Lifestyle, socioeconomic and biological determinants of survival in Nonagenarians and Centenarians: A systematic review and meta-analysis

Abstract Background and Objectives Identifying factors associated with survival beyond age 90 is essential for understanding healthy aging trajectories. This study sought to investigate the associations between biological, socioeconomic, and lifestyle factors and survival in individuals aged ≥90 years. Research design and Methods Systematic review with meta-analysis. Cohort studies reporting information on lifestyle, socioeconomic and biological determinants of survival in individuals aged ≥90 years (nonagenarians, centenarians, and supercentenarians) were searched in the MEDLINE, EMBASE, and Web of Science databases up to June 2025. Random effects meta-analyses via the empirical Bayes method generated pooled hazard ratios (HRs). Meta-regression and sensitivity analyses were conducted. Results Twenty-three studies were included. Being a woman (HR = 0.83; 95% confidence interval CI, 0.80–0.86), having normal cognition (HR = 0.55; 95%CI, 0.40–0.76), having activities of daily living (ADL) independence (HR = 0.69; 95%CI, 0.63–0.76), having high handgrip strength (HR = 0.69; 95%CI, 0.48–0.99), not smoking (HR = 0.83; 95%CI, 0.74–0.93), and alcohol abstinence (HR = 0.88; 95%CI, 0.78–0.99) were associated with lower mortality. Education level was not significantly associated with survival. Meta-regression revealed no modifying effect of age or follow-up length. Multivariate meta-analysis confirmed the independent contribution of each factor and ranked ADLs (p 0.001), cognition (p 0.001), and handgrip strength (p 0.001) as the top three survival predictors. Discussion and implications Survival in the oldest-old is closely linked to female sex, preserved cognitive and physical function, and healthy lifestyle choices. The consistent predictive value of ADLs, cognition, and handgrip strength highlights the relevance of modifiable factors for promoting longevity, even in advanced age.