30, I2 = 9.7%, P = .351); cognitively impaired people (alone) had a lower risk of falls (OR 1.36, 95% CI 1.03-1.79, I2 = 0.0%, P = .440). Among cross-sectional studies, cognitive frailty was associated with the risk of falls (OR 2.74, 95% CI 2.20-3.40, I2 = 53.1%, P = .019). Although high heterogeneity was noted among 11 cross-sectional studies reporting ORs, the sensitivity analysis showed that no single study significantly affected the final pooled results.

      Conclusions and Implications

      This systematic review and meta-analysis confirms the findings that cognitive frailty was demonstrated to be a significant predictor of future falls in older adults. However, further prospective investigations are warranted.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization
        WHO Global report on falls prevention in older age.
        WHO, Geneva2008
        • Salari N.
        • Darvishi N.
        • Ahmadipanah M.
        • Shohaimi S.
        • Mohammadi M.
        Global prevalence of falls in the older adults: a comprehensive systematic review and meta-analysis.
        J Orthop Surg Res. 2022; 17: 334
        • Ye P.
        • Er Y.
        • Wang H.
        • et al.
        Burden of falls among people aged 60 years and older in mainland China, 1990-2019: findings from the Global Burden of Disease Study 2019.
        Lancet Public Health. 2021; 6: e907-e918
        • James S.L.
        • Lucchesi L.R.
        • Bisignano C.
        • et al.
        The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017.
        Inj Prev. 2020; 26: i3-i11
        • WHO
        Step safely: strategies for preventing and managing falls across the life-course.
        World Health Organization, Geneva2021
        • The National Center for Chronic and Noncommunicable Disease Control and Prevention, China CDC
        National injury monitoring data set.
        People's Medical Publishing House, Beijing2019
        • Markle-Reid M.
        • Browne G.
        • Gafni A.
        • et al.
        A cross-sectional study of the prevalence, correlates, and costs of falls in older home care clients ’at risk’ for falling.
        Can J Aging. 2010; 29: 119-137
        • Tsai C.Y.
        • Lin E.S.
        • Li Y.T.
        • Tung T.H.
        • Chen W.C.
        The relationship between storey of buildings and fall risk.
        Front Public Health. 2021; 9: 665985
        • Pfortmueller C.A.
        • Lindner G.
        • Exadaktylos A.K.
        Reducing fall risk in the elderly: risk factors and fall prevention, a systematic review.
        Minerva Med. 2014; 105: 275-281
        • Callis N.
        Falls prevention: Identification of predictive fall risk factors.
        Appl Nurs Res. 2016; 29: 53-58
        • Kelaiditi E.
        • Cesari M.
        • Canevelli M.
        • et al.
        Cognitive frailty: rational and definition from an (I.A.N.A./I.A.G.G.) international consensus group.
        J Nutr Health Aging. 2013; 17: 726-734
        • Chang S.F.
        • Lin P.L.
        Frail phenotype and mortality prediction: A systematic review and meta-analysis of prospective cohort studies.
        Int J Nurs Stud. 2015; 52: 1362-1374
        • Collard R.M.
        • Boter H.
        • Schoevers R.A.
        • Oude Voshaar R.C.
        Prevalence of frailty in community-dwelling older persons: a systematic review.
        J Am Geriatr Soc. 2012; 60: 1487-1492
        • Panza F.
        • Sardone R.
        • Dibello V.
        • Daniele A.
        • Solfrizzi V.
        • Lozupone M.
        Frailty and outcome after traumatic brain injury.
        Lancet Neurol. 2022; 21: 107-108
        • Fried L.P.
        • Tangen C.M.
        • Walston J.
        • et al.
        • Cardiovascular Health Study Collaborative Research Group
        Frailty in older adults: evidence for a phenotype.
        J Gerontol A Biol Sci Med Sci. 2001; 56: M146-M156
        • Rockwood K.
        • Mitnitski A.
        Frailty in relation to the accumulation of deficits.
        J Gerontol A Biol Sci Med Sci. 2007; 62: 722-727
        • Gobbens R.J.
