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Data were obtained from the China Health and Retirement Longitudinal Study (CHARLS). A total of 4,060 participants aged\u2009\u2265\u200945 years who were free of diabetes, heart disease, and stroke at baseline were included. The PFI was constructed from 15 items covering psychological distress, cognitive orientation, subjective physical vulnerability, and memory function. Incident CMD was defined as the occurrence of diabetes, heart disease, or stroke during follow-up. Multivariable Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Restricted cubic spline analyses assessed dose\u2013response relationships, and receiver operating characteristic analyses evaluated the incremental predictive value of PFI. During a median follow-up of 24 months, higher PFI was significantly associated with increased risk of incident CMD. In the fully adjusted model, each 0.1-point increase in PFI was associated with higher risks of CMD (HR\u2009=\u20091.16, 95% CI: 1.09\u20131.23), diabetes (HR\u2009=\u20091.13, 95% CI: 1.02\u20131.26), heart disease (HR\u2009=\u20091.14, 95% CI: 1.05\u20131.24), and stroke (HR\u2009=\u20091.43, 95% CI: 1.24\u20131.64). Participants in the highest PFI group had significantly greater risks of CMD and its components than those in the lowest group, with the strongest association observed for stroke. Spline analyses suggested a progressive increase in CMD risk across higher PFI levels. Adding PFI to traditional risk factors significantly improved discrimination for overall CMD and stroke, but not for diabetes or heart disease. Higher PFI was independently associated with incident CMD, particularly stroke, among middle-aged and older adults. PFI may serve as a complementary marker for cardiometabolic risk assessment, especially for identifying individuals at elevated risk of overall CMD and stroke.<\/jats:p>","DOI":"10.1038\/s41598-026-55226-0","type":"journal-article","created":{"date-parts":[[2026,6,12]],"date-time":"2026-06-12T06:56:51Z","timestamp":1781247411000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Higher psychological frailty index is associated with incident cardiometabolic diseases in Chinese adults aged 45 years and older"],"prefix":"10.1038","volume":"16","author":[{"given":"Qian","family":"Gui","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beijia","family":"Liu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yue","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gui","family":"Yu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,12]]},"reference":[{"key":"55226_CR1","doi-asserted-by":"crossref","unstructured":"He, X. et al. 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