BACKGROUND:While many Western countries have reported a declining trend in dementia incidence, epidemiological data on the dementia burden in Chinese populations remain scarce. We aimed to examine the trends in the incidence, prevalence, and mortality of dementia in the older Hong Kong Chinese population from 2005 to 2019. METHODS:Using the territory-wide electronic health record database, we identified all public healthcare service users aged ≥60 years in Hong Kong between 2005 and 2019. The annual incidence and prevalence of dementia were estimated, and time trends were analyzed using joinpoint regression. We matched each dementia case with up to 10 dementia-free controls and compared their 1-year and 5-year mortality risk across the study period using Cox models, adjusted for age, sex, and comorbidities. RESULTS:Among 2,224,854 individuals, 151,511 developed incident dementia during the study period. Age-standardized incidence per 1,000 person-years increased from 7.4 in 2005 to 9.4 in 2010 (annual percent change [APC]: 5.5%; 95% CI: 2.6-10.8) but subsequently declined to 6.3 in 2019 (APC: -3.6%; 95% CI: -5.1 to -2.5), with the most pronounced decrease observed in the oldest-old adults aged ≥80 years. The overall prevalence of dementia increased from 3.9% in 2005 to 4.8% in 2019. Individuals with dementia had significantly higher 1-year (hazard ratio [HR]: 2.92; 95% CI: 2.88-2.96) and 5-year (HR: 2.07; 2.06-2.09) mortality risks; these associations remained consistent throughout the study period. CONCLUSIONS:Dementia incidence has declined substantially after 2010 among older Hong Kong Chinese, particularly in the oldest-old adults. However, dementia prevalence remains high and is strongly associated with increased mortality risk, highlighting the need for continued public health efforts to address its burden.

AIM:This community-based cohort study aimed to examine whether baseline heart diseases predict incident frailty over 20 years. METHODS:A total of 3,998 non-frail adults (2,000 men, 1,998 women) aged ≥65 years were included at study entry. Heart disease was defined as self-reported, medication-verified chronic heart failure, myocardial infarction, or angina pectoris. Frailty was assessed at interval using the FRAIL scale (score ≥3 defining frailty) at baseline and was repeated at: 2-years, 4-years, 14-years, 18-years and finally 20-years follow-up. Cox proportional hazards models, stratified by sex and adjusted for age, diabetes, hypertension, smoking, and BMI, analysed the association between heart disease and time to incident frailty. RESULTS:At baseline, heart disease prevalence was 18.3% in men and 16.5% in women. Over a total follow-up duration of 62,012 person-years, baseline heart disease was demonstrated to be a significant independent predictor of frailty after adjustment for confounders. The risk was greater in men (adjusted hazard ratio [aHR] 1.77, 95% confidence interval [CI]: 1.26-2.48, p 0.001) than in women (aHR 1.34, 95% CI: 1.00 - 1.80; p=0.048) CONCLUSIONS: Heart diseases, apart from being a primary driver of mortality, are significant independent predictors of incident frailty in older adults, with a stronger effect observed in men. This highlights the need for frailty screening and preventive strategies in older patients with heart disease.

