连续性健康管理对提高老年共病患者生活质量的重要性分析  

Importance of Performing Continuous Health Management to the Elderly Patients with Multimorbidity in Order to Improve the Quality of Life

作　　者：闫巍[1] 王杰萍[1] 张洪波[1] 吴薇[1] 王斐 张洁[2] 张新焕[2] 朱钟慧 杜雪平[5] YAN Wei;WANG Jie-ping;ZHANG Hong-bo;WU Wei;WANG Fei;ZHANG Jie;ZHANG Xin-huan;ZHU Zhong-hui;DU Xue-ping(Department of General Practice,Fuxing Hospital,Capital Medical University,Beijing 100038,China;Geriatric Department,Fuxing Hospital,Capital Medical University,Beijing 100038,China;School of Public Health,Capital Medical University,Beijing 100069,China;Beijing Key Laboratory of Environmental Toxicology,Capital Medical University,Beijing 100069,China;Yuetan Community Health Service Center,Fuxing Hospital,Capital Medical University,Beijing 100038,China)

机构地区：[1]首都医科大学附属复兴医院全科医学科,北京市100038 [2]首都医科大学附属复兴医院综合科,北京市100038 [3]首都医科大学公共卫生学院,北京市100069 [4]首都医科大学环境毒理学北京市重点实验室,北京市100069 [5]首都医科大学附属复兴医院月坛社区卫生服务中心,北京市100038

出　　处：《中国全科医学》2018年第27期3302-3306,共5页Chinese General Practice

基　　金：首都医科大学基础-临床科研合作基金(16JL59)

摘　　要：老年共病患者较老年单一慢性病患者存在衰弱、肌少症、营养不良、跌倒等诸多问题,生活质量明显下降。当前老年人的医疗以患者为中心,以减少失能、提高日常生活能力为目标。因此,本文特别关注了老年共病与生活质量的相关性,提出对老年共病患者实行分级诊疗,关注老年综合征,运用多学科团队制定综合诊疗方案,重视急性病恢复期的老年中期照护,实行连续性健康管理,预防并减少各种急性并发症发生,减少住院次数,延缓认知功能障碍发生,最终提高患者生活质量,改善长期预后。Compared to patients with single chronic disease,the elderly patients with comorbidity are accompanied by many problems,such as weakness,sarcopenia,malnutrition and tumble,which leads to a decline in their quality of life.In order to reduce disability and enhance the capability in daily lives,patient-centered medical mode is implemented.Therefore,this paper focuses on the correlation between the elderly patients with comorbidity and the quality of life.Hierarchical medical system should be implemented,geriatric syndromes valued,and comprehensive diagnosis and treatment plan formulated by multidisciplinary teams.The intermediate careduring the recovery period of acute disease should be paid attention to,and continuous health management employed so as to prevent and reduce all kinds of acute complications,reduce hospitalization and delay the occurrence of cognitive impairment.The long-term goal of improving quality of life and long-term prognosis will be achieved lasting the end.

关 键 词：老年人 共病现象 生活质量 连续性健康管理 患者分级医疗 

分 类 号：R339.34[医药卫生—人体生理学]