        • Luijkx K.G.
        • Wijnen-Sponselee M.T.
        • Schols J.M.
        In search of an integral conceptual definition of frailty: opinions of experts.
        J Am Med Dir Assoc. 2010; 11: 338-343
        • Drew D.A.
        • Weiner D.E.
        • Sarnak M.J.
        Cognitive impairment in CKD: pathophysiology, management, and prevention.
        Am J Kidney Dis. 2019; 74: 782-790
        • Qiu Y.
        • Li G.
        • Wang X.
        • et al.
        Prevalence of cognitive frailty among community-dwelling older adults: a systematic review and meta-analysis.
        Int J Nurs Stud. 2022; 125: 104112
        • Kojima G.
        Frailty as a predictor of future falls among community-dwelling older people: a systematic review and meta-analysis.
        J Am Med Dir Assoc. 2015; 16: 1027-1033
        • Lan X.
        • Li H.
        • Wang Z.
        • Chen Y.
        Frailty as a predictor of future falls in hospitalized patients: a systematic review and meta-analysis.
        Geriatr Nurs. 2020; 41: 69-74
        • Booth V.
        • Logan P.
        • Harwood R.
        • et al.
        Falls prevention interventions in older adults with cognitive impairment: a systematic review of reviews.
        Int J Ther Rehabil. 2015; 22: 289-296
        • Fernando E.
        • Fraser M.
        • Hendriksen J.
        • Kim C.H.
        • Muir-Hunter S.W.
        Risk factors associated with falls in older adults with dementia: a systematic review.
        Physiother Can. 2017; 69: 161-170
        • Kearney F.C.
        • Harwood R.H.
        • Gladman J.R.
        • Lincoln N.
        • Masud T.
        The relationship between executive function and falls and gait abnormalities in older adults: a systematic review.
        Dement Geriatr Cogn Disord. 2013; 36: 20-35
        • Wennberg A.M.
        • Savica R.
        • Mielke M.M.
        Association between various brain pathologies and gait disturbance.
        Dement Geriatr Cogn Disord. 2017; 43: 128-143
        • Avila-Funes J.A.
        • Amieva H.
        • Barberger-Gateau P.
        • et al.
        Cognitive impairment improves the predictive validity of the phenotype of frailty for adverse health outcomes: the three-city study.
        J Am Geriatr Soc. 2009; 57: 453-461
        • Boyle P.A.
        • Buchman A.S.
        • Wilson R.S.
        • Leurgans S.E.
        • Bennett D.A.
        Physical frailty is associated with incident mild cognitive impairment in community-based older persons.
        J Am Geriatr Soc. 2010; 58: 248-255
        • Auyeung T.W.
        • Lee J.S.
        • Kwok T.
        • Woo J.
        Physical frailty predicts future cognitive decline - a four-year prospective study in 2737 cognitively normal older adults.
        J Nutr Health Aging. 2011; 15: 690-694
        • Malmstrom T.K.
        • Morley J.E.
        The frail brain.
        J Am Med Dir Assoc. 2013; 14: 453-455
        • Fan Xiaolei
        • Han Binru
        • Zhao Xia
        • et al.
        Analysis of cognitive frailty and its influencing factors in elderly patients with acute coronary syndrome [J].
        Chin J Modern Nurs. 2021; 27: 4492-4498
        • Wang C.
        • Chong Y.
        • Wang L.
        • Wang Y.
        The correlation between falls and cognitive frailty in elderly individuals with hypertension in a chinese community.
        Front Aging Neurosci. 2022; 14: 783461
        • Stang A.
        Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses.
        Euro J Epidemiol. 2010; 25: 603-605
        • Ma L.L.
        • Wang Y.Y.
        • Yang Z.H.
        • Huang D.
        • Weng H.
        • Zeng X.T.
        Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better?.
        Mil Med Res. 2020; 7: 7
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Egger M.
        • Davey Smith G.
        • Schneider M.
        • Minder C.
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Duval S.
        • Tweedie R.
        Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.
        Biometrics. 2000; 56: 455-463
        • Brigola A.G.