Background: The progression of cognitive decline is accelerated in older adults with sarcopenia, but the protective dietary factors have remained uncertain. Objective: This study aims to investigate the association between dietary factors and cognitive decline in older adults, and to explore the potential mediating effects of sarcopenic components. Methods: Data from the Mr. OS and Ms. OS cohort study in Hong Kong (N = 3146, aged ≥65 years) were used. Cognitive function was assessed based on the Mini-Mental State Examination (MMSE). Sarcopenic status was assessed according to the Asian Working Group for Sarcopenia 2019 updated consensus. Dietary protein intake and adherence to dietary patterns were assessed using a food frequency questionnaire. Linear regression was used to examine the associations between dietary factors and MMSE scores. Mediation analysis was conducted to identify the possible mediators in the diet–cognition associations. Results: Sarcopenia and its components were associated with baseline MMSE and MMSE changes. Positive associations were observed for plant protein intake (β = 0.79, 95% CI 0.24–1.35) and dietary patterns such as the Dietary Approaches to Stop Hypertension (DASH) diet (β = 0.14, 95% CI 0.02–0.26) and diets with lower Dietary Inflammatory Index (DII) scores (β = −0.18, 95% CI −0.26–−0.09) with better MMSE outcomes. Protective effects were more profound in participants with sarcopenia/severe sarcopenia. The effects of the DASH diet and DII were more profound in female participants, while higher adherence to the Mediterranean–DASH Intervention for Neurodegenerative Delay (MIND) diet was associated with an increment in MMSE score in male participants with sarcopenia. Handgrip strength and physical performance are significant mediators in the diet–cognition associations. Conclusions: The protective effects of healthy dietary patterns were beneficial, especially for participants with sarcopenia, while handgrip strength and walking speed potentially mediated the associations.

BACKGROUND:Whether survival at extreme ages can be accurately predicted remains unclear. This study explored the feasibility of using machine learning (ML) and electronic health records (EHRs) to predict mortality in centenarians and identify key survival determinants. METHODS:We analyzed 9718 centenarians (83% women) from the population-based EHR database in Hong Kong (2004-2018). Data were randomly split into 70% training and 30% testing cohorts. Using 82 predictors, including demographics, diagnoses, prescriptions, and laboratory results, we trained stepwise logistic regression and four ML algorithms to predict 1-year, 2-year, and 5-year all-cause mortality after age 100. Model performance was evaluated using discrimination (area under the receiver operating characteristic curve [AUROC]) and calibration metrics. In an independent cohort of 174 606 oldest-old adults aged 85-105 years, we further compared AUROCs of models incorporating the identified predictors versus comorbidity and frailty scores across different age groups. RESULTS:Among the ML models, eXtreme Gradient Boosting algorithm provided the best performance, with AUROCs of 0.707 (95% CI = 0.685-0.730) for 1-year mortality and 0.704 (0.686-0.723) for 2-year mortality in the testing cohort. However, all models showed poor calibration for 5-year mortality. Top three predictors of mortality included lower albumin levels, more frequent hospitalizations, and higher urea levels. Models including these predictors consistently outperformed comorbidity and frailty for mortality prediction among oldest-old adults. CONCLUSIONS:Utilizing ML models and routinely collected EHRs can predict short-term survival in centenarians with moderate accuracy. Further research is needed to determine whether mortality predictors differ across age in the oldest-old population.

BACKGROUND:Electronic health record (EHR) has been in place in many parts of the world. This fits in very well to the frailty index calculation proposed by Rockwood and thus a frailty index can potentially be generated automatically from an EHR database. Therefore, the Hong Kong Hospital Authority (HA) attempted to develop an electronic frailty index (HK eFI), by employing thirty-eight health variables from her own EHR database. METHODS:Five cohorts of patients aged 60 years or above ever attended any services provided by the Hong Kong HA in the year 2015, 2016, 2017, 2018 and 2019, were included. The HK eFI trajectory with ageing, generated by the five cohorts, were compared to the one described by Rockwood's group. Following the UK eFI method, 4 levels of frailty were categorized, and they were examined whether they were related to mortality, readmission rate and hospitalization patient days. RESULTS:Each successive cohort consisted of increasing number of patients aged 60 years or above. (2015, 1.14 million; 2016, 1.19 million; 2017,1.25 million; 2018, 1.31 million; 2019, 1.38 million). The gradients of the five trajectories ranged from 0.035 to 0.037, representing an increase in FI approximately 3.6 % annually. The intercept of the curves converged at 0.1, representing the FI at age 60 years was 0.1. Compared to the fit group, the adjusted hazard ratios of mortality of the mild, moderate and severe frail group were 1.77, 3.31 and 6.65 respectively and they were all statistically higher than the fit group. (p < 0.005) Likewise, there was a stepwise increase in readmission rate and hospital patient days utilization with increasing frailty levels. CONCLUSION:It is feasible to develop an eFI and a biological age trajectory from a large EHR database with local adaptation.

