Perceived Environmental Age Friendliness and Frailty Among Community-Dwelling Older Adults.

Importance: An age-friendly environment (AFE) is a key goal for healthy aging, but its association with frailty in older adults remains unclear. Objective: To examine associations of AFE perception with both frailty onset and transitions among community-dwelling older adults, using a culturally adapted AFE scale. Design, Setting, and Participants: This cohort study was conducted in Shanghai, China, from June to December 2020 (baseline period) through June to November 2023 (follow-up period). Participants 60 years or older were enrolled at baseline and completed baseline and follow-up assessments. Statistical analyses were performed from August to December 2025. Exposures: AFE perception was assessed with the 32-item Age-Friendly Community Evaluation Scale covering 6 domains: housing, transportation, built environment, social participation, social inclusion, and community and health services. Each item was rated on a 5-point Likert scale, yielding total scores ranging from 32 to 160, with higher scores indicating greater perceived community age friendliness. Demographic characteristics, health behaviors, and medical history were included as covariates. Main Outcomes and Measures: Frailty was assessed using the 30-item Frailty Index, which classified participants' frailty status as robust, prefrail, or frail. Frailty transitions included frailty progression (deterioration in frailty or death) or frailty improvement. Results: A total of 4067 participants (mean [SD] age, 71.2 [6.3] years; 2244 women [55.2%]) were included. Over the 3 years of follow-up, 1061 participants (26.1%) experienced frailty progression, while 656 of 1411 participants (46.5%) with baseline prefrail or frail status achieved frailty improvement. After adjusting for covariates, higher standardized AFE scores were associated with lower odds of frailty progression (odds ratio [OR], 0.87; 95% CI, 0.81-0.94; P < .001). Significant inverse associations were observed for all AFE domains (eg, social inclusion: OR, 0.88; 95% CI, 0.82-0.95; P = .001). However, there was no association between AFE scores and frailty improvement. Among 3658 participants with nonfrail status at baseline, 351 (9.6%) developed frailty. Higher standardized AFE scores were associated with lower odds of frailty onset (OR, 0.83; 95% CI, 0.73-0.94; P = .003). All AFE domains (except transportation and built environment) were inversely associated with frailty onset: housing (OR, 0.80; 95% CI, 0.71-0.91; P = .001), social participation (OR, 0.83; 95% CI, 0.74-0.94; P = .003), social inclusion (OR, 0.84; 95% CI, 0.74-0.95; P = .005), and community and health services (OR, 0.88; 95% CI, 0.78-0.99; P = .02). Significant nonlinear associations between AFE scores and frailty transitions or onset were not observed. Subgroup analyses showed that a monthly income less than ¥2000 Chinese yuan renminbi (approximately <US $290) moderated the association between AFE scores and frailty onset (OR, 0.44; 95% CI, 0.28-0.68). Conclusions and Relevance: In this cohort study of community-dwelling older adults, greater perception of an age friendly community environment was associated with reduced risk of frailty. These results suggest that targeted interventions focusing on comprehensive and specific AFE domains may help reduce frailty in this population.