Frailty and Multimorbidity in the Elderly：Challenges for General Medical Services Delivered by Healthcare Facilities in a Compact Medical Consortium and Recommended Solutions

doi:10.12114/j.issn.1007-9572.2021.00.509

Abstract

Abstract: Multimorbidity in the elderly is a global public health problem. Most elderly people with multimorbidity have cognitive impairment，mental and psychological problems with much higher risks of falls，disability and even death. Multimorbidity coexisting and interacting with frailty may worsen the conditions of elderly people，increasing the risk of adverse outcome，which brings new challenges to general practice. Regarding frailty and multimorbidity in the elderly in China，we proposed the recommendation：developing a general practitioners-led multidisciplinary team formed by professionals working in healthcare facilities in a compact medical consortium to deliver holistic management services，including standardized pharmacological treatment，cognitive improvement treatment，psychotherapy，in combination with exercise rehabilitation and nutritional support. We hope the recommendation could treat multimorbidity with reversing or delaying frailty，and improve the quality of life and reduce medical burden of these people.

Key words: Frailty, Comorbidity, Multiple chronic conditions, Aged, General practice, General practitioners, Medical alliance

摘要： 老年共病现象是当前全球公共卫生问题之一。老年衰弱共病患者多存在认知障碍、精神-心理问题且跌倒、失能及死亡风险明显升高。共病与衰弱相互影响并形成恶性循环，会导致老年人不良预后发生风险升高、医疗负担加重，为全科医学带来了新挑战。本文聚焦老年衰弱共病患者现状、面临的问题，提出应对策略如下：在紧密医联体模式下由全科医生主导组建多学科团队并实行全人管理，涉及规范用药方案、改善认知功能、关注精神-心理问题、联合康复锻炼和营养治疗等，以期在治疗多种慢性病同时逆转衰弱或延缓衰弱的进展，提高患者生活质量，减轻患者医疗负担。

关键词: 衰弱, 共病现象, 慢性病共病, 老年人, 全科医学, 全科医生, 医联体

XU Haihong,WANG Yongli,YAN Wei. Frailty and Multimorbidity in the Elderly：Challenges for General Medical Services Delivered by Healthcare Facilities in a Compact Medical Consortium and Recommended Solutions　[J]. Chinese General Practice, 2021, 24(24): 3026-3031. DOI: 10.12114/j.issn.1007-9572.2021.00.509.
徐海红,王永利,闫巍. 老年衰弱共病患者：紧密医联体模式下全科医学面临的挑战与应对策略[J]. 中国全科医学, 2021, 24(24): 3026-3031. DOI: 10.12114/j.issn.1007-9572.2021.00.509.

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