Frailty and socioeconomic status: a systematic review

  • Jiunn Wang
    University of Exeter Medical School, Exeter, United Kingdom.
  • Claire Hulme
    University of Exeter Medical School, Exeter, United Kingdom.


The relationship between frailty and socioeconomic status has been widely explored in the literature. A deeper understanding toward the underlying mechanism is required to further assist policy makers in reducing the inequalities. The objective of this study is to systematically review evidence investigating the direct relationship between frailty and socioeconomic status. The review was conducted following the principles of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Among the included studies, 52.38% explored the pattern of frailty in age and 42.86% explored mediators as the pathway variables. With various measures and methodologies, included studies did not point to the same conclusions. In terms of the pattern of frailty in age, we found evidence for the age as leveller hypothesis, the status maintenance hypothesis and the cumulative advantage hypothesis. The included mediators differed across studies. However, we found that these mediators can be categorised into behaviours, health, social factors, material resources and mental status. These categories indicate the important aspects to consider for policies aiming at reducing the inequalities in frailty. To obtain a full picture of the underlying mechanism, future research should harmonise different measures for frailty and socioeconomic indicators and apply more comprehensive sets of mediators.


Clegg A, Bates C, Young J, et al. Development and validation of an electronic frailty index using routine primary care electronic health record data. Age Ageing 2016;45:353-60. DOI:

Kojima G, Iliffe S, Walters K. Frailty index as a predictor of mortality: a systematic review and meta-analysis. Age Ageing 2018;47:193-200. DOI:

Hoogendijk EO, Heymans MW, Deeg DJ, Huisman M. Socioeconomic inequalities in frailty among older adults: results from a 10-year longitudinal study in the Netherlands. Gerontology 2018;64:157-64.

Alvarado BE, Zunzunegui MV, Béland F, Bamvita JM. Life course social and health conditions linked to frailty in latin american older men and women. J Gerontol A Biol Sci Med Sci 2008;63:1399-406. DOI:

Arrighi Y, Rapp T, Sirven N. The impact of economic conditions on the disablement process: A Markov transition approach using SHARE data. Health Policy 2017;121:778-85. DOI:

Franse CB, Van Grieken A, Qin L, et al. Socioeconomic inequalities in frailty and frailty components among community-dwelling older citizens. PLoS One 2017;12:e0187946. DOI:

Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res 2011;2011:569194. DOI:

Gill TM, Baker DI, Gottschalk M, et al. A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med 2002;347:1068-74. DOI:

Ng TP, Feng L, Nyunt MSZ, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med 2015;128:1225-36. DOI:

Halfon M, Phan O, Teta D. Vitamin D: a review on its effects on muscle strength, the risk of fall, and frailty. BioMed Res Int 2015;2015:953241. DOI:

Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-M57. DOI:

Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of aging. ScientificWorldJournal 2001;1:323-36. DOI:

George LK. The Life Course Perspective. In: Gu D, Dupre ME, editors. Encyclopedia of Gerontology and Population Aging. Cham: Springer; 2019. p. 1-9. DOI:

Stolz E, Mayerl H, Waxenegger A, et al. Impact of socioeconomic position on frailty trajectories in 10 European countries: evidence from the Survey of Health, Ageing and Retirement in Europe (2004–2013). J Epidemiol Community Health 2017;71:73-80. DOI:

Brown TH, Richardson LJ, Hargrove TW, Thomas CS. Using multiple-hierarchy stratification and life course approaches to understand health inequalities: The intersecting consequences of race, gender, SES, and age. J Health Soc Behav 2016;57:200-22. DOI:

Kim J, Durden E. Socioeconomic status and age trajectories of health. Soc Sci Med 2007;65:2489-502. DOI:

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 2009;62:1006-12. DOI:

Von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg 2014;12:1495-9. DOI:

Brunner EJ, Shipley MJ, Ahmadi-Abhari S, et al. Midlife contributors to socioeconomic differences in frailty during later life: a prospective cohort study. Lancet Public Health. 2018;3:e313-e22. DOI:

Gardiner PA, Mishra GD, Dobson AJ. The effect of socioeconomic status across adulthood on trajectories of frailty in older women. J Am Med Dir Assoc 2016;17:372.e1-3. DOI:

Hajizadeh M, Mitnitski A, Rockwood K. Socioeconomic gradient in health in Canada: Is the gap widening or narrowing? Health Policy 2016;120:1040-50. DOI:

Rodriguez Lopez S, Montero P, Carmenate M. Educational inequalities and frailty in Spain: What is the role of obesity? J Frailty Aging 2014;3:120-5.

Etman A, Kamphuis CBM, Van Der Cammen TJM, et al. Do lifestyle, health and social participation mediate educational inequalities in frailty worsening? Eur J Public Health. 2015;25:345-50. DOI:

Stolz E, Mayerl H, Waxenegger A, Freidl W. Explaining the impact of poverty on old-age frailty in Europe: material, psychosocial and behavioural factors. Eur J Public Health 2017;27:1003-9. DOI:

Uccheddu D, Gauthier AH, Steverink N, Emery T. Gender and socioeconomic inequalities in health at older ages across different European welfare clusters: Evidence from SHARE data, 2004-2015. Eur Sociol Rev 2019;35:346-62. DOI:

Chaudhary M, Chowdhary R. Age and socioeconomic gradients in frailty among older adults in India. J Public Health 2019;27:675-85. DOI:

Hoogendijk EO, Rijnhart JJM, Kowal P, et al. Socioeconomic inequalities in frailty among older adults in six low- and middle-income countries: Results from the WHO Study on global AGEing and adult health (SAGE). Maturitas 2018;115:56-63. DOI:

Hoogendijk EO, Heymans MW, Deeg DJH, Huisman M. Socioeconomic inequalities in frailty among older adults: Results from a 10-year longitudinal study in the Netherlands. Gerontology 2018;64:157-64. DOI:

Hoogendijk EO, van Hout HPJ, Heymans MW, et al. Explaining the association between educational level and frailty in older adults: Results from a 13-year longitudinal study in the Netherlands. Ann Epidemiol 2014;24:538-44.e2. DOI:

Huibregtse BM, Newell-Stamper BL, Domingue BW, Boardman JD. Genes related to education predict frailty among older adults in the United States. J Gerontol B Psychol Sci Soc Sci 2019:gbz092. DOI:

Yang Y, Lee LC. Dynamics and heterogeneity in the process of human frailty and aging: Evidence from the U.S. older adult population. J Gerontol B Psychol Sci Soc Sci 2010;65:246-55. DOI:

Kim HJ, Park S, Park SH, et al. The significance of frailty in the relationship between socioeconomic status and health-related quality of life in the Korean community-dwelling elderly population: mediation analysis with bootstrapping. Qual Life Res 2017;26:3323-30. DOI:

Soler-Vila H, García-Esquinas E, León-Muñoz LM, et al. Contribution of health behaviours and clinical factors to socioeconomic differences in frailty among older adults. J Epidemiol Commun Health 2016;70:354-60. DOI:

Marshall A, Nazroo J, Tampubolon G, Vanhoutte B. Cohort differences in the levels and trajectories of frailty among older people in England. J Epidemiol Commun Health 2015;69:316-21. DOI:

Chamberlain AM, St Sauver JL, Jacobson DJ, et al. Social and behavioural factors associated with frailty trajectories in a population-based cohort of older adults. BMJ Open 2016;6:e011410. DOI: