Volume 20 Issue 8
Aug.  2022
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YAO Yuan-long, SHI Wei-li, FENG Xian, HUANG Wen-bo, WANG Liu-yi. Research management strategies for multimorbidity in elderly patients[J]. Chinese Journal of General Practice, 2022, 20(8): 1267-1270. doi: 10.16766/j.cnki.issn.1674-4152.002574
Citation: YAO Yuan-long, SHI Wei-li, FENG Xian, HUANG Wen-bo, WANG Liu-yi. Research management strategies for multimorbidity in elderly patients[J]. Chinese Journal of General Practice, 2022, 20(8): 1267-1270. doi: 10.16766/j.cnki.issn.1674-4152.002574

Research management strategies for multimorbidity in elderly patients

doi: 10.16766/j.cnki.issn.1674-4152.002574


  • Received Date: 2021-10-11
    Available Online: 2022-09-26
  • At present, the aging of the global population is serious and China has also entered the accelerated stage of aging. Multimorbidity caused by aging brings severe challenges to economic and social development. Multimorbidity seriously affects the quality of life of elderly patients and increases the burden of multiple medications and treatments. With the increase in the number of chronic diseases, some patients are troubled by psychological diseases. Elderly multimorbidity could also lead to an increase in the number of hospitalisation, which directly leads to a remarkable increase in medical costs and resource utilisation. Thus, multimorbidity has gradually become a social health problem. Comorbid chronic disease management has also become the concerns of "Healthy China 2030". The current chronic disease management guidelines for single disease are more concentrated in the processing and they are often overlooked in the elderly with comorbidity. A large number of clinical practice showed that the guide for single disease is not a suitable for multimorbidity as the solution of the problem in better manage patients, with much research from domestic and foreign scholars. In 2012, The American Geriatrics Society issued guidelines for the diagnosis and treatment of geriatric multimorbidity, proposing patient-centred diagnosis and treatment strategies. The principles provide a reference and theoretical framework for multimorbidity management in China and domestic scholars have accumulated relevant experience in multi-morbidities research. The emphasis is on enhanced management of multimorbidity by establishing a multidisciplinary integrated team, developing a general practitioner system, adopting patient-centred management model and self-management model, attaching importance to comprehensive geriatric assessment and paying attention to multiple medications. This paper reviews the concept, epidemiology, hazard and management of multimorbidity to