Biological aging (BA) markers such as frailty and telomere length are closely linked to cognitive impairment (CI). However, the incremental value of biochemical marker-enriched frailty index (FI) and telomere length for predicting CI remains underexplored. We aimed to assess the incremental value of BA markers beyond conventional cognitive tests for CI risk stratification. A total of 1674 community-dwelling older adults without baseline CI were obtained from the Mr. OS Ms. OS (Hong Kong) cohort. Baseline BA measures included frailty phenotype, three FI versions (without/with 2 or 4 serum biochemical markers: creatinine, homocysteine, high-sensitivity C-reactive protein, and 25-hydroxyvitamin D), and leukocyte telomere length. CI was assessed by concurrently using the MMSE and CSI-D tests at the 7-year follow-up. Penalized logistic regression was used to evaluate the incremental value of BA indicators beyond cognitive tests for CI prediction, with the area under the precision-recall curve (AUPRC) as the primary performance metric. The mean age of the study sample was 70.7 years (SD: 4.2), and 44.1

Background Frailty and chronic inflammatory diseases are known risk factors for adverse outcomes and have been associated with epigenetic age acceleration (EAA), a quantitative estimation of biological age based on DNA methylation. We investigated the interrelationships between EAA, atherogenic dyslipidaemia and frailty; determined the best performing epigenetic clock for EAA estimation of atherosclerotic cardiovascular disease (ASCVD) risks; and prospectively analysed the capacity of EAA to predict future adverse outcomes. Methods A structured cardiogeriatric evaluation including frailty and physical capacity assessment was performed in community-living older adults aged 60 years or above who met predefined eligibility criteria and had no previous history of heart failure. We prioritised the selection of all available frail older adults from our bioresource and used computerised randomisation to select the more abundant robust and pre-frail individuals for relatively balanced analyses among groups. DNA methylation analysis was performed using the Infinium MethylationEPIC platform. Quantitative proton-nuclear magnetic resonance (NMR) was used for targeted metabolomic analysis of serum. Five common epigenetic clocks were compared for associations with frailty, systemic inflammation, lipid-metabolome and prediction of incident adverse outcomes. Clinical outcomes were queried using electronic medical record systems and by interview. Findings Among 535 older adults, GrimAge 2-estimated EAA (Grim2AA) performed best in classifying and predicting the frailty phenotype. Grim2AA was significantly associated with systemic inflammation indicated by GlycA, increased risk of ASCVD comorbidities, and an atherogenic lipid profile characterised by reduced low-density lipoprotein (LDL) particle size and abnormal triglycerides in lipoproteins. Small LDL particle size but not other lipid/lipoprotein features were also associated with frailty. Of the five epigenetic clocks analysed and benchmarked against the ACC/AHA ASCVD Risk Calculator, Grim2AA was the most strongly associated. For each 10-year increment in Grim2AA, the risk was estimated at 4.92% (p=0.0002). During a median follow-up of 4.68 years, 55 all-cause deaths occurred and 101 individuals experienced cardiovascular hospitalisation. Analysis of cardiovascular hospitalisation revealed marked differences in EAA depending on the cause, and pointed to ASCVD (excluding stroke) as being most common with the highest median Grim2AA at 0.73 years. Kaplan-Meier analysis did not show a difference in the rates of cardiovascular hospitalisation between Grim2AA greater than or equal to 0 and <0 years (p=0.19). However, the rates of ASCVD hospitalisation (42 of 101) were significantly higher in older adults with the former (p=0.0027). Interpretation As the most comprehensive targeted analysis of blood lipid-metabolome and DNA methylation-based epigenetic clock to date, this study has linked frailty, inflammageing, atherogenic dyslipidaemia and ASCVD risks that can be collectively indicated by Grim2AA in older adults. Grim2AA is an independent predictor of future ASCVD hospitalisation, and may serve as a potential biomarker for monitoring disease trajectory and target for secondary prevention. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Research Grants Council General Research Fund (GRF) no. 2141212. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Clinical Research Ethics Committee of the Joint Chinese University of Hong Kong-New Territories East Cluster gave ethical approval for this work (no.2017.286). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors.