        • Ottaviani A.C.
        • Alexandre T.D.S.
        • Luchesi B.M.
        • Pavarini S.C.I.
        Cumulative effects of cognitive impairment and frailty on functional decline, falls and hospitalization: A four-year follow-up study with older adults.
        Arch Gerontol Geriatr. 2020; 87: 104005
        • Ma Y.
        • Li X.
        • Pan Y.
        • et al.
        Cognitive frailty and falls in Chinese elderly people: a population-based longitudinal study.
        Euro J Neurol. 2021; 28: 381-388
        • Rivan N.F.M.
        • Singh D.K.A.
        • Shahar S.
        • et al.
        Cognitive frailty is a robust predictor of falls, injuries, and disability among community-dwelling older adults.
        BMC Geriatr. 2021; 21: 593
        • YUAN Jing-lin
        • MA Ya-jun
        • Xiao-dong L.I.
        • et al.
        Cognitive frailty increases the risk of falls of elderly in five years.
        Basic Clin Med. 2022; 42: 201-207
        • Zhang X.M.
        • Yuan L.
        • Guo N.
        • et al.
        Cognitive frailty and falls in a national cohort of older Chinese inpatients.
        J Nutr Health Aging. 2021; 25: 993-998
        • Jiang T.T.
        • Dan Y.
        • Du L.P.
        • et al.
        Cognitive frailty in elderly patients with hemodialysis and its relationship with fear of falling.
        Chin Nurs Manage. 2020; 20: 1005-1009
        • Kim H.
        • Awata S.
        • Watanabe Y.
        • et al.
        Cognitive frailty in community-dwelling older Japanese people: prevalence and its association with falls.
        Geriatr Gerontol Int. 2019; 19: 647-653
        • Ma L.
        • Zhang L.
        • Zhang Y.
        • Li Y.
        • Tang Z.
        • Chan P.
        Cognitive frailty in China: results from China comprehensive geriatric assessment study.
        Front Med (Lausanne). 2017; 4: 174
        • Wang Ling-xiao
        • Yang Yong-xue
        • Guan Li-juan
        • Shen Jing
        Current status of cognitive frailty and its influencing factors in hospitalized elderly with comorbidities.
        Chin J Mult Organ Dis Elder. 2019; 18: 738-742
        • Wang Weihua
        • Kou Jingli
        • Zhang Tong
        • Yang Shenshen
        Cognitive frailty of patients in Department of Geriatrics and its influencing factors.
        Chin J Mod Nurs. 2022; 28: 296-301
        • YAN Jing
        • Xin-tao C.H.E.N.
        • Dong-ni M.O.
        • et al.
        Cognitive frailty and its influencing factors in hospitalized elderly patients with hypertension.
        Pract Geriatr. 2021; 35: 727-730
        • Zhao D.
        • Li J.
        • Fu P.
        • et al.
        What Role does activity engagement play in the association between cognitive frailty and falls among older adults? Evidence from Rural Shandong, China.
        Gerontology. 2020; 66: 593-602
        • Wang X.J.
        • Xu Y.
        • Zhou Y.Y.
        • et al.
        Meta-analysis on the incidence of falls among the elderly in Chinese community.
        Chin Evid-Based Nurs. 2020; 6: 1149-1154
        • Moreland B.
        • Kakara R.
        • Henry A.
        Trends in nonfatal falls and fall-related injuries among adults aged ≥65 years - United States, 2012-2018.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 875-881
        • Apóstolo J.
        • Cooke R.
        • Bobrowicz-Campos E.
        • et al.
        Predicting risk and outcomes for frail older adults: an umbrella review of frailty screening tools.
        JBI Database System Rev Implement Rep. 2017; 15: 1154-1208
        • Muir S.W.
        • Gopaul K.
        • Montero Odasso M.M.
        The role of cognitive impairment in fall risk among older adults: a systematic review and meta-analysis.
        Age Ageing. 2012; 41: 299-308
        • Ge M.L.
        • Simonsick E.M.
        • Dong B.R.
