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.

References

［1］BARNETT K，MERCER S W，NORBURY M，et al．Epidemiology of multimorbidity and implications for health care，research，and medical education：a cross-sectional study［J］．Lancet，2012，380（9836）：37-43．DOI：10.1016/S0140-6736（12）60240-2.
［2］CLEGG A，YOUNG J，ILIFFE S，et al．Frailty in elderly people［J］．Lancet，2013，381（9868）：752-762．DOI：10.1016/S0140-6736（12）62167-9.
［3］谭潇，齐海梅，黄大海，等．全科与老年科的无缝对接探讨［J］．中华老年医学杂志，2016，35（7）：692-696．DOI：10.3760/cma.j.issn.0254-9026.2016.07.002.
TAN X，QI H M，HUANG D H，et al．Seamless handover between general practice and geriatrics［J］．Chinese Journal of Geriatrics，2016，35（7）：692-696．DOI：10.3760/cma.j.issn.0254-9026.2016.07.002.
［4］闫巍，王杰萍，张洪波，等．老年共病患者在诊疗中面临的问题及应对策略［J］．中国全科医学，2018，21（3）：261-264．DOI：10.3969/j.issn.1007-9572.2017.00.207.
YAN W，WANG J P，ZHANG H B，et al．Challenges and solutions for elderly patients with multimorbidity during receiving management in China［J］．Chinese General Practice，2018，21（3）：261-264．DOI：10.3969/j.issn.1007-9572.2017.00.207.
［5］PAREKH A K，BARTON M B.The challenge of multiple comorbidity for the US health care system［J］．JAMA，2010，303（13）：1303-1304．DOI：10.1001/jama.2010.381.
［6］闫巍，李瑞，王杰萍，等．北京市某三级医院综合科老年共病住院患者临床特点分析［J］．中国全科医学，2018，21（14）：1648-1656．DOI：10.3969/j.issn.1007-9572.2018.00.119.
YAN W，LI R，WANG J P，et al．Clinical characteristics of elderly inpatients with multimorbidity in geriatric department of a tertiary hospital in Beijing［J］．Chinese General Practice，2018，21（14）：1648-1656．DOI：10.3969/j.issn.1007-9572.2018.00.119.
［7］周白瑜，陶永康，石婧，等．北京市社区老年人衰弱状况及其相关因素分析［J］．中华老年医学杂志，2020，39（2）：214-219．DOI：10.3760/cma.j.issn.0254-9026.2020.02.021.
ZHOU B Y，TAO Y K，SHI J，et al．Analysis of the frailty status and its related factors among elderly adults of urban community in Beijing［J］．Chinese Journal of Geriatrics，2020，39（2）：214-219．DOI：10.3760/cma.j.issn.0254-9026.2020.02.021.
［8］WU C，SMIT E，XUE Q L，et al．Prevalence and correlates of frailty among community-dwelling Chinese older adults：the China Health and Retirement Longitudinal Study［J］．J Gerontol A Biol Sci Med Sci，2018，73（1）：102-108.
［9］周莉华，王凌霄，杨永学，等．住院共病老年人衰弱状态分布及其影响因素［J］．中华老年多器官疾病杂志，2019，18（1）：6-11．DOI：10.11915/j.issn.1671-5403.2019.01.002.
ZHOU L H，WANG L X，YANG Y X，et al．Frail status and influencing factors in elderly inpatients with comorbidity［J］．Chinese Journal of Multiple Organ Diseases in the Elderly，2019，18（1）：6-11．DOI：10.11915/j.issn.1671-5403.2019.01.002.
［10］郭朝唤，侯莉明，王宁，等．西安市某社区老年人群衰弱的相关危险因素分析［J］．中华老年多器官疾病杂志，2019，18（8）：561-564．DOI：10.11915/j.issn.1671-5403.2019.08.121.
GUO Z H，HOU L M，WANG N，et al．Risk factors for frailty among community-dwelling elderly in Xi'an［J］．Chinese Journal of Multiple Organ Diseases in the Elderly，2019，18（8）：561-564．DOI：10.11915/j.issn.1671-5403.2019.08.121.