Heart failure (HF) is a clinical syndrome associated with a range of pathophysiological disorders, including secondary sarcopenia that reduces patients’ quality of life, mobility, physical fitness, and capacity to undergo rehabilitation and recovery from acute decompensation. Although international expert writing groups have convened and developed consensus documents for sarcopenia, the vast majority of the content has focused on the disorder from the aging perspective. HF is rarely or never considered in the available consensus statements and recommendations. Moreover, there are differences in the sarcopenia diagnostic criteria pertaining to race/ethnicity (translating into differences in body composition and anthropometry), investigative methodologies, practice patterns, and variations in access to health care resources across nations that are not discussed in the current HF-management guidelines. Here, we review the key contents of the recent major international consensus documents concerning sarcopenia that were published between 2019 and 2024. We highlight the gaps in knowledge (eg, sarcopenic obesity, cardiac atrophy/wasting) and recent developments in HF treatment (eg sodium glucose co-transporter 2 inhibitors) and interventions (eg, rehabilitation, inspiratory muscle training) that may benefit sarcopenia; and we reformulate the 4-step pathway of early screening, investigation, diagnosis and severity determination (Find-Assess-Confirm-Severity) for sarcopenia as a vital part of HF management under a multidisciplinary care team.

Background: Dementia often seen in people aged ≥65y years is a major public health burden in Hong Kong, as its men and women have one of the longest lifespan worldwide. Using territory wide electronic health records (EHRs) spanning >20 years, we investigated the impact of cardiometabolic comorbidities on dementia risk. Methods: EHRs of public hospitals provided by Hong Kong’s Hospital Authority (HADCL) were examined for patient visits from 01/01/2000 to 12/31/2020. Included were individuals born in 1920,1930,1940,1950 with ICD-10 codes for all-cause dementia, or use of dementia and/or psychotropic drugs. Atrial fibrillation, stroke, hypertension, myocardial infarction, diabetes mellitus, chronic kidney disease, and hyperlipidemia identified by ICD codes or dispensed diabetic drug(s) or dihydropyridine calcium channel blocker (for hypertension) were investigated for age-dependent association with dementia using landmark analysis with multivariate Cox models. Results: A total of 222,418 patients (49% female) in four birth cohorts were examined with landmark analysis, which showed similar incidences for dementia. Adjusted for multiple testing, increased risk of all-cause dementia stratified by birth cohorts were significantly associated with hypertension and stroke from age 65, diabetes from age 50, and chronic kidney disease among men from age 58–64 (Figure). Earlier onset of these comorbidities except for hypertension were associated with increased dementia risk. Moreover, while the risk of dementia declined with old age in patients with diabetes, the risk for dementia markedly increased with hypertension after age 80. Surprisingly, the most recent birth cohorts, especially males, showed dementia risk elevation with diabetes, stroke and chronic kidney disease. Conclusion: We showed hypertension is a major risk for dementia in men/women >80 years, indicating hypertension management is critical for dementia risk reduction in the aged. The increase in dementia risk with stroke, diabetes, and chronic renal disease in the recent birth cohorts indicates disease burden acceleration predicting increase in economic burden. Further studies are warranted to investigate possible epigenetic mechanisms modulating dementia risk.

Anaemia is a common comorbid condition in older patients admitted to hospitals. Currently, anaemia in older adults is attributed to three major causes: nutritional deficiencies, anaemia of inflammation (AI), and unexplained anaemia of ageing (UAA) [1].

