Multimorbidity patterns and cognitive trajectories in older adults: functional, behavioral, and environmental pathways—a longitudinal analysis of CHARLS

Yanhui Jiao; Xiaohui Zhai; Jiaxin Li; Xiaohan Sun; Qing Li

doi:10.54254/3049-5458/2026.35878

Article Information

Received: 27 July 2026

Published: 10 August 2026

DOI: https://doi.org/10.54254/3049-5458/2026.35878

Article Type: Research Article

Cite this article

Jiao,Y.;Zhai,X.;Li,J.;Sun,X.;Li,Q. (2026). Multimorbidity patterns and cognitive trajectories in older adults: functional, behavioral, and environmental pathways—a longitudinal analysis of CHARLS. Journal of Clinical Technology and Theory,4(4),91-117.

Data availability

The datasets used and/or analyzed during the current study will be available from the authors upon reasonable request.

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Journal: Journal of Clinical Technology and Theory

Volume: Vol.4, Issue 4

ISSN: 3049-5458 (Print) / 3049-5466 (Online)

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[1]United Nations Department of Economic and Social Affairs Population Division. (2019).World population ageing 2019: Highlights. ST/ESA/SER.A/430.

[2]Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: An analysis for the Global Burden of Disease Study 2019. (2022).Lancet Public Health, 7(2), e105–e125.

[3]Zhou, Y., You, Y., Zhang, Y., Zhang, Y., Yuan, C., & Xu, X. (2025). Multimorbidity and risk of dementia: A systematic review and meta-analysis of longitudinal cohort studies.Journal of Prevention of Alzheimer's Disease, 12(7), 100164.

[4]Stirland, L. E., González-Saavedra, L., Mullin, D. S., Ritchie, C. W., Muniz-Terrera, G., & Russ, T. C. (2020). Measuring multimorbidity beyond counting diseases: Systematic review of community and population studies and guide to index choice.BMJ, 368, m160.

[5]Palmese, F., Remelli, F., Dekhtyar, S., Grande, G., Marengoni, A., & Calderón-Larrañaga, A. (2026). Multimorbidity patterns and mental health in late life: A systematic review of longitudinal studies.European Geriatric Medicine, 17(2), 465–487.

[6]Wei, M. Y., Levine, D. A., Zahodne, L. B., Kabeto, M. U., & Langa, K. M. (2020). Multimorbidity and cognitive decline over 14 years in older Americans.Journals of Gerontology: Series A, Biological Sciences and Medical Sciences, 75(6), 1206–1213.

[7]Ojijieme, N. G., & Xiao, L. (2026). Multimorbidity and functioning disparities in retired older adults: Longitudinal trajectories, disease clusters, and mediating mechanisms.BMC Geriatrics, 26(1), 698.

[8]Chen, C., Zhang, S., Huang, N., Zhang, M., Fu, J., & Guo, J. (2024). Effects of physical multimorbidity on cognitive decline trajectories among adults aged 50 years and older with different wealth status: A 17-year population-based cohort study.Global Mental Health (Cambridge), 11, e131.

[9]Liu, C., Shu, R., Liang, H., & Liang, Y. (2022). Multimorbidity patterns and the disablement process among public long-term care insurance claimants in the city of Yiwu (Zhejiang Province, China).International Journal of Environmental Research and Public Health, 19(2).

[10]Posis, A. I. B., Shadyab, A. H., Parada, H., Alcaraz, J. E., Kremen, W. S., & McEvoy, L. K. (2024). Multimorbidity, social engagement, and age-related cognitive decline in older adults from the Rancho Bernardo Study of Healthy Aging.Journal of Alzheimer's Disease, 97(4), 1689–1702.

[11]Zhang, Y., Zhou, Y., Kivimäki, M., Holt-Lunstad, J., Carrillo-Larco, R. M., & Xu, X. (2025). Cardiometabolic multimorbidity, social activity, and joint trajectories of physical disability, depressive symptom, and cognitive function in mid-to-late life: A multicohort study.BMC Medicine, 23(1), 577.