［11］卫尹，曹艳佩，杨晓莉，等．老年住院患者衰弱综合征现状及影响因素［J］．复旦学报（医学版），2018，45（4）：496-502．DOI：10.3969/j.issn.1672-8467.2018.04.010.
WEI Y，CAO Y P，YANG X L，et al．Frailty syndrome in hospitalized geriatric patients and its risk factors［J］．Fudan University Journal of Medical Sciences，2018，45（4）：496-502．DOI：10.3969/j.issn.1672-8467.2018.04.010.
［12］叶丽钦，张莹，张海林，等．社会支持对维持性血液透析老年患者衰弱的影响［J］．中华老年医学杂志，2019，38（1）：72-75．DOI：10.3760/cma.j.issn.0254-9026.2019.01.017.
YE L Q，ZHANG Y，ZHANG H L，et al．Influence of social supports on frailty in elderly maintenance hemodialysis patients［J］．Chinese Journal of Geriatrics，2019，38（1）：72-75．DOI：10.3760/cma.j.issn.0254-9026.2019.01.017.
［13］CANEVELLI M，CESARI M.Cognitive frailty：what is still missing？［J］．J Nutr Health Aging，2015，19（3）：273-275．DOI：10.1007/s12603-015-0464-5.
［14］RUAN Q，YU Z，CHEN M，et al．Cognitive frailty，a novel target for the prevention of elderly dependency［J］．Ageing Res Rev，2015，20（3）：1-10．DOI：10.1016/j.arr.2014.12.004.
［15］PAULSON D，LICHTENBERG P A.Vascular depression：an early warning sign of frailty［J］．Aging Ment Health，2013，17（1）：85-93．DOI：10.1080/13607863.2012.692767.
［16］BUIGUES C，PADILLA-SáNCHEZ C，GARRIDO J F，et al．
The relationship between depression and frailty syndrome：
a systematic review［J］．Aging Ment Health，2015，19（9）：762-772．DOI：10.1080/13607863.2014.967174.
［17］SáNCHEZ-GARCíA S，SáNCHEZ-ARENAS R，GARCíA-PE?A C，et al．Frailty among community-dwelling elderly Mexican people：prevalence and association with sociodemographic characteristics，health state and the use of health services［J］．Geriatr Gerontol Intern，2014，14（2）：395-402．DOI：10.1111/ggi.12114.
［18］刘硕，朱鸣雷，刘晓红.老年住院患者衰弱和抑郁的相关性［J］．中华老年多器官疾病杂志，2020，19（6）：419-423．DOI：10.11915/j.issn.1671-5403.2020.06.099.
LIU S，ZHU M L，LIU X H.Correlation between frailty and depression in the elderly hospitalized patients［J］．Chinese Journal of Multiple Organ Diseases in the Elderly，2020，19（6）：419-423．DOI：10.11915/j.issn.1671-5403.2020.06.099.
［19］HUON J F，LENAIN E，LEGUEN J，et al．How drug use by French elderly patients has changed during the last decade［J］．Drugs Real World 0utcomes，2015，2（4）：327-333．DOI：10.1007/s40801-015-0041-6.
［20］刘淼，李嘉琦，吕宪玉，等．≥80岁老年人多重用药现况及影响因素分析［J］．中国公共卫生，2017，33（3）：412-414．DOI：10.11847/zgggws2017-33-03-18.
LIU M，LI J Q，LYU X Y，et al．Prevalence and influencing factors of polypharmacy among persons aged 80 years or older［J］．Chinese Journal of Public Health，2017，33（3）：412-414．DOI：10.11847/zgggws2017-33-03-18.
［21］唐杨琛，顾朋颖，靳松，等．80岁以上老年人多重用药的临床观察［J］．中国临床保健杂志，2018，21（2）：156-159．DOI：10.3969/J.issn.1672-6790.2018.02.004.
TANG Y C，GU P Y，JIN S，et al．Clinical observation of polypharmacy in the elderly aged over 80 years［J］．Chinese Journal of Clinical Healthcare，2018，21（2）：156-159．DOI：10.3969/J.issn.1672-6790.2018.02.004.
