老年期痴呆全病程管理体系建设的策略与思考——基于认知障碍专科能力建设实践  

Strategies and reflections on the construction of a comprehensive management system for dementia in the elderly: based on the practice of cognitive disorder specialty capacity building

作　　者：邱琼琼 唐毅[1] Qiu Qiongqiong;Tang Yi(Department of Neurology,Xuanwu Hospital,Capital Medical University,Beijing 100053,China)

机构地区：[1]首都医科大学宣武医院神经内科,北京100053

出　　处：《中华医学杂志》2025年第13期947-952,共6页National Medical Journal of China

基　　金：国家重点研发计划(2022YFC3602600);北京高校卓越青年科学家计划(JWZQ20240101023);青年北京学者(043号)。

摘　　要：随着人口老龄化的加速,老年期痴呆患病人数不断攀升,已成为影响公共健康的重大社会问题,亟需完善的全病程管理模式来应对。然而,我国在老年期痴呆诊疗方面仍面临诸多挑战,包括公众认知不足、基层筛查能力有限、专科医师匮乏、管理体系缺乏连续性以及康复和照护服务不完善等。本文从认知障碍专科能力建设项目出发,依托各级医疗卫生机构为主体的认知障碍诊疗中心体系建设,围绕老年期痴呆的早期筛查与干预、规范化诊疗以及康复与照护三大关键环节展开策略分析。提出统筹现有资源,因地制宜开展筛查与早期干预,优化上下转诊渠道,完善多学科协作诊疗模式,并推动居家与社区照护服务的衔接等具体举措。通过这些措施,探索适合我国国情的老年期痴呆全病程管理模式与路径,为我国老年期痴呆的防控工作提供参考。With the acceleration of population aging,the number of elderly individuals suffering from dementia continues to rise sharply,becoming a significant social issue that affects public health and urgently requires a comprehensive management model throughout the disease course to address it.However,China still faces numerous challenges in the diagnosis and treatment of senile dementia,including insufficient public awareness,limited screening capabilities at the grassroots level,a shortage of specialist physicians,a lack of continuity in management systems,and inadequate rehabilitation and care services.Drawing on the Cognitive Disorder Specialty Capacity Building Project and the establishment of a cognitive disorder diagnosis and treatment center system across various levels of medical and health institutions,the authors conduct a strategic analysis on three key aspects of dementia in the elderly:early screening and intervention,standardized diagnosis and treatment,and rehabilitation and care.It proposes specific measures such as integrating existing resources,conducting screening and early intervention according to local conditions,optimizing referral channels,improving multidisciplinary collaborative diagnosis and treatment models,and promoting the connection between home and community care services.Through these measures,the paper explores a management model and path for the entire course of dementia in the elderly that is suitable for national conditions,providing a reference for the prevention and control of dementia in the elderly in China.

关 键 词：痴呆 老年人 认知障碍 阿尔茨海默病 全病程管理 

分 类 号：R749.1[医药卫生—神经病学与精神病学]