        • Kasper J.D.
        • Xue Q.L.
        Frailty, with or without cognitive impairment, is a strong predictor of recurrent falls in a US population-representative sample of older adults.
        J Gerontol A Biol Sci Med Sci. 2021; 76: e354-e360
        • Ge M.
        • Zhang Y.
        • Zhao W.
        • et al.
        Prevalence and its associated factors of physical frailty and cognitive impairment: findings from the West China Health and Aging Trend Study (WCHAT).
        J Nutr Health Aging. 2020; 24: 525-533
        • Lundin-Olsson L.
        • Nyberg L.
        • Gustafson Y.
        "Stops walking when talking" as a predictor of falls in elderly people.
        Lancet. 1997; 349: 617
        • Azadian E.
        • Majlesi M.
        • Jafarnezhadgero A.A.
        The effect of working memory intervention on the gait patterns of the elderly.
        J Bodyw Mov Ther. 2018; 22: 881-887
        • Kearney F.C.
        • Harwood R.H.
        • Gladman J.R.
        • Lincoln N.
        • Masud T.
        The relationship between executive function and falls and gait abnormalities in older adults: a systematic review.
        Dement Geriatr Cogn Disord. 2013; 36: 20-35
        • Rivan N.F.M.
        • Shahar S.
        • Rajab N.F.
        • et al.
        Incidence and predictors of cognitive frailty among older adults: a community-based longitudinal study.
        Int J Environ Res Public Health. 2020; 17: 1547
        • Sazlina S.G.
        • Chan Y.M.
        • Hamid T.A.
        • et al.
        Associations between falls and psychosocial factors, self-rated health, disability and sleep among community dwelling older people in Malaysia[J].
        J Clin Gerontol Geriatr. 2018; 9: 85-90
        • Solfrizzi V.
        • Scafato E.
        • Lozupone M.
        • et al.
        Additive role of a potentially reversible cognitive frailty model and inflammatory state on the risk of disability: the italian longitudinal study on aging.
        Am J Geriatr Psychiatry. 2017; 25: 1236-1248
        • Michaud M.
        • Balardy L.
        • Moulis G.
        • et al.
        Proinflammatory cytokines, aging, and age-related diseases.
        J Am Med Dir Assoc. 2013; 14: 877-882
        • MA Lina
        • Ying L.I.
        Influence of chronic inflammation on physical frailty and cognitive impairment in the elderly.
        J Chin Pract Diagn. 2020; 34: 1078-1080
        • Sink K.M.
        • Espeland M.A.
        • Castro C.M.
        • et al.
        Effect of a 24-month physical activity intervention vs health education on cognitive outcomes in sedentary older adults: The LIFE randomized trial.
        JAMA. 2015; 314: 781-790
        • Zhang Y.
        • Xu X.J.
        • Lian T.Y.
        • et al.
        Development of frailty subtypes and their associated risk factors among the community-dwelling elderly population.
        Aging (Albany NY). 2020; 12: 1128-1140
        • Negm A.M.
        • Kennedy C.C.
        • Thabane L.
        • et al.
        Management of frailty: a systematic review and network meta-analysis of randomized controlled trials.
        J Am Med Dir Assoc. 2019 Oct; 20: 1190-1198
        • Valls-Pedret C.
        • Sala-Vila A.
        • Serra-Mir M.
        • et al.
        Mediterranean diet and age-related cognitive decline: a randomized clinical trial.
        JAMA Intern Med. 2015; 175: 1094-1103
        • Buchman A.S.
        • Yu L.
        • Wilson R.S.
        • Boyle P.A.
        • Schneider J.A.
        • Bennett D.A.
        Brain pathology contributes to simultaneous change in physical frailty and cognition in old age.
        J Gerontol A Biol Sci Med Sci. 2014; 69: 1536-1544
        • Martin K.L.
        • Blizzard L.
        • Srikanth V.K.
        • et al.
        Cognitive function modifies the effect of physiological function on the risk of multiple falls--a population-based study.
        J Gerontol A Biol Sci Med Sci. 2013; 68: 1091-1097