［22］王湾湾，李园园，石小天，等．老年住院患者衰弱的影响因素分析及其与营养不良的相关性研究［J］．中国全科医学，2021，24（6）：678-684．DOI：10.12114/j.issn.1007-9572.2020.00.594.
WANG W W，LI Y Y，SHI X T，et al．Frailty-related factors and degree of association of frailty with malnutrition in elderly inpatients［J］．Chinese General Practice，2021，24（6）：678-684．DOI：10.12114/j.issn.1007-9572.2020.00.594.
［23］闫巍，杜雪平，黄璇，等．优化双向转诊模式以提升家庭医生签约服务能力——以首都医科大学附属复兴医院为例［J］．中国全科医学，2018，21（24）：2974-2979．DOI：10.12114/j.issn.1007-9572.2018.00.139.
YAN W，DU X P，HUANG X，et al．Fuxing Hospital，Capital Medical University optimizes the bidirectional referral model to improve the service capabilities of family doctors［J］．Chinese General Practice，2018，21（24）：2974-2979．DOI：10.12114/j.issn.1007-9572.2018.00.139.
［24］闫巍，王杰萍，张洪波，等．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［J］．中国全科医学，2018，21（27）：3302-3306．DOI：10.12114/j.issn.1007-9572.2018.00.113.
YAN W，WANG J P，ZHANG H B，et al．Importance of performing continuous health management to the elderly patients with multimorbidity in order to improve the quality of life［J］．Chinese General Practice，2018，21（27）：3302-3306．DOI：10.12114/j.issn.1007-9572.2018.00.113.
［25］FOUGèRE B，DELRIEU J，DEL CAMPO N，et al．Cognitive frailty：mechanisms，tools to measure，prevention and controversy［J］．Clin Geriatr Med，2017，33（3）：339-355．DOI：10.1016/j.cger.2017.03.001.
［26］马丽娜，陈彪.认知衰弱：一个新的概念［J］．中华老年医学杂志，2018，37（2）：227-231．DOI：10.3760/cma.j.issn.0254-9026.2018.02.026.
MA L N，CHEN B.Cognitive frailty：a new concept［J］．Chinese Journal of Geriatrics，2018，37（2）：227-231．DOI：10.3760/cma.j.issn.0254-9026.2018.02.026.
［27］王伟，谭淑慧，张斌，等．加强基层医务工作者对痴呆的识别与诊治是中国痴呆防控的关键［J］．中国全科医学，2021，24（6）：637-642．DOI：10.12114/j.issn.1007-9572.2021.00.058.
WANG W，TAN S H，ZHANG B，et al．Strengthening primary healthcare workers' identification，diagnosis and treatment of dementia is the key to the prevention and control of dementia in China［J］．Chinese General Practice，2021，24（6）：637-642．DOI：10.12114/j.issn.1007-9572.2021.00.058.
［28］尚晓峰，张莹，李虹，等．老年急性缺血性脑卒中患者衰弱与卒中后抑郁的相关性研究［J］．中国全科医学，2020，23（30）：3834-3838．DOI：10.12114/j.issn.1007-9572.2020.00.462.
SHANG X F，ZHANG Y，LI H，et al．Frailty and post-stroke depression in elderly patients with acute ischemic stroke［J］．Chinese General Practice，2020，23（30）：3834-3838．DOI：10.12114/j.issn.1007-9572.2020.00.462.
［29］方力争，徐志杰.《澳大利亚与新西兰老年医学会立场声明：老年人处方》解读［J］．中国全科医学，2019，22（7）：747-752．DOI：10.12114/j.issn.1007-9572.2019.07.001.
FANG L Z，XU Z J.Interpretation of Australian and New Zealand Society for Geriatric Medicine Position Statement of Prescribing in Older People［J］．Chinese General Practice，2019，22（7）：747-752．DOI：10.12114/j.issn.1007-9572.2019.07.001.
［30］闫巍，陈雪，丁静.全科医师面对老年共病患者多重用药的应对策略［J］．中国全科医学，2020，23（15）：1859-1863，1872．DOI：10.12114/j.issn.1007-9572.2020.00.325.
