认知障碍患者居家康复管理的中国专家共识（2026版）

doi:10.12114/j.issn.1007-9572.2025.0466

摘要/Abstract

摘要： 认知障碍是我国老龄化社会面临的重大健康挑战，对患者生活质量及照护负担产生深远影响。目前，国内在认知障碍居家康复方面仍存在干预措施碎片化、家庭支持体系不健全等问题。为构建适合我国国情的认知障碍居家康复服务框架，中国康复医学会社区康复工作委员会组织多学科专家团队，在系统分析国内外证据的基础上，制定《认知障碍患者居家康复管理的中国专家共识（2026版）》。本共识通过检索国内外相关指南与高质量研究，依据循证医学原则形成推荐意见，重点围绕认知障碍的早期筛查、非药物干预策略、家庭环境适配、照护者支持与培训等核心问题进行阐述，旨在为社区医务人员及照护者提供科学、实用的居家康复指导，提升家庭康复能力，延缓疾病进展，改善患者与照护者的生活质量。

关键词: 认知障碍, 居家康复, 认知训练, 专家共识

Abstract:

Cognitive impairment poses a major health challenge in China's aging society, profoundly affecting patients' quality of life and increasing the care burden. Currently, home-based rehabilitation for cognitive impairment in China faces several issues, including low detection rates, fragmented intervention measures, and an inadequate family support system. To establish a home-based rehabilitation framework suited to China's context, the Community Rehabilitation Working Committee of Chinese Rehabilitation Medicine Association organized a multidisciplinary expert panel to develop the Chinese Expert Consensus on the Management of Home-based Rehabilitation for Cognitive Impairment (2026 Edition), based on a systematic review of domestic and international evidence. This consensus retrieved relevant guidelines and high-quality studies from both Chinese and international databases and developed recommendations following evidence-based medicine principles. It focused on key issues such as early screening, non-pharmacological interventions, home environment adaptation, and caregiver support and training. The document aimed to provide scientific and practical guidance for community healthcare workers and caregivers, enhance family rehabilitation capacity, delay disease progression, and improve the quality of life for both patients and caregivers.

Key words: Cognitive impairment, Home-based rehabilitation, Cognitive training, Expert consensus

中图分类号:

R 741

中国康复医学会社区康复工作委员会. 认知障碍患者居家康复管理的中国专家共识（2026版）[J]. 中国全科医学, 2026, 29(14): 1793-1802. DOI: 10.12114/j.issn.1007-9572.2025.0466.
Community Rehabilitation Working Committee of Chinese Rehabilitation Medicine Association. Chinese Expert Consensus on the Management of Home-based Rehabilitation for Cognitive Impairment (2026 Edition)[J]. Chinese General Practice, 2026, 29(14): 1793-1802. DOI: 10.12114/j.issn.1007-9572.2025.0466.

图/表 4

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推荐级别	代表意义
1类	基于高级别临床研究证据，专家意见高度一致
2A类	基于低级别临床研究证据，专家意见高度一致；或基于高级别临床研究证据，专家意见基本一致
2B类	基于低级别临床研究证据，专家意见基本一致
3类	不论基于何种级别临床证据，专家意见明显分歧

推荐级别	代表意义
1类	基于高级别临床研究证据，专家意见高度一致
2A类	基于低级别临床研究证据，专家意见高度一致；或基于高级别临床研究证据，专家意见基本一致
2B类	基于低级别临床研究证据，专家意见基本一致
3类	不论基于何种级别临床证据，专家意见明显分歧

执行者角色	主要职责
专业医疗机构医师	接诊、系统评估、明确诊断、建立档案、制定个体化康复处方、判定居家康复资格
康复治疗师	协助制定康复技术方案、指导家属操作技巧、参与随访评估
家属/照料者	接受培训后，在家执行康复方案、记录康复过程、观察病情变化、提供日常照护与情感支持
社区多学科团队（社区医师、护士、康复人员等）	负责定期随访、监测康复进展、收集数据、提供社区宣教、应急支持
质控小组（质控负责人、护士长、医师等）	监督全流程质量、评估康复效果、提出改进措施、确保闭环管理

执行者角色	主要职责
专业医疗机构医师	接诊、系统评估、明确诊断、建立档案、制定个体化康复处方、判定居家康复资格
康复治疗师	协助制定康复技术方案、指导家属操作技巧、参与随访评估
家属/照料者	接受培训后，在家执行康复方案、记录康复过程、观察病情变化、提供日常照护与情感支持
社区多学科团队（社区医师、护士、康复人员等）	负责定期随访、监测康复进展、收集数据、提供社区宣教、应急支持
质控小组（质控负责人、护士长、医师等）	监督全流程质量、评估康复效果、提出改进措施、确保闭环管理