[12]Luo, H., Hu, H., Zheng, Z., Sun, C., & Yu, K. (2024). The impact of living environmental factors on cognitive function and mild cognitive impairment: Evidence from the Chinese elderly population.BMC Public Health, 24(1), 2814.

[13]Qin, A., Wang, M., Chen, Y., Fu, Z., & Sun, L. (2026). Household fuel use, social engagement, and cognitive decline in older Chinese adults: A prospective cohort study based on CHARLS.BMC Geriatrics, 26(1), 176.

[14]Zhao, Y., Hu, Y., Smith, J. P., Strauss, J., & Yang, G. (2014). Cohort profile: The China Health and Retirement Longitudinal Study (CHARLS).International Journal of Epidemiology, 43(1), 61–68.

[15]Wei, J., Li, Z., Lyapustin, A., Sun, L., Peng, Y., Xue, W., Su, T., & Cribb, M. (2021). Reconstructing 1-km-resolution high-quality PM2.5 data records from 2000 to 2018 in China: Spatiotemporal variations and policy implications.Remote Sensing of Environment, 252, 112136.

[16]von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., & Vandenbroucke, J. P. (2014). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies.International Journal of Surgery, 12(12), 1495–1499.

[17]Zhang, Z., Cai, Z., Li, C., Liu, S., Li, S., Liu, L., Yang, J., & Wang, Y. (2025). Spatiotemporal trend of sensory impairments in China and its provinces from 2011 to 2018: Insights from CHARLS.BMC Public Health, 25(1), 3752.

[18]Wu, Y., Zhang, Y. S., Kobayashi, L. C., Mayeda, E. R., & Gross, A. L. (2024). How to assess cognitive decline when test administration changes across study waves? Harmonizing cognitive scores across waves in the China Health and Retirement Longitudinal Study.Journal of Alzheimer's Disease Reports, 8(1), 1661–1669.

[19]Hou, S., Zhao, X., & Liu, R. (2025). Association between living environmental quality and body pain in middle-aged and older adults: A national study in China.Archives of Public Health, 83(1), 236.

[20]Stekhoven, D. J., & Bühlmann, P. (2012). MissForest—non-parametric missing value imputation for mixed-type data.Bioinformatics, 28(1), 112–118.

[21]Pedersen, M. H., Lasgaard, M., Nielsen, C. P., Prior, A., Duncan, P., Schramm, S., Christensen, A. I., & Larsen, F. B. (2026). Multimorbidity patterns and their associations with patient-perceived treatment burden: A latent class analysis of 14,344 Danish adults.Journal of Multimorbidity and Comorbidity, 16, 26335565261417433.

[22]Kunicki, Z. J., Nichols, E., De Vito, A. N., Kosar, C. M., Rich, A., Briceño, E. M., Levine, D. A., & Gross, A. L. (2025). The pace of memory decline in older adults without a neurocognitive disorder: Results from 22 years of follow-up in a nationally representative sample.Neuroepidemiology, 1–8.

[23]Zhu, S., Sagherian, K., Wang, Y., Nahm, E. S., & Friedmann, E. (2021). Longitudinal moderated mediation analysis in parallel process latent growth curve modeling in intervention studies.Nursing Research, 70(3), 184–192.

[24]Verbrugge, L. M., & Jette, A. M. (1994). The disablement process.Social Science & Medicine, 38(1), 1–14.

[25]Wang, L., Lou, Y., Jiang, Q., Wang, H., Huang, S., Xie, Y., Zhang, Y., & Xu, X. (2025). Association between multimorbidity trajectories and subsequent cognitive decline: Evidence from two nationwide longitudinal cohorts.Journal of Affective Disorders, 391, 119958.