YAN W，CHEN X，DING J.General practitioners' coping strategies for polypharmacy in elderly patients with multimorbidity［J］．Chinese General Practice，2020，23（15）：1859-1863，1872．DOI：10.12114/j.issn.1007-9572.2020.00.325.
［31］张丹，李根，李莉，等．临床药师参与1例老年患者的精准用药实践［J］．中国药业，2019，28（5）：90-92．DOI：10.3969/j.issn.1006-4931.2019.05.031.
ZHANG D，LI G，LI L，et al．Clinical pharmacist's participation in the practice of precise drug use in an elderly patient［J］．China Pharmaceuticals，2019，28（5）：90-92．DOI：10.3969/j.issn.1006-4931.2019.05.031.
［32］FRIED L P，TANGEN C M，WALSTON J，et al．Frailty in older adults：evidence for a phenotype［J］．J Gerontol A Biol Sci Med Sci，2001，56（3）：M146-156．DOI：10.1093/gerona/56.3.m146.
［33］ROCKWOOD K，SONG X，MACKNIGHT C，et al．A global clinical measure of fitness and frailty in elderly people［J］．CMAJ，2005，173（5）：489-495．DOI：10.1503/cmaj.050051.
［34］RONDANELLI M，KLERSY C，TERRACOL G，et al．Why protein，amino acids，and vitamin D supplementation with physical activity increases fat-free mass and strength，functionality，and quality of life and decreases inflammation in sarcopenic elderly［J］．Am J Clin Nutr，2016，103（3）：830-840．DOI：10.3945/ajcn.115.113357.
［35］刘雅茹，朱鸣雷，刘晓红.β-羟基-β-甲基丁酸治疗肌少症的临床研究现状［J］．中华老年多器官疾病杂志，2018，17（4）：309-312．DOI：10.11915/j.issn.1671-5403.2018.04.068.
LIU Y R，ZHU M L，LIU X H.β-hydroxy-β-methylbutyrate in treatment of sarcopenia in the elderly：clinical research update［J］．Chinese Journal of Multiple Organ Diseases in the Elderly，2018，17（4）：309-312．DOI：10.11915/j.issn.1671-5403.2018.04.068.
［36］中华医学会肠外肠内营养学分会老年营养支持学组.中国老年患者肠外肠内营养应用指南（2020）［J］．中华老年医学杂志，2020，39（2）：119-132．DOI：10.3760/cma.j.issn.0254-9026.2020.02.002.
Geriatric Nutrition Support Group，Society of Parenteral and Enteral Nutrition，Chinese Medical Association.Guidelines for the application of parenteral and enteral nutrition in elderly Chinese patients［J］．Chinese Journal of Geriatrics，2020，39（2）：119-132．DOI：10.3760/cma.j.issn.0254-9026.2020.02.002.
［37］RICH M W，CHYUN D A，SKOLNICK A H，et al．Knowledge gaps in cardiovascular care of the older adult population：a scientific statement from the American Heart Association，American College of Cardiology，and American Geriatrics Society［ J］．J Am Coll Cardiol，2016，67（20）：2419-2440．DOI：10.1016/j.jacc.2016.03.004.
［38］徐虎，范利，曹丰.老年共病管理的临床挑战与应对策略［J］．中华老年多器官疾病杂志，2019，18（12）：942-946．DOI：10.11915/j.issn.1671-5403.2019.12.197.
XU H，FAN L，CAO F.Challenges and strategies for management of comorbidity in the elderly［J］．Chinese Journal of Multiple Organ Diseases in the Elderly，2019，18（12）：942-946．DOI：10.11915/j.issn.1671-5403.2019.12.197.
［39］王辉，赵付英，姜岳，等．全科医生主导的多学科团队服务模式管理老年人共病的实践与思考［J］．中华全科医师杂志，2019，18（8）：798-800．DOI：10.3760/cma.j.issn.1671-7368.2019.08.022.
WANG H，ZHAO F Y，JIANG Y，et al．General practitioner-led multidisciplinary team model in management of elderly comorbidity patients in community［J］．Chinese Journal of General Practitioners，2019，18（8）：798-800．DOI：10.3760/cma.j.issn.1671-7368.2019.08.022.

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