Pre-frailty and frailty as predictors of fractures in older adults: an updated systematic review and meta-analysis of over 2.5 million individuals

Background: Frailty is a multidimensional geriatric syndrome linked to adverse outcomes, but its role in predicting fractures remains unclear. We performed a systematic review and meta-analysis to evaluate the association between frailty and fracture risk. Methods: PubMed, Embase, MEDLINE, CINAHL Plus, PsycINFO, Cochrane Library, CNKI, and Wanfang databases were searched up to 28 June 2025 for observational studies assessing frailty (using validated criteria) and fracture outcomes in adults aged ≥60 years. Study quality was appraised using the Newcastle–Ottawa Scale and Agency for Healthcare Research and Quality criteria. Relative risks (RRs) with 95% confidence intervals (CIs) were pooled using random-effects models. Subgroup, meta-regression, sensitivity, and publication bias analyses were conducted. Results: Twenty-six studies involving 2 578 508 participants were included. Frailty was associated with a markedly increased fracture risk (RR = 1.95; 95% CI: 1.79–2.13), compared with pre-frailty (RR = 1.28; 95% CI: 1.18–1.38; P < 0.001). Frailty strongly predicted lower limb (RR = 2.97), upper limb (RR = 2.14), vertebral (RR = 2.24), and hip fractures (RR = 1.95), whereas pre-frailty was associated with hip (RR = 1.36), non-spinal (RR = 1.16), and other fractures (RR = 1.20). Among frailty assessment tools, the electronic Frailty Index (eFI) was the strongest predictor (RR = 2.53). Associations were more pronounced in participants aged >75 years and in studies with longer follow-up. Sensitivity analyses confirmed the robustness of results, although publication bias could not be excluded. Conclusions: Pre-frailty and frailty are independent predictors of fractures in adults aged ≥60 years, with frailty demonstrating substantially stronger associations. Early identification through routine screening, coupled with targeted multidimensional interventions, may reduce fracture risk and improve outcomes in older adults.