Hypercholesterolemia is an independent risk factor for atherosclerotic cardiovascular diseases, exerting a profound impact on the health of the elderly. However, evidence regarding the disease burden of hypercholesterolemia in the elderly remains limited and requires further elucidation.

To analyze the disease burden and temporal trends of hypercholesterolemia among the elderly globally and in China from 1990 to 2021, thereby providing a reference for optimizing health resource allocation and precisely formulating management strategies.

Data on deaths and disability-adjusted life years (DALYs) of "High LDL cholesterol" in individuals aged≥60 years globally, in China, and across 5 sociodemographic index (SDI) regions were collected from the Global Burden of Disease (GBD) 2021 database. Joinpoint regression was used to analyze temporal trends in age-standardized mortality rate (ASMR) and DALYs rate (ASDR). A three-factor decomposition method was used to quantify the relative impacts of population aging, population growth, and epidemiological changes on the burden. The Bayesian age-period-cohort model was employed to predict the number of deaths and DALYs from 2022 to 2035.

In 2021, global and Chinese elderly experienced 2 779 100 and 692 000 hypercholesterolemia-related deaths, increasing 50.34% and 252.34% from 1990, and the DALYs were 50 226 100 and 12 170 100 person-years, rising by 46.62% and 200.96%, respectively. Globally, both ASMR and ASDR for elderly hypercholesterolemia showed a decreasing trend overall (AAPC_ASMR=-1.65%, 95%CI=-1.81% to -1.48%, P<0.001; AAPC_ASDR=-1.51%, 95%CI=-1.67% to -1.36%, P<0.001) from 1990 to 2021, whereas they remained relatively stable in China (P=0.089, P=0.388). The overall ASMR of elderly men in China has been on the rise, with an average annual increase of 0.71% (95%CI=0.31% to 1.11%, P<0.001). In 2021, elderly males globally and in China exhibited a higher number of deaths and DALYs, as well as higher ASMR and ASDR, than elderly females. Except for the high-SDI region, the number of deaths and DALYs of hypercholesterolemia in the total elderly population in other SDI regions in 2021 increased to varying degrees compared with 1990. Furthermore, in 2021, the 80-84 years age group accounted for the largest proportion of deaths both globally (463 100 cases, 16.66%) and in China (128 300 cases, 18.54%). Population growth was identified as the main driver of increasing disease burden among all regions. The Bayesian age-period-cohort model indicated that the disease burden of hypercholesterolemia among the elderly population would continue to rise globally and in China from 2022 to 2035. By 2035, the number of deaths and DALYs from hypercholesterolemia in the global elderly population would increase by 42.67% and 41.20%, respectively, compared with 2021, while in China they would increase by 82.76% and 72.18%, respectively.

The disease burden of hypercholesterolemia among the elderly is substantial both globally and in China, and is expected to grow steadily. To effectively mitigate this escalating burden, it is imperative to enhance public health consciousness, refine the allocation of health resources, and strengthen the research and development of novel lipid-lowering medications.