Chronic diseases often lead to metabolic disorders, causing anabolic resistance and increased energy consumption, which result in cachexia. Cachexia, in turn, can lead to major clinical consequences such as impaired quality of life, shortened life expectancy, and increased healthcare expenditure. Existing international diagnostic criteria for cachexia employ thresholds derived from Western populations, which may not apply to Asians due to differing body compositions. To address this issue, the Asian Working Group for Cachexia (AWGC) was initiated. The AWGC comprises experts in cachexia research and clinical practice from various Asian countries and aims to develop a consensus on diagnostic criteria and significant clinical outcomes for cachexia in Asia. The AWGC, composed of experts in cachexia research and clinical practice from several Asian countries, undertook three‐round Delphi surveys and five meetings to reach a consensus. Discussions were held on etiological diseases, essential diagnostic items for cachexia, including subjective and objective symptoms and biomarkers, and significant clinical outcomes. The consensus highlighted the importance of multiple diagnostic factors for cachexia, including chronic diseases, either or both weight loss or low body mass index, and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C‐reactive protein levels (>5 mg/L [0.5 mg/dL]). The AWGC proposed a significant weight change of 2% or more over a 3–6 month period and suggested a tentative cut‐off value of 21 kg/m 2 for low body mass index in diagnosing cachexia. Critical clinical outcomes were determined to be mortality, quality of life as assessed by tools such as EQ‐5D or the Functional Assessment of Anorexia/Cachexia Therapy, and functional status as measured by the Clinical Frailty Scale or Barthel Index, with significant emphasis on patient‐reported outcomes. The AWGC consensus offers a comprehensive definition and user‐friendly diagnostic criteria for cachexia, tailored specifically for Asian populations. This consensus is set to stimulate future research and enhance the multidisciplinary approach to managing cachexia. With plans to develop further guidelines for the optimal treatment, prevention, and care of cachexia in Asians, the AWGC criteria are expected to drive research across chronic co‐morbidities and cancer in Asia, leading to future refinement of diagnostic criteria.

Older patients are vulnerable to complications from hospitalisation, particularly during the COVID-19 pandemic.We report four cases of complications (psychological distress, deconditioning and pressure injuries, delirium, and poor feeding) that occurred during the stay in the community treatment facility.These complications are common and tend to be overlooked during the pandemic because of the isolation policy with decreased contact between healthcare workers and patients, increased patient load, and shortage of healthcare manpower.The usual preventive measure should be implemented despite the difficulties during the pandemic.Early mobilisation with decreased bedrest and early discharge arrangement should be considered once medical condition stabilised and isolation period completed.

In recent years, we have faced challenges in managing coronavirus disease 2019 (COVID-19), especially in older adults. The pandemic has precipitated a global health crisis that impeded older adults from maintaining their health. Disruption of the routine management of chronic diseases, physical inactivity deteriorating physical function and quality of life, malnutrition, and mental disorders have been suggested as major threats to the health of older adults. To address these problems and facilitate reactivation of normal care activities, this article summarizes the contents of a webinar held by the Annals of Geriatric Medicine and Research (AGMR) regarding the future directions of geriatric medicine and research in the post-COVID-19 era.

Annals of Geriatric Medicine and Research held its inaugural international editorial board virtual meeting on September 16, 2021, to brainstorm ideas for sustainable growth. This special article summarizes the key concepts obtained from the webinar proceedings, with further development of ideas from ensuing discussions occurring after the meeting. From the initial discussion points provided by eight editorial board members, including six presenters, email discussions further enriched these ideas to construct the current special article. The key points discussed were: impactful research and impact factors, international and Asian perspectives, and challenges to sustainable growth. The editors noted the existing gap between the impact factor and research impact as a challenge for the growth paths of regional journals. However, they agreed that persevering with impactful research would ultimately translate into parallel and gradual gains in impact, which is, therefore, consistent with the organic growth of the journal. Acknowledging challenges in navigating between unique Asian perspectives and international outlooks, the editors encouraged academic journals to serve as bridges linking international evidence with the richness of local perspectives. For sustainable growth, the editors suggested that journals may be forged into the academic ecosystems of the region, diversify value streams, and establish themselves as reputable brands in disciplines. By combining these discussions, we proposed the "IMPACT" strategy for journals on the growth path in the region, which stands for IMmersive user experience encompassing authors, reviewers, and readers; Pasteur's quadrant use-inspired research; Asia-Pacific context; Collaborative; and Translation to practice and policy.

