Heart failure (HF) is an important public health problem characterized by increased morbidity, mortality, and healthcare costs, especially in older populations (Savarese et al., 2023). The management of HF in the elderly is complicated by common comorbidities such as frailty and cognitive impairment (Faulkner et al., 2021). Frailty is a common syndrome in the elderly and is characterized by reduced physiological reserve and increased sensitivity to stressors (X. Chen et al., 2014). Cognitive dysfunction ranges from mild cognitive impairment to dementia and worsens the clinical course of heart failure, leading to poor outcomes (Cannon et al., 2017).

The coexistence of these two conditions results in a distinct clinical entity called cognitive frailty, a particularly vulnerable subgroup of patients (Kelaiditi et al., 2013). Cognitive frailty is increasingly recognized as an important determinant of adverse outcomes, including longer hospital stays, readmissions, and mortality in various populations (B. Chen et al., 2022; Fogg et al., 2019; Zheng et al., 2022). In line with the current state of the art, recent studies have emphasized the multidimensional nature of cognitive frailty, its prognostic significance in cardiovascular populations, and the importance of integrating physical and cognitive assessments into clinical practice (Liu et al., 2025; Wleklik et al., 2025).

Chen et al. (2022) showed that cognitive frailty is associated with longer hospital stays, while Zheng et al. (2022) described cognitive frailty as a condition characterized by additional risk and highlighted the need for targeted interventions in this population. The specific impact of cognitive frailty on elderly HF patients has been understudied despite its clinical relevance, especially with respect to traditional HF risk factors such as NT-proBNP levels, New York Heart Association (NYHA) classification, and comorbidities. Recent studies have identified the individual contributions of these factors (Ráduly et al., 2024; Rullman et al., 2020), finding that NT-proBNP is an important marker of HF severity, while Pagnesi et al. (2024) demonstrated that malnutrition and low body mass index (BMI) are important determinants of poor prognosis in patients with HF.

The interaction of frailty and cognitive impairment on clinical outcomes such as length of hospital stay, readmission and survival has not yet been fully explored. This gap in the literature highlights the need for a comprehensive assessment of cognitive frailty in the context of HF. Previous studies have usually addressed frailty and cognitive impairment separately or in heterogeneous populations, limiting comparability and clinical relevance. Moreover, the underlying interplay between physical and cognitive vulnerability — sometimes referred to as cognitive frailty — has rarely been investigated among patients hospitalized for heart failure. This study adds novel evidence by jointly examining these two geriatric domains within a single prospective cohort of hospitalized heart failure patients. Understanding this interplay may contribute to a better characterization of patient vulnerability and help inform future approaches to post-discharge management.

Therefore, the present study aimed to examine the association between physical frailty, cognitive impairment, and adverse clinical outcomes in older patients hospitalized for heart failure, and to determine whether their coexistence confers an increased risk of prolonged hospital stay, rehospitalization, and mortality during a mid-term (12-month) follow-up period.