[26]Nichols, L., Taverner, T., Crowe, F., Richardson, S., Yau, C., Kiddle, S., Dunn, W., & Reeves, D. (2022). In simulated data and health records, latent class analysis was the optimum multimorbidity clustering algorithm.Journal of Clinical Epidemiology, 152, 164–175.

[27]Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C., Costafreda, S. G., Dias, A., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Ogunniyi, A., … Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission.Lancet, 396(10248), 413–446.

[28]Whitlock, E. L., Diaz-Ramirez, L. G., Glymour, M. M., Boscardin, W. J., Covinsky, K. E., & Smith, A. K. (2017). Association between persistent pain and memory decline and dementia in a longitudinal cohort of elders.JAMA Internal Medicine, 177(8), 1146–1153.

[29]Seeman, T. E., Singer, B. H., Rowe, J. W., Horwitz, R. I., & McEwen, B. S. (1997). Price of adaptation—allostatic load and its health consequences. MacArthur studies of successful aging.Archives of Internal Medicine, 157(19), 2259–2268.

[30]Wilson, R. S., Beckett, L. A., Barnes, L. L., Schneider, J. A., Bach, J., Evans, D. A., & Bennett, D. A. (2002). Individual differences in rates of change in cognitive abilities of older persons.Psychology and Aging, 17(2), 179–193.

[31]Ferraro, K. F., & Shippee, T. P. (2009). Aging and cumulative inequality: How does inequality get under the skin?Gerontologist, 49(3), 333–343.

[32]Sullivan, G. M., & Feinn, R. (2012). Using effect size—or why the P value is not enough.Journal of Graduate Medical Education, 4(3), 279–282.

[33]Powell, C., Tomlinson, J., Quinn, C., & Fylan, B. (2022). Interventions for self-management of medicines for community-dwelling people with dementia and mild cognitive impairment and their family carers: A systematic review.Age and Ageing, 51(5).

[34]Gorelick, P. B., Scuteri, A., Black, S. E., Decarli, C., Greenberg, S. M., Iadecola, C., Launer, L. J., Laurent, S., Lopez, O. L., Nyenhuis, D., Petersen, R. C., Schneider, J. A., Tzourio, C., Arnett, D. K., Bennett, D. A., Chui, H. C., Higashida, R. T., Lindquist, R., Nilsson, P. M., … Seshadri, S. (2011). Vascular contributions to cognitive impairment and dementia: A statement for healthcare professionals from the American Heart Association/American Stroke Association.Stroke, 42(9), 2672–2713.

[35]Livingston, G., Huntley, J., Liu, K. Y., Costafreda, S. G., Selbæk, G., Alladi, S., Ames, D., Banerjee, S., Burns, A., Brayne, C., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Nakasujja, N., Rockwood, K., Samus, Q., … Mukadam, N. (2024). Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission.Lancet, 404(10452), 572–628.

[36]Kerari, A., Bahari, G., Alharbi, K., & Alenazi, L. (2024). The effectiveness of the chronic disease self-management program in improving patients' self-efficacy and health-related behaviors: A quasi-experimental study.Healthcare (Basel), 12(7).

[37]Graffigna, G., & Barello, S. (2018). Spotlight on the Patient Health Engagement model (PHE model): A psychosocial theory to understand people's meaningful engagement in their own health care.Patient Preference and Adherence, 12, 1261–1271.

[38]Huang, X., Steinmetz, J., Marsh, E. K., Aravkin, A. Y., Ashbaugh, C., Murray, C. J. L., Charlson, F. J., & Hay, S. I. (2025). A systematic review with a Burden of Proof meta-analysis of health effects of long-term ambient fine particulate matter (PM(2.5)) exposure on dementia.Nature Aging, 5(5), 897–908.

[39]Mu, Y., & Li, Z. (2025). Indoor housing conditions, neighborhood environment satisfaction, and mental health among older adults in China: Urban-rural differences.Cities, 167, 106392.

[40]Evans, G. W., & Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure.Annual Review of Public Health, 23, 303–331.