Objective To investigate the effect of cognitive frailty (CF) on the risk of arteriovenous fistula (AVF) dysfunction in elderly patients undergoing maintenance hemodialysis (MHD).  Methods A total of 247 patients aged ≥60 years and received MHD at BenQ Medical Center Affiliated to Nanjing Medical University from January to June 2023 were enrolled in this study. According to cognitive status and Montreal Cognitive Assessment scores, patients were divided into CF group (n=94) and non-CF group (n-153). Patients were followed up until May 31, 2025. Bedside Doppler ultrasound examination was performed every 3 months to evaluate AVF status, with AVF dysfunction as the endpoint event. Kaplan-Meier method and COX proportional hazards model were used to analyze the relationship between CF and AVF dysfunction.  Results There were statistically significant differences in age (χ²=37.325, P<0.001), gender (χ²=4.029, P=0.045), marital status (χ²=8.365, P=0.004), average monthly personal income (χ²=12.717, P=0.002), educational level (χ²=11.974, P=0.003), dialysis vintage (χ²=7.283, P=0.026), primary disease (χ²=13.654, P=0.003), regular exercise (χ²=45.527, P<0.001), serum phosphorus (χ²=15.401, P<0.001), albumin (t=4.887, P<0.001), prealbumin (t=6.741, P<0.001), and hemoglobin (t=2.770, P=0.006) between the two groups. The median follow-up duration was 29.7 (29.5, 30.2) months. A total of 64 cases with AVF dysfunction were detected, including 37 cases (39.4%) in the CF group and 27 cases (17.6%) in the non-CF group. The risk of AVF dysfunction was significantly higher in the CF group than in the non-CF group (Log-rank, χ²=14.302, P<0.001). After adjusting confounding factors using the COX proportional hazards model, CF was identified as an independent risk factor for AVF dysfunction (HR=2.015, 95% CI: 1.106～3.670, P=0.022), and the effect  of CF remained after further adjustment of baseline characteristics.  Conclusion CF independently increases the risk of AVF dysfunction in elderly MHD patient, which can serve as a reference indicator for the assessment and nursing intervention of AVF dysfunction risk.