Abstract
BACKGROUND: The risk factors on the transition from robustness to cognitive frailty (CF), characterized by concurrent cognitive impairment and physical frailty (PF), may vary through different transition routes. METHODS: Data from the National Institute for Longevity Sciences-Longitudinal Study of Aging (2000−2012) were analyzed, including data for 1,061 older individuals (baseline age: 60–83 years; 51.5% men) who had a Mini-Mental State Examination (MMSE) score ≥ 24, and were dementia- and CF-free at baseline. Mild cognitive impairment (MCI) was defined as a MMSE score 24–27, PF as ≥ 1 Fried criteria, and CF as both conditions. Dietary diversity (assessed using the Quantitative Index for Dietary Diversity score; 0–1) and energy intake were categorized into sex-specific tertiles (T1–T3). Multistate modeling estimated hazard ratios of risk factors for transitions among robustness (no MCI and PF), MCI, PF, and CF states. RESULTS: At baseline, robustness, MCI, and PF proportions were 36.9%, 14.4%, and 48.7%, respectively. In robust individuals, aging increased (HR = 1.22), and high dietary diversity (HR = 0.62 for T3) and higher energy intake (HR = 0.36 for T2, 0.37 for T3) mitigated MCI risk. Conversely, obesity (HR = 1.37) and smoking (HR = 1.66) elevated, and stroke history (HR = 0.43) and high dietary diversity (HR = 0.63 for T3) lowered PF risk. Among those with MCI, female sex (HR = 1.69) and higher education (HR = 1.75 for 10−12 years, 2.19 for ≥ 13 years) facilitated recovery, while moderate energy intake impeded it (HR = 0.40 for T2). Aging (HR = 1.32), female sex (HR = 2.63), and smoking (HR = 2.91) increased CF risk, whereas moderate energy intake mitigated it (HR = 0.50 for T2). In PF participants, moderate dietary diversity (HR = 1.49 for T2), high energy intake (HR = 1.39 for T3), and alcohol consumption (HR = 1.32) promoted recovery, while depressive symptoms (HR = 0.25) and living alone (HR = 0.58) hindered it. Aging (HR = 1.28) increased CF risk, whereas higher education decreased it (HR = 0.55 for 10−12 years, 0.54 for ≥ 13 years). CONCLUSIONS: Tailoring intervention strategies according to specific health statuses of older adults may prevent and delay CF onset and facilitate recovery from MCI and PF. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12877-025-06295-9.