Four biological aging markers tracked over 18.25 years in 4,000 Hong Kong adults (mean age 72.5) revealed distinct mortality patterns. Frailty phenotype, clinical deficit index, biochemical-enhanced index (including eGFR, homocysteine, hsCRP, vitamin D), and telomere length each predicted different death risks. Pre-frail individuals faced 24% higher mortality risk, while frail participants showed 66% increased risk. Each standard deviation increase in frailty indices correlated with 22-23% higher death rates, while longer telomeres reduced mortality risk by 7% per standard deviation. This represents the largest long-term study integrating multiple aging biomarkers in Asian populations, addressing a critical gap since most longevity research focuses on Western cohorts. The findings reveal biological aging affects cardiovascular and overall mortality but surprisingly shows no association with cancer deaths, suggesting different aging pathways influence distinct disease processes. While telomere length specifically predicted cardiovascular mortality, frailty measures broadly captured systemic decline. The modest predictive improvements (0.32-7.90% C-index gains) indicate these markers offer incremental rather than transformative risk assessment capabilities. For clinical practice, combining multiple aging biomarkers may enhance personalized intervention strategies, though the practical utility remains limited by modest effect sizes.