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Introduction/background: Frailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty., Purpose: The purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium., Methods: A retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder., Main Outcomes and Measures: Frailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview., Results: A total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI <0.25, n=56 (26%)), pre-frail (FI =0.25-0.35, n=86 (39%)), and frail (FI >0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, p =0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, p =0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium., Conclusion: This study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium., Competing Interests: This paper/was presented at the 2019 Gerontological Society of America Annual Meeting as a poster presentation with interim findings entitled “The Association of a Frailty Index and Incident Delirium in Hospitalized Veterans”. The conference abstract was published in Innovations In Aging with DOI: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6845397/]. Dr Culley reports grants from NIGMS, during the conduct of the study; personal fees from American Society of Anesthesiology, personal fees from American Board of Anesthesiology, outside the submitted work. Dr. Arora reports an unrestricted educational grant from Pfizer Canada Inc. and honoraria from Abbott Nutrition, and honorarium from Edwards Lifesciences, outside the submitted work. Dr Rudolph reports being an unpaid board member of the American Delirium Society - a professional society dedicated to the advancement of delirium science. The authors report no other potential conflicts of interest for this work., (© 2020 Sillner et al.)