Coronavirus disease 2019 (COVID-19) disproportionately affects older people in Hong Kong. In Hong Kong, as of 17 July 2020, of the 10 recorded mortalities, seven involved patients aged ≥70 years. Social distancing as a strategy to limit the spread of COVID-19 has restricted the access to health and community services and has induced social isolation for older people. Hospital practice became less elderly friendly when infection control took priority over humanistic considerations. In 2004, The Hong Kong Geriatrics Society published a position statement on management of older patients with severe acute respiratory syndrome. Those guidelines were also followed during the current COVID-19 pandemic. Herein, we report our experience of caring for older people in Hong Kong during the COVID-19 pandemic, including the effect on older people of restricted access to health and community services, infection control measures in residential care homes for the elderly, treatment of older patients after admission to hospitals, end-of-life care, and the emergence of telecare.

In this issue of the Asian Journal of Gerontology and Geriatrics, The Hong Kong Geriatrics Society, represented by a group of geriatricians, describe the situation of older patients in Hong Kong.1 The article is a joint effort from a group of geriatricians working in the public sector in Hong Kong. The article was prepared after the second wave of coronavirus disease 2019 (COVID-19), in July 2020, and at the emergence of the third wave. Because of the rapidly changing situation, some of the information and views in that article need to be updated and supplemented. Despite this, when intensive care beds or ventilators are scarce, these older patients are selected out because of their premorbid conditions leading to adverse treatment outcomes.

Frailty is a condition indicating a reduced reserve in multiple systems and their disconnections. The whole body system cannot repair or recover by itself and may go into irreversible decline should interventions not be carried out early. This review discusses frailty in terms of the conceptual framework, pathophysiology, measurement and identification, lifecourse trajectory, and clinical application of assessment. It is anticipated that clinical application of the electronic frailty index expands to various specialties beyond geriatric medicine.

Clinical and research interest in sarcopenia has burgeoned internationally, Asia included. The Asian Working Group for Sarcopenia (AWGS) 2014 consensus defined sarcopenia as "age-related loss of muscle mass, plus low muscle strength, and/or low physical performance" and specified cutoffs for each diagnostic component; research in Asia consequently flourished, prompting this update. AWGS 2019 retains the previous definition of sarcopenia but revises the diagnostic algorithm, protocols, and some criteria: low muscle strength is defined as handgrip strength <28 kg for men and <18 kg for women; criteria for low physical performance are 6-m walk <1.0 m/s, Short Physical Performance Battery score ≤9, or 5-time chair stand test ≥12 seconds. AWGS 2019 retains the original cutoffs for height-adjusted muscle mass: dual-energy X-ray absorptiometry, <7.0 kg/m2 in men and <5.4 kg/m2 in women; and bioimpedance, <7.0 kg/m2 in men and <5.7 kg/m2 in women. In addition, the AWGS 2019 update proposes separate algorithms for community vs hospital settings, which both begin by screening either calf circumference (<34 cm in men, <33 cm in women), SARC-F (≥4), or SARC-CalF (≥11), to facilitate earlier identification of people at risk for sarcopenia. Although skeletal muscle strength and mass are both still considered fundamental to a definitive clinical diagnosis, AWGS 2019 also introduces "possible sarcopenia," defined by either low muscle strength or low physical performance only, specifically for use in primary health care or community-based health promotion, to enable earlier lifestyle interventions. Although defining sarcopenia by body mass index-adjusted muscle mass instead of height-adjusted muscle mass may predict adverse outcomes better, more evidence is needed before changing current recommendations. Lifestyle interventions, especially exercise and nutritional supplementation, prevail as mainstays of treatment. Further research is needed to investigate potential long-term benefits of lifestyle interventions, nutritional supplements, or pharmacotherapy for sarcopenia in Asians.