Redefining Chronic Disease Care in Ageing Populations: Proactive Measures for Better Outcomes

Ageing populations face rising multimorbidity and a heavy chronic disease burden, prompting a shift to proactive, patient-centred care. Priorities include prevention and early diagnosis with genomics and non-invasive biomarkers, continuous monitoring via telehealth, wearables and AI, and disease-modifying options from senolytics to gene therapy, supported by stronger primary care and policy action.

Key Points

• Ageing populations face rising multimorbidity and chronic disease burden.
• Prevention and early diagnosis require large-scale screening.
• Digital health, wearables and AI enable continuous monitoring and self-management.
• Emerging therapies target senescence, mitochondria and immune dysfunction.
• Stronger primary care, data systems and policy frameworks are essential.

According to World Health Organization, by 2030, 1 in 6 people will be above the age of 60, and the global elderly population will increase from 1 billion in 2020 to 1.4 billion. The number of adults over 80 years is also expected to triple between 2020 and 2050 (WHO 2025a). This unprecedented demographic shift points toward one of the greatest healthcare challenges, creating a demand to address unmet needs of this population.

Chronic diseases such as cardiovascular diseases, cancer, chronic respiratory disorders and diabetes account for majority of morbidity and mortality in adults, and in 2023, nearly 75% of global deaths were caused by chronic diseases (WHO 2025c). In the European region, 90% of the overall deaths are due to chronic diseases (Charalampous et al. 2022). This burden is alarmingly high in the geriatric population, underscoring an urgent need for innovative strategies in prevention, diagnosis, disease modifying therapy and long-term management. Alongside the well-documented chronic conditions such as cardiovascular diseases and diabetes, neurodegenerative diseases (NDDs), including Alzheimer’s disease, Parkinson’s disease and other forms of dementia, also pose a formidable health challenge, with a huge socioeconomic burden. The incidence of these disorders sharply increases after the age of 75, and with global life expectancy increasing, the number of individuals affected is projected to more than double by 2050 (Alzheimer’s Disease International n. d.).

While the number of older adults living with one or two chronic conditions is on the rise, multimorbidity, the coexistence of two or more chronic diseases, is a growing concern among older adults globally. There is a pressing need to develop strategies that can prevent or manage these concurrent diseases. Improving outcomes with novel risk assessment and early diagnosis to innovative next-generation therapies, as well as improving access with remote patient care and AI-assisted health management, are driving how the world can tackle chronic diseases and progress in chronic diseases management.

Unravelling Ageing at the Molecular and Cellular Level

Most age-associated diseases share common mechanisms and pathogenesis. Molecular and cellular changes over time lead to senescence and act as major drivers of chronic diseases such as diabetes, cardiovascular and neurodegenerative diseases. DNA damage, epigenetic changes, telomere shortening, mitochondrial dysfunction and loss of protein homeostasis are some of the hallmarks of ageing.

An area of growing scientific and clinical interest is to explore underlying mechanisms of cellular senescence in age-related diseases. Effective screening and prevention strategies enhance discovery of new biomarkers (genetic, metabolic, epigenetic) linked to age-related disease pathophysiology; they also help to unravel patterns of disease co-occurrence, such as hypertension, diabetes and arthritis often linked with advanced ageing. Several senolytics and senomorphics are in preclinical and clinical development to target age related senescence neurodegenerative diseases, cardiovascular conditions and osteoarthritis. There is also a growing body of R&D efforts to delineate the role of mitochondria in ageing and chronic diseases like cancers, cardiomyopathies and overall deterioration of organ function.

Despite active research, there is still a need to identify the detailed molecular mechanism behind mitochondrial dysfunction, including the decrease in mitophagy in ageing cells and their association with the overall ageing process. Comprehensive molecular and clinical studies are required to effectively utilise mitochondrial dysfunction as a target for anti-aging therapies.

Focus on Preventive Strategies and Early Diagnosis

One of the key strategies for chronic disease management in elderly people is to carry out large scale screening programmes and preventive testing for early disease detection and prevention. Use of full-risk prediction tools and algorithms for large scale screening should be extensively adopted by governments for preventive health management. Currently, most of the diagnosis is delayed, and not predictive in nature. Also, diagnostics are often expensive, invasive and associated with side effects, creating barriers to routine screening in ageing populations. Development of non-invasive tests using advanced biomarkers, wearables, point of care diagnostics and use of digital technologies has supported a shift toward large scale screening.

The declining cost of genomic sequencing now allows for polygenic risk scoring and molecular screening at scale, uncovering individual susceptibility to conditions such as cancer, cardiovascular disease, diabetes and neurodegeneration prior to clinical onset. This is especially crucial for colorectal, bladder cancer and other cancers where risk increases significantly with age. Accessibility of cancer screening tests in low-middle income countries can support large scale screening which is currently low in these regions. It is crucial that governments introduce incentivised schemes to increase awareness, preparedness and increase testing targeting the ageing population.

Non-invasive tools such as retinal imaging biomarkers, echocardiography-based imaging are now being expanded for early diagnosis and prediction for several chronic conditions, including CVD and neurodegenerative diseases. For instance, retinal imaging can predict biological age, and models like EchoAge can estimate the biological age of the heart. Ageing population is often diagnosed with multiple chronic conditions with the most prevalent being cardiovascular diseases and diabetes and other inflammatory conditions; screening for various novel biomarkers could help identify the interplay between them and help identify precision treatment and management regimes.

