Falls and frailty transitions in older adults: A multi-state analysis of a national longitudinal cohort

Falls and frailty are common, interrelated conditions and major contributors to disability and mortality. While frailty is a recognized risk factor for falls, less is known about whether falls influence subsequent frailty transitions. We examined the association between falls and transitions across frailty states and mortality in community-dwelling older adults.

We analyzed longitudinal data from the China Health and Retirement Longitudinal Study (2011-2020). Participants aged ≥60 years with at least two survey waves were included. Frailty was assessed using a 32-item frailty index and categorised as robust, pre-frail, frail, and death (absorbing state). Falls were treated as a time-varying exposure. Frailty transitions were modelled using a multi-state survival framework with transition-specific incidence rate ratios (IRRs), adjusting for sociodemographic factors, health behaviors and pain.

Among 12,501 participants (44,129 observations), falls were associated with adverse frailty transitions. Falls were associated with increased progression from robust to pre-frail (IRR 1.18, 95% CI 1.09-1.27) and pre-frail to frail (1.51, 1.42-1.60), reduced recovery, and higher mortality from pre-frail and frail states. Similar but generally stronger associations were observed for injurious falls. Women accumulated frailty more rapidly over time, whereas men experienced higher mortality, particularly following a fall. Chronic pain, older age, and socioeconomic disadvantage further accelerated frailty progression.

Falls represent clinically actionable sentinel events in the frailty life-course, accelerating transitions toward disability and long-term care needs. Integrating falls prevention and post-fall rehabilitation within frailty care pathways may slow functional decline and improve healthy ageing outcomes.