老年人“共病”问题概述

老年人同时患多种疾病和/或老年综合征,统称为"共病"。共病发生率高,增加医疗资源的消耗,增加发生不良事件、失能和死亡的风险。老年人"共病"概念的提出,提示老年医务工作者的临床工作应由针对疾病的亚专科诊疗模式转向老年医学的综合评估及个体化治疗模式。本文针对共病的概念、流行病学、影响、诊治策略等方面进行简要阐述。     

与时俱进，迎接老年保健医学的挑战

本文首先对成功老化、现代老年保健医学服务理念进行了阐述,强调现代老年医学已由关注"病"转变到关注"人",老年医学的目标除了防治疾病外,更加强调对老年生理、认知功能的维持和心理康复治疗,达到"成功老化".实现现代老年医学的核心技术之一是老年综合评估.本文对老年综合评估技术、老年不合理用药、老年共病现象、常见老年疾病防治的研究进展和面临的挑战进行了深入探讨.     

高龄老年住院患者1004例慢性病共病特点分析

目的了解高龄老年住院患者慢性病种类、慢性共病类型及其分布特点。方法统计2013年6月至2016年6月期间于武汉大学中南医院老年病科住院的1004例高龄老年患者的疾病信息,筛选出23种慢性疾病,对慢性病类型及慢性共病特点进行统计分析。计数资料采用卡方检验;计量资料采用t检验或单因素方差分析。结果 23种慢性病中患病率最高的前5位疾病分别为高血压(72.51%)、脑血管病(52.29%)、冠心病(37.25%)、心功能不全(36.25%)及骨关节病(33.96%)。93.73%的高龄老人患有两种或两种以上的慢性疾病,平均慢性共病为(4.67±2.18)种。将慢性病两两组合成疾病对,特定疾病对的实际共同患病率较理论患病率高,如高血压与糖尿病(OR=1.25,95%CI 1.02~1.54;P=0.03)、冠心病与心功能不全(OR=2.14,95%CI 1.69~2.69;P0.01)、心功能不全与心律失常(OR=1.77,95%CI 1.34~2.35;P0.01)。结论高龄老年人群共病患者呈现高患病率、平均共病个数较多的特点。慢性病之间相互联系组合可形成特定的疾病对。     

老年肿瘤的中医认识与治疗

随着人民生活水平的提高及卫生条件的改善，人类平均寿命逐渐延长，人口趋于老龄化。老年人口剧增，随之而来的是老年疾病的增多。老年人因增龄的生理变化，更易在各种慢性疾病的基础上发生癌症，其发生率远远高于中青年，预测到2030年，65岁以上人群中癌肿患病率将进一步增高，约占肿瘤总病数的70％。由于老年肿瘤患者身体器官渐趋老化，功能减退，且合并多种慢性疾病，常不能接受或耐受常规治疗方法，从而影响疗效，因此，对如何采取积极、系统、全面的综合治疗尤显重要。     

全科医师对老年共病病人管理的效果分析

正共病是指2种或2种以上的慢性疾病共存于同一病人中,慢性疾病包括躯体疾病和精神疾病[1]。随着年龄的增长,共病在老年病人中最为常见,在美国从1998年到2008年老年病人患有1种或1种以上慢性病的发生率由86.9%上升至92.2%,患有4种以上慢性病发生率由11.7%上升至17.4%,均呈上升趋势[2]。在中国调查显示,社区成年居民慢性病共病患     

国家老年疾病临床医学研究中心

正国家老年疾病临床医学研究中心(以下简称中心)拥有国家老年医学重点学科、军队与北京市重点实验室及解放军总医院老年保健基地。本中心以老年共病的综合防治为切入点,以50多年老年多器官功能不全患者的救治经验为基础,整合、优化精准齐全的老年病亚专科,在牟善初、王士雯等为代表的老年共病诊疗精     

