Ageing, Cardiovascular Disease and Stroke: Time to focus on multimorbidity and exercise interventions

Professor Gillian Mead Professor of Stroke and Elderly Care Medicine, University of Edinburgh. President of the British and Irish Association of Stroke Physicians. She tweets @MeadGillian

I chose a career in geriatric medicine, and latterly in stroke, as I was fascinated by the challenges of managing people with multiple medical problems and was in awe of how my consultant colleagues used their skills to provide holistic, person-centred care. Now that I am a consultant myself, the challenges of managing older people with stroke and other complex medical problems continue to fascinate me. Every day I learn something new.

Advances in medicine underpinned by high quality research have enabled people to live longer. Of course, increasing longevity is a cause for celebration; but as people age, the prevalence of multimorbidity increases. Thus, the research we develop now must be applicable to people with multimorbidity as well as to those with single conditions. For example, can we identify clusters of individuals with particular patterns of multimorbidity? Should we design clinical trials where multimorbidity is the index clinical condition? And what sort of interventions should we test for multimorbidity? Should we test how best to organise care? Should we test ‘lifestyle’ interventions? Should we do large trials testing exercise interventions in people with multimorbidity? And what about ‘polypills’? And how might frailty, sarcopenia and polypharmacy influence the design of these trials? Should we be challenging commonly held assumptions about risks and benefits of drugs in patients with multimorbidity, such as antiplatelets being contraindicated in people with prior bleeds? And in people with polypharmacy, how do we design trials of ‘deprescribing’? But we must be careful not to assume that every older person has multimorbidity - this perception could lead to older people with single conditions missing out on specialist care that has the potential to be highly effective. Indeed, Masouli and colleagues point out that in a UK audit, people over the age of 80 had lower rates of specialist input from cardiology compared to younger people after heart attack, even though they benefit from percutaneous interventions.

This collection in Age and Ageing showcases some of the best research in cardiovascular ageing. The 13 selected papers cover the key topics of blood pressure, orthostatic hypertension, coronary heart disease and heart failure - of course, many patients have all these conditions, which makes their management more complex. Interestingly, but perhaps not surprisingly, it was noted that specialist journals tended to publish papers on specific interventions. The management of blood pressure is complex, and we need to carefully weigh up the potential benefits of treatment (e.g. reduction in stroke risk, frailty, postural hypotension, comorbidity, and side effects of drugs) when deciding which drugs to prescribe. This is difficult as trials tend to exclude people with comorbidity. Falls are a major cause of admission to hospital in older people, and orthostatic hypertension is a common contributory factor. Non-pharmacological measures are sensible first steps - more research is needed to determine the role of drug management. Cardiac rehabilitation of which exercise is a major component  is effective in older people and can be delivered at home.

One of my passions is physical activity and exercise - this is not just because I have personal experience of the joys of mountaineering in Scotland, but also because I have spent many years generating evidence about the benefits of exercise training after stroke, and how to put this evidence into practice. If exercise was a pill, everyone would be taking it. It has virtually no side effects, and there are very few absolute contraindications. So to address the challenges of multimorbidity and cardiovascular ageing, we should all consider how to integrate exercise into the management of our older patients, both to prevent common cardiovascular conditions and stroke in older people, and as part of rehabilitation and secondary prevention. Exercise has massive potential to improve the health and wellbeing of the entire population in the years to come. Future research needs to explore how to break down barriers to its more widespread implementation.

Read the Age and Ageing collection on cardiovascular disease here.