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

BACKGROUND: 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. METHODS: 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. FINDINGS: 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. INTERPRETATION: 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.