老年综合评估及多学科团队服务在老年共病干预中的应用

目的 探讨住院老年患者通过老年综合评估(CGA)及多学科团队服务(GITS)进行多维度诊疗,为老年患者提供科学、合理的个性化诊疗模式,有效改善共病诊疗效果及生活质量。方法 选取年龄≥60岁的老年科共病患者,分为观察组和对照组。使用自主开发的“老年综合评估软件V2.0”对210例老年患者入院7天内进行老年综合评估,随后观察组根据评估结果给予共病、老年综合征、心理、认知及生活方式等全面综合干预,对照组仅给予共病干预。干预3个月后行第2次老年综合评估,比较观察组与对照组共病及生活质量改善情况。结果 (1)观察组比对照组血压、血糖控制效果更好(P<0.05),观察组比对照组慢性心衰急性加重、慢性阻塞性肺疾病急性加重发生人数减少(P<0.05)。(2)老年综合征及生活质量：观察组比对照组Barthel指数得分及MMSE得分显著提高(P<0.05),观察组比对照组营养、抑郁、焦虑、跌倒、衰弱均有显著改善(P<0.05),因促眠药物的应用观察组与对照组睡眠障碍均有改善,改善程度无显著差异(P>0.05)。结论 老年患者住院期间进行老年综合评估并结合多学科团队服务,可以及...     

社区家庭照护患者的老年综合征研究

目的研究社区家庭病床患者老年综合征患病率。方法采用老年综合评估和常规的医学评估两种方法对60名65岁以上患有多种慢性疾病的社区家庭病床的老年患者进行老年综合征的患病率评估。结果60名老年患者,年龄67～94岁,平均年龄（79．84-2．1）岁,其中男28人,女32人,患有已明确诊断的慢性病有（6．6±2.0）种。老年综合评估为认知功能减退19例（31．7％）,抑郁症状10例患者（16．6％）,生活活动功能下降22例（36．7％）,在最近1年跌倒16例（26．7％）,尿失禁17例（28．3％）。而常规的医学评估,有明确的认知障碍者2例（3．3％）,抑郁症1例（1．7％）活动功能下降8例（13．3％）,跌倒2例（3．3％）,尿失禁3例（5％）,经过配对卡方检验,与老年综合评估方法比较,P值均〈0．05,差异有统计学意义。结论老年综合征在社区家庭照护老年患者中有较高的患病率,常规的医学评估容易忽视这些症状,推荐常规使用老年综合评估的方法进行检查。     

注意老年肾脏病患者的心血管问题

慢性肾脏疾病（CKD）主要是一种老年患者的疾病。美国流行病学调查资料显示CKDⅢ期，即肾小球滤过率（GFR）在30～60ml／min／1．73m^2，在整个人群中只占4.3％，而在70岁以上的老年人中占了25％。英国的资料也显示慢性’肾功能不全肌酐值男性〉180μmol／L，女性〉135μmol／L在70岁以上的老年人群中明显增高。随着我国社会平均寿命的逐渐延长，CKD的发病率也逐年增加并导致终末期肾衰（ESRD）患者的人数也越来越多。而心血管疾病是CKD，尤其是ESRD患者的主要死亡原因。老年患者由于其既往的心血管基础及调节能力差，心血管疾病的发生率及死亡率比一般CKD患者还要高。     

老年医学跨学科团队治疗多病共存高龄帕金森病患者1例

1例高龄女性帕金森病患者,出现进行性加重的吞咽障碍、消瘦及精神行为症状,患者同时合并多种慢性病及老年综合征。经过老年医学跨学科团队合作,采用肠内营养支持、吞咽康复、药物重整等措施,患者体重显著增加,恢复自主进食能力。基于老年综合评估的老年医学跨学科团队协作模式在老年患者多病共存管理、功能状态维护方面行之有效。     

Era of geriatric medical challenges: Multimorbidity among older patients

The number of older adults is increasing worldwide, including in Asian countries. Various problems associated with medical care for older adults are being highlighted in aging societies. As the number of chronic diseases increases with age, older adults are more likely to have multiple chronic diseases simultaneously (multimorbidity). Multimorbidity results in poor health‐related outcomes, leading to increased use and cost of healthcare. Above all, it leads to deterioration in older adults’ quality of life. However, it is unclear whether any medical interventions are effective for multimorbidity, which means medical practitioners currently offer medical care “in the dark.” It is therefore necessary for researchers and medical professionals involved in geriatric medicine to establish ways to manage multimorbidity among older adults. This means that the development of research in this field is essential. Geriatr Gerontol Int 2019; 19: 699–704 .     

Geriatrietypische Multimorbidit?t im Spiegel von Routinedaten – Teil?1

Background

In Germany, typical geriatric multimorbidity is—next to age itself—of special significance for the identification of target groups for specific geriatric care offers. The present article primarily focuses on typical geriatric multimorbidity in the claims data of statutory health insurance and long-term care insurance in Germany. Using the definition of “the geriatric patient” that is agreed on by providers of services as well as by cost bearers, geriatric multimorbidity is defined as the coexistence of at least 2?of 15?typical geriatric conditions. A suggestion made by the German Geriatric Association was to assign ICD-10-GM codes to each of these 15?conditions. Thus, it becomes possible to identify the corresponding geriatric conditions in claims data.

Methods

The article investigates the frequency of geriatric conditions and, thus, of geriatric multimorbidity of patients aged ≥?60?years admitted to a hospital with a geriatric ward. Patients treated in a geriatric ward were compared with those who did not receive geriatric care. In anticipation of a high correlation between typical geriatric conditions and specific features that are preconditions for receiving long-term care insurance benefits (such as care levels and status of a nursing home resident), claims data of the long-term care insurance were included for external validation.

Results

The analyses showed a distinctly higher proportion of insured people with typical geriatric multimorbidity or rather a certain care level among the geriatrically treated cases than among those patients not receiving geriatric treatment (68.5%/67.9% versus 24.2%/33.4%). The different proportions of typical geriatric multimorbidity coded among the patients with features of a certain care level in the two given groups give rise to the suspicion that typical geriatric multimorbidity is not always statistically recorded—especially in cases of treatment without provision of geriatric care.

Conclusion

The frequency of cases of typical geriatric multimorbidity and a certain care level shows that—even when a specific geriatric offer exists—a considerable proportion of cases with typical geriatric conditions are treated in other medical departments.     

Multimorbidität bei älteren Rheumapatienten Teil 2

While diseases, such as cardiovascular diseases and osteoporosis in the elderly are categorized as comorbidities of rheumatoid arthritis, elderly rheumatic patients are often additionally affected by thyroid dysfunctions and diabetes mellitus type 2, so that the risk of multimorbidity (coexistence of at least two chronic and/or acute diseases) will increase significantly in elderly patients already suffering from systemic rheumatic diseases. Restricted cognition, adherence or compliance may additionally complicate the treatment of elderly rheumatic patients. Furthermore, the pharmacokinetics of the elderly is another challenging task. Referring to selected aspects of geriatric pharmacotherapy, the use of certain substance classes is described in this context.     

Rapidly developing multimorbidity and disability in older adults: does social background matter?

Background

Multimorbidity is among the most disabling geriatric conditions. In this study, we explored whether a rapid development of multimorbidity potentiates its impact on the functional independence of older adults, and whether different sociodemographic factors play a role beyond the rate of chronic disease accumulation.

Methods

A random sample of persons aged ≥60 years (n = 2387) from the Swedish National study on Aging and Care in Kungsholmen (SNAC‐K) was followed over 6 years. The speed of multimorbidity development was estimated as the rate of chronic disease accumulation (linear mixed models) and further dichotomized into the upper versus the three lower rate quartiles. Binomial negative mixed models were used to analyse the association between speed of multimorbidity development and disability (impaired basic and instrumental activities of daily living), expressed as the incidence rate ratio (IRR). The effect of sociodemographic factors, including sex, education, occupation and social network, was investigated.

Results

The risk of new activity impairment was higher among participants who developed multimorbidity faster (IRR 2.4, 95% CI 1.9–3.1) compared with those who accumulated diseases more slowly overtime, even after considering the baseline number of chronic conditions. Only female sex (IRR for women vs. men 1.6, 95% CI 1.2–2.0) and social network (IRR for poor vs. rich social network 1.7, 95% CI 1.3–2.2) showed an effect on disability beyond the rate of chronic disease accumulation.

Conclusions

Rapidly developing multimorbidity is a negative prognostic factor for disability. However, sociodemographic factors such as sex and social network may determine older adults' reserves of functional ability, helping them to live independently despite the rapid accumulation of chronic conditions.     

老年门诊患者共病状况的临床研究

目的研究老年门诊患者共病及老年综合征的发病情况及各疾病的分布。方法在6月内对389例在我院老年医学科门诊就诊的老年患者进行常规诊疗与老年评估,采用门诊简易老年患者疾病与功能评估的流程,由老年专科医师记录目前疾病状况,包括：躯体疾病、功能状态、精神状态;详细记录用药清单,由专人进行老年综合征评估。结果 389例老年门诊患者中有376例合并有老年综合征,其中患2种疾病的老年人有32例（8.2%）,患〉2种疾病的有344例（88.4%）。老年慢性躯体疾病中发病率较高的分别为高血压、冠心病、高脂血症、糖尿病、脑卒中、肿瘤等。老年综合征中多重用药、视力障碍、睡眠障碍、听力障碍、跌倒高风险、慢性疼痛等发生率均〉40%。结论老年门诊患者中96.6%患者合并存在老年综合征,按筛查比例从高到低分别为多重用药、视力障碍、睡眠障碍、听力障碍、跌倒高风险、慢性疼痛、骨质疏松、尿便异常、营养风险或营养不良、半失能或完全失能、认知障碍、抑郁状态、衰弱综合征。     

Spezielle Versorgungsanforderungen bei ?lteren und alten Menschen

This contribution refers to the 2009 Council of Experts Report on health system development and discusses the special care requirements of old people. This includes the geriatric phenomenon of multimorbidity, polypharmacy in old people with multiple diseases, and the need for care. The probability and complexity of multiple diseases increase with age. About half the German citizens who are over 65 have three or more relevant chronic diseases. Multimorbity often causes elderly people to concomitantly consume many different pharmaceuticals. Twenty percent of the insurance holders aged 70–99 who were prescribed drugs in 2005 received 13 or more pharmaceutical agents. However, multimorbidity also has a negative effect on the quality of life, subjective state of health and physical functioning. As a result, particularly people over 80 will eventually need help and care. At present, 2.13 million German citizens are considered to be in need of care in terms of Social Code Book XI. The Council of Experts predicts that the number will increase to 4.35 million by 2050. Finally, the discussion also focuses on the steps health policy makers must take to cope with these requirements. Apart from expanding prevention, these include improving the quality of outpatient treatment and care, upgrading case and care management, and modernizing institutional care.     

功能性鼻内镜鼻窦手术治疗老年慢性鼻-鼻窦炎鼻息肉的安全性评估

目的探讨老年慢性鼻-鼻窦炎鼻息肉患者行功能性鼻内镜鼻窦手术（functional endoscopic sinus surgery,FESS）的安全性。方法回顾性对照性研究,分析中山大学附属第一医院耳鼻咽喉科医院2007年8月至2010年4月拟行FESS手术的老年患者（≥60岁）101名的病例资料,并随机抽取同期行FESS手术的中青年患者（18～59岁）100例作为对照组,比较合并疾病、手术出血量、手术时间和手术并发症的差异,围手术期合并疾病情况。结果101名老年患者中60％合并基础疾病,高于中青年组（19％,P〈0．05）,老年组5例经术前评估不能耐受手术,其余96名行FESS手术,手术时间（50minVS60min）、手术出血量（50mLVS50mL）和并发症发生率（1％VS2％）两组间差异无统计学意义（P〉0．05）。并发症：老年组1例,为术后需要输血,中青年组2例,均为纸样板损伤。所有病例围手术期基础疾病无恶化。结论经过仔细的术前评估处理,老年慢性鼻-鼻窦炎鼻息肉行FESS手术的安全性良好。     

高龄老年慢性骨髓增殖性疾病转化的急性粒细胞白血病1例

1例慢性增殖性疾病的高龄老年患者（82岁）,予羟基脲治疗,并按血小板、白细胞数调整剂量;此后转化为急性粒细胞白血病,增加羟基脲剂量的同时出现粒细胞缺乏及感染,加之患者高龄、基础疾病多,给治疗带来极大难度。经血液科、呼吸内科会诊综合调整,加强支持治疗,现患者一般情况尚可,病情相对稳定,但总体预后不佳。如何针对高龄老年血液病完善治疗,是非血液专业的老年科医师亟待加强的问题。