Rise in neurodegenerative diseases are also a looming issue, with limited diagnostic and treatment options. There have been concerted efforts to develop blood-based tests for early detection of Parkison’s Alzheimers’s and other NDDs. Earlier in October, Roche in collaboration with Eli Lilly has launched the Elecsys® pTau181 test, which is the first FDA approved blood test to diagnose Alzheimer’s related amyloid pathology for use in primary health centres in adults above the age of 55. With such developments in place, healthcare systems and diagnostics developers will be poised to handle chronic diseases in a more proactive manner.

Transform Chronic Disease Management with Emerging Therapeutic Modalities

Most of the therapeutic interventions target chronic diseases much later after they develop and aim to only halt or delay progression. Nevertheless, there is a focus on developing disease-modifying therapies that could prevent, treat and even reverse damage caused by age-related chronic diseases. For instance, targeting senescent cells with senolytics, regenerative cell therapies and mitochondrial therapeutics could be the answer to curing many serious and debilitating ageing conditions which do not have a cure yet.

Mitochondrial dysfunction plays a central role in ageing, and the transfer of healthy mitochondria into damaged cells via mitochondrial transplant is  emerging as a novel therapeutic strategy. This method may restore mitochondrial function and can benefit in overcoming age-related diseases such as neurodegeneration and cardiovascular disorders. Immunosenescence is another major contributor of chronic inflammation; to reduce systemic inflammation and restore immune function, emerging targeted immunotherapies can be used. These methods, including cell therapies and immune cell reprogramming, can improve the outcomes of many chronic diseases such as diabetes, cardiovascular conditions and NDDs. Gene therapy strategies targeting age-related pathologies, including neurodegenerative, cardiovascular, metabolic and ophthalmological disorders, have also gained momentum in providing long-term therapeutic relief.

Create and Strengthen Sustainable Healthcare Systems

World Health Organization is actively working toward educating people on the importance of elderly care and chronic disease management. Although the prevalence of chronic diseases is increasing globally among ageing populations, many nations are not well-equipped to manage these conditions at a primary healthcare level. Infectious diseases receive higher priority, and chronic diseases are often not allocated the same resources for management. Primary health care systems lack the resources to monitor and manage chronic diseases, especially in low- and middle-income countries. To ensure better primary care, it needs to be strengthened by setting up necessary infrastructure, resources and data systems to break the socio-economic barriers. While there is a special provision for child health, maternal health and other conditions, many governments have not focused on developing well-defined frameworks for managing the ageing population. However, the scenario is changing with few countries focusing on age-related health crisis, and conducting campaigns, regulatory and preventive policies against the sales and consumption of substances leading to chronic diseases.

European countries and the USA have action plans in place to establish national frameworks toward healthy ageing. Program of All-Inclusive Care for the Elderly (PACE) is a government-funded healthcare model set up to provide elderly care in the United Sates of America in 1971. This model continues to play a crucial role in supporting elders above the age of 55 through providing home-care assistance for those suffering from long-term chronic illnesses. In 2024, the Biden- Harris administration invested US$200 million (€172 million) to improve elderly care including patients with Alzheimer’s and other dementia. In 2021, the European government launched an initiative called Healthier together – EU non-communicable diseases (NCD) initiative (2022-2027) to support EU countries to better manage the risks of cardiovascular diseases, diabetes, neurological and mental disorders. This initiative will also significantly benefit ageing population in cost-effective diagnosis and holistic life improvement.

Since 2021, the European Commission has funded a SmartCare project to enable aged population to manage chronic diseases by themselves. This project enables elderly population to keep track of their own health parameters, such as weight, blood pressure and heart function, and notify caregivers and doctors at timely intervals.

Shift Towards Connected and Continuous Care with AI and Digital Health

Digital health and remote monitoring are transforming chronic disease management, especially in the ageing population. Digital health platforms have drastically reduced costs and improved healthcare access, but equitable use of telehealth by older adults is essential.

Identifying barriers and developing platforms and solutions that address specific needs of elderly people would encourage a larger percentage of them to use digital platforms such as wearables, connected devices and healthcare apps to manage their chronic conditions better. This includes digital biomarkers, medicine adherence reminders, telehealth consultations and symptom reporting apps.

Wearables and digital health apps have proven to be highly impactful in tracking patient health, especially in ageing population. Often overlooked, mental health disorders such as anxiety, depression and insomnia affect nearly 20% of older adults, compounding chronic disease outcomes. Integrating behavioural therapy, digital CBT (cognitive behavioural therapy) and AI- based mental health apps into chronic care pathways could close this gap.

AI-powered health apps and wearables have also been useful to detect health parameter deviations, allowing to predict health deterioration and need for hospitalisation. This can improve outcomes and reduce the need for multiple hospital visits. Continuous data from wearables (heart rate, ECG, activity, sleep, blood pressure, SpO₂) and AI have helped in monitoring day-to-day health, treatment optimisation and recovery very closely by patients themselves and health practitioners.

Al-integrated imaging technology is also drastically improving early disease detection. AI-enhanced neuroimaging techniques, including MRI, PET and CT scans along with genomics and proteomics data analysis, can detect early signs of Alzheimer’s in elderly people. AI-powered liquid biopsies and imaging are also making waves in cancer research, diagnosis and treatment optimisation.

Towards a Future of Healthier Ageing

Growing awareness and preparedness by governments, health organisations, health practitioners will come a long way in ensuring availability of health resources for dependent ageing population. Investments toward strengthening primary health systems, technology interventions and offering broad health insurance coverage will help in reducing cost burden on elderly people.

Patient-centric approaches through continuous individual-health data collection, detecting early signs of chronic diseases/remote diagnostics, notifying healthcare practitioners directly will be the future of chronic disease management in ageing population.

As technologies and approaches converge to tackle chronic diseases, the focus will be on shifting away from the current scenario of inevitable decline to one that can be modified and even reversed.

Conflict of Interest

None.