老年肌少症社区管理方案

于溯; 孙艳格; 丁倩; 李晶; 杜雪平; 张萍; 王鹏; 任龙兵

doi:10.16766/j.cnki.issn.1674-4152.004356

老年肌少症社区管理方案

doi: 10.16766/j.cnki.issn.1674-4152.004356

于溯¹,
孙艳格^1, ,,
丁倩²,
李晶¹,
杜雪平¹,
张萍³,
王鹏⁴,
任龙兵⁵

1.
北京市西城区首都医科大学附属复兴医院月坛社区卫生服务中心，北京 100045
2.
北京市大兴区礼贤镇中心卫生院，北京 102604
3.
北京积水潭医院老年医学中心，北京 100035
4.
首都医科大学附属复兴医院综合/老年科，北京 100038
5.
北京市海淀区北京大学医学部公共卫生学院中国卫生发展研究中心，北京 100083

基金项目:

首都卫生发展科研专项项目首发2022-3-70211

国家自然科学基金青年基金项目 72404010

详细信息

通讯作者:
孙艳格，E-mail：13488796993@163.com

中图分类号: R746 R197.61
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- 文章访问数: 11
- HTML全文浏览量: 7
- PDF下载量: 3
- 被引次数: 0
出版历程
- 收稿日期: 2025-07-07
- 网络出版日期: 2026-04-11

Community-based management plan for sarcopenia in older adults

1.
Yuetan Community Health Center, Fuxing Hospital of Capital Medical University, Beijing 100045, China

摘要

摘要: 肌少症是一种以骨骼肌量和肌力进行性下降为特征的老年综合征，显著增加老年人跌倒、失能风险，严重影响老年人的生活质量。我国基层医疗服务机构对于肌少症的认识与研究起步较晚，作为肌少症防控的主战场，亟需规范化的管理方案。本方案由北京市月坛社区卫生服务中心牵头，基于国内外最新共识与指南，经全科医学、老年医学、营养学、康复医学等多学科专家团队反复讨论制定，旨在为基层医疗工作者提供系统指导。该方案内容包括：明确以65岁以上社区老年人为重点管理对象，遵循“预防为主、防治结合”及“个性化干预”原则；构建以全科医生为核心，联合护士、康复师、营养师的多学科协作团队；强调通过线上线下结合开展科普教育；利用小腿围、SARC-CalF量表、握力测试进行早期筛查；采用肌量、肌力及躯体功能综合评估和诊断；以营养及运动干预为核心，推荐每日蛋白质摄入≥1.2 g/(kg·d)并适当补充维生素D，同时结合抗阻与有氧训练，制定个体化运动处方；并建立转诊标准与随访机制，旨在规范社区肌少症管理流程，改善患者肌肉功能，实现科学防治。
- 肌少症 /
- 社区管理 /
- 社区老年人群 /
- 营养干预 /
- 运动干预
Abstract: Sarcopenia is a geriatric syndrome characterized by progressive loss of skeletal muscle mass and strength, which significantly increases the risk of falls and disability among older adults and severely impairs quality of life. In China, primary healthcare institutions have relatively limited experience in the recognition and management of sarcopenia, and standardized management strategies remain lacking. As the frontline of sarcopenia prevention and control, primary care settings require practical and evidence-based management protocols. This program was led by the Yuetan Community Health Service Center in Beijing and developed based on the latest domestic and international consensus and guidelines. It was formulated through repeated discussions by a multidisciplinary expert team including general practitioners, geriatricians, nutritionists, and rehabilitation specialists. It aims to provide systematic guidance for primary healthcare workers. The program identified adults aged 65 years and older as the primary management population and follows the principles of "prevention first, combining prevention and treatment" and "personalized intervention". A multidisciplinary collaborative model is established, with general practitioners at the core coordinators and support from nurses, rehabilitation specialists, and nutritionists. Emphasized health education and public awareness through both online and offline chan-nels. Early screening is conducted using calf circumference, SARC-CalF questionnaire, and handgrip strength testing, followed by comprehensive assessment and diagnosis based on muscle mass, muscle strength, and physical performance. Interventions focus on nutrition and exercise, recommending a daily protein intake of ≥1.2 g/kg body weight with appropriate vitamin D supplementation, combined with resistance and aerobic exercise to develop individualized exercise prescriptions. Referral criteria and follow-up mechanisms are also clearly defined. The goal is to standardize community-based sarcopenia management procedures, improve muscle function in older adults, and achieve evidence-based prevention and treatment of sarcopenia.
- Sarcopenia /
- Community-based management /
- Community elderly population /
- Nutritional intervention /
- Exercise intervention

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图 1 指环试验

Figure 1. Finger running test

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图 2 社区肌少症诊疗流程

Figure 2. Community diagnosis and treatment process for sarcopenia

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表 1 肌少症自我筛查量表(SARC-CalF)

Table 1. SARC-CalF

条目	评分
Q1小腿围测量值：cm(填写两侧小腿围平均值)	10=男性≤34 cm，女性≤33 cm；0=男性＞34 cm，女性＞33 cm
Q2提起并搬运4.5公斤重物是否困难？	0=无困难，1=有一些困难，2=有很大困难或不能完成
Q3步行走过房间是否困难？	0=无困难，1=有一些困难，2=有很大困难，需要辅助，或不能完成
Q4从床上或椅子上起身是否困难？	0=无困难，1=有一些困难，2=有很大困难，或没有他人帮助不能完成
Q5上10级台阶是否困难？	0=无困难，1=有一些困难，2=有很大困难或不能完成
Q6过去1年内您跌倒了多少次？	0=没有，1=1~3次，2=4次以上
注：SARC-CalF量表评分≥11分为筛查阳性。

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表 2 肌少症运动处方

Table 2. Exercise prescription for sarcopenia

阶段	项目	内容
第一阶段：热身		进行5 min的拉伸运动有助于预防肌肉拉伤
第二阶段：正式运动	抗阻训练(30 min)	卧位。a1.双桥运动：20次/组，3组/d；b1.侧桥运动(左右两侧)：20次/组，3组/d；c1.空中蹬自行车训练：10次/组，3组/d；d1.直腿抬高训练(包括髋屈曲、外展、后伸动作)：20次/组，2组/d
		坐位。a2.上肢哑铃举重训练，包括腕关节屈曲、上臂及肩部的屈曲、外展和后伸动作：10次/组，3组/d；b2.下肢弹力带抗阻训练，专注于膝关节的伸展动作：20次/组，3组/d；c2.使用股四头肌训练仪进行抗阻训练，20次/组，3组/d
		立位。a3.下肢弹力带抗阻训练，包括髋屈曲、外展、后伸动作：10次/组，3组/d；b3.功率自行车抗阻训练：每组持续10 min
	有氧运动	a4.散步：持续30 min；b4.快走：持续20 min；c4.慢跑：持续10 min
第三阶段：恢复整理		5 min的温和拉伸有助于预防乳酸的积累
注：正式的运动时段可以根据实际情况灵活安排，但累积的运动时间应≥30 min，并且建议每周进行3~4次。应确保每日对运动组合进行记录。

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表 3 肌少症患者随访记录表

Table 3. Muscle atrophy patient follow-up record form

肌少症患者随访记录表
一、基本信息
姓名：________性别：____年龄：____
档案号：________随访日期：________
随访方式：□门诊□家访□电话/视频
二、随访内容
1. 症状与功能评估
□近3个月跌倒史：____次(时间/情景：________________)
□ 5次起立实验时间：____秒
□ 6 m步速：____秒
□握力：____kg
□日常活动能力(ADL量表评分)：____分
2. 营养状况
每日蛋白质摄入：□达标(≥1.2 g/kg体重) □不足
维生素D补充：□是(剂量____ IU/日) □否
每日热量摄入：________□达标□未达标
其他营养问题：________________________
3. 运动依从性
抗阻训练：□每周≥3次□偶尔□未执行
有氧运动：□每周≥150分钟□偶尔□未执行
运动障碍原因：□时间不足□疼痛□缺乏指导□其他____
4. 合并症与用药
新增疾病：________________________
药物调整(如激素、降糖药等)：________________
5. 辅助检查
□肌肉量检测(BIA/DXA)：____kg(较前□增加□稳定□下降)
□ 25(OH)D水平：____nmol/L
□其他：________________
三、干预调整方案
1. 运动处方：新增/调整：□抗阻训练(____组/次) □平衡训练□其他____
2. 营养建议：□增加蛋白质至____g/日□补充维生素D ____IU/日□增加热量至____
3. 药物调整：________________________
4. 转诊建议：□康复科□营养科□老年科□其他________
四、下次随访计划
时间：____年____月____日
重点目标：□肌力提升□跌倒预防□营养改善□其他____
五、备注
患者疑问：________________________
家属沟通要点：______________________
随访医生签名：________
随访时间：________
使用说明:
1.随访频率：建议初期每3个月1次，稳定后6个月1次。
2.红色预警：出现≥2次跌倒或ADL显著下降需紧急干预。
3.多学科协作：合并骨质疏松、糖尿病等需联合专科管理。

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