Most Common Chronic Diseases and Management Strategies
The Most Common Chronic Diseases
The most prevalent chronic diseases affecting adults are hypertension, ischemic heart disease, hyperlipidemia, diabetes, chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), arthritis, and heart failure, with these conditions frequently coexisting in the same patient. 1
Among Medicare beneficiaries with heart failure, the most common co-occurring conditions are:
- Hypertension (84.2% in those ≥65 years) 1
- Ischemic heart disease (71.9%) 1
- Hyperlipidemia (60.0%) 1
- Diabetes (46.3%) 1
- Chronic kidney disease (42.3%) 1
- COPD (30.0%) 1
The mean number of chronic conditions in older adults with heart failure is 6.1, highlighting the reality that chronic disease management must address multiple conditions simultaneously rather than treating diseases in isolation 1.
Core Management Principles Across All Chronic Diseases
Lifestyle Therapy as Foundation
Lifestyle optimization is the cornerstone of chronic disease management and must be implemented before or alongside pharmacotherapy. 1
Mental health must be addressed first, as mood disturbances, substance abuse, and psychosocial limitations undermine all other interventions; refer to specialized care when necessary 1.
Nutrition: Encourage fruits, vegetables, whole grains, lean poultry, fish, and legumes while discouraging processed foods with excess saturated fat, salt, and sugar 1. A Mediterranean-style, plant-based diet reduces both cardiovascular and kidney disease risk 2. Caloric restriction alone does not address obesity mechanisms and is insufficient 1.
Physical activity: At least 150 minutes per week of moderate-intensity aerobic plus resistance activity is required, though any amount of daily activity (even 5-10 minutes of extra walking) provides benefit 1. For cardiovascular risk reduction specifically, 150-300 minutes/week of moderate intensity or 75-150 minutes of vigorous exercise is recommended 2.
Sleep: Ensure 7-9 hours nightly, as sleep deprivation worsens insulin resistance, hypertension, hyperglycemia, dyslipidemia, and increases inflammatory cytokines 1.
Smoking cessation is the single most important lifestyle intervention, and clinician encouragement is a frequent motivator for patients to quit 1.
Disease-Specific Management Strategies
1. Hypertension Management
For patients with heart failure and hypertension, guideline-directed medical therapy (GDMT) with ACE inhibitors or ARBs forms the foundation of treatment, though optimal blood pressure targets in HFrEF patients remain undefined. 1
Ambulatory blood pressure monitoring should be performed in patients with obstructive sleep apnea, as nocturnal hypertension is common and contributes to cardiorenal syndrome 2.
Target blood pressure <140/90 mmHg for most patients, though <150/90 mmHg is acceptable in very complex/poor health older adults 1.
2. Diabetes Management
Glycemic targets must be stratified by patient health status rather than applying universal A1C goals:
- Healthy older adults (few comorbidities, intact function): A1C <7.5%, fasting glucose 90-130 mg/dL 1
- Complex/intermediate health (multiple comorbidities, mild-moderate cognitive impairment): A1C <8.0%, fasting glucose 90-150 mg/dL 1
- Very complex/poor health (end-stage illness, moderate-severe cognitive impairment): A1C <8.5%, fasting glucose 100-180 mg/dL 1
SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) should be prescribed for diabetic patients with CKD or cardiovascular disease, as they reduce CKD progression and cardiovascular events. 1, 2
Statin therapy is recommended unless contraindicated or not tolerated 1.
Control of other cardiovascular risk factors (hypertension, lipids) produces greater reductions in morbidity and mortality than tight glycemic control alone in older adults 1.
3. Chronic Kidney Disease (CKD) Management
ACE inhibitor or ARB therapy is the cornerstone of slowing CKD progression, especially with albuminuria present. 2
Nephrology referral is mandatory when GFR <60 mL/min/1.73m² or with rising creatinine to optimize medical management and guide medication dosing 3.
Limit protein intake to 0.8 g/kg body weight/day to slow progression 2.
SGLT2 inhibitors reduce CKD progression and cardiovascular events and should be prescribed for patients with diabetes and CKD stage 3a or higher 2.
When contrast imaging is necessary, use iso-osmolar contrast agents and minimize volume to prevent contrast-induced nephropathy 3, 2.
Adjust all renally cleared medication doses based on creatinine clearance 3.
Monitor closely for increased bleeding complications due to platelet dysfunction in CKD 3.
4. Chronic Obstructive Pulmonary Disease (COPD) Management
COPD is defined as FEV1 <80% predicted and FEV1/FVC <0.7, with airflow obstruction that is progressive, not fully reversible, and predominantly caused by smoking. 1
Screen COPD patients for obstructive sleep apnea (OSA), as overlap syndrome (concurrent COPD and OSA) causes worse nocturnal hypoxemia, higher mortality, and increased cardiovascular complications compared to either disease alone. 4
For overlap syndrome, CPAP treatment is the cornerstone of therapy and significantly reduces mortality, hospitalizations, and pulmonary hypertension 4.
Long-acting bronchodilators (tiotropium, olodaterol) form the foundation of COPD pharmacotherapy 5. Tiotropium with olodaterol combination therapy improves symptoms and reduces exacerbations 5.
Avoid beta-blockers in COPD patients as they may produce severe bronchospasm, though cardioselective beta-blockers can be considered cautiously after myocardial infarction when no alternatives exist 5.
Oxygen therapy must be carefully managed in overlap patients to avoid CO2 retention, maintaining PaO2 >60 mmHg or SpO2 >90% without causing respiratory acidosis 4.
5. Cardiovascular Disease Management
For stable coronary artery disease (CAD) with CKD stage 3a, intensive medical therapy is the initial approach rather than invasive procedures. 2
High-intensity statin therapy to reduce LDL-C by ≥50% or achieve LDL-C <1.4 mmol/L (55 mg/dL) for patients with CAD and CKD 2.
Low-dose aspirin 75-100 mg daily for secondary prevention in established CAD 2.
ACE inhibitor or ARB as first-line therapy for CAD with CKD 2.
Prioritize invasive strategy only if: acute/unstable coronary symptoms, unacceptable angina despite optimal medical therapy, left ventricular systolic dysfunction attributable to ischemia, or left main disease on imaging 2.
6. Heart Failure Management
For heart failure with reduced ejection fraction (HFrEF), guideline-directed medical therapy includes:
- ACE inhibitor or ARB 1
- Beta-blocker 1
- Mineralocorticoid receptor antagonist 1
- SGLT2 inhibitor (sodium-glucose cotransporter-2 inhibitor) 1
Iron deficiency (ferritin <100 mg/L or 100-300 mg/L with transferrin saturation <20%) should be treated with intravenous ferric carboxymaltose, which improves exercise capacity, NYHA classification, and quality of life 1. Oral iron is inadequate due to poor absorption 1.
Do not use erythropoietin-stimulating agents for anemia in heart failure, as they provide no benefit and increase thrombotic events including stroke 1.
Cardiac resynchronization therapy (CRT) should be considered for appropriate candidates 1.
Integrated Care Coordination for Multimorbidity
For older adults with multiple chronic diseases, care-coordination strategies significantly improve outcomes, particularly for specific disease combinations:
For [depression + COPD] or [CVD + diabetes]: Care coordination significantly improves depressive symptoms (standardized mean difference -0.41) and reduces HbA1c levels (mean difference -0.51), though mortality reduction was not significant 6.
For [arthritis + depression] or [diabetes + depression]: Care coordination reduces functional impairment 6.
For [diabetes + depression] or [heart failure + COPD]: Care coordination improves cognitive functioning 6.
Care-coordination strategies with or without education should be implemented for patients with diabetes and either depression or cardiovascular disease, or with coexistence of COPD and heart failure 6.
Common Pitfalls to Avoid
Underestimating bleeding risk in CKD patients due to platelet dysfunction 3.
Failing to adjust medication doses for renal clearance, leading to toxicity 3.
Delaying nephrology referral until GFR is critically low; refer when GFR <60 mL/min/1.73m² 3.
Using oral iron for iron deficiency in heart failure, which is inadequate due to poor absorption 1.
Prescribing erythropoietin-stimulating agents for anemia in heart failure, which increases stroke risk 1.
Treating COPD patients with non-selective beta-blockers, which can cause severe bronchospasm 5.
Failing to screen COPD patients for sleep apnea, missing the opportunity to treat overlap syndrome with CPAP 4.
Applying universal A1C targets to all diabetic patients regardless of health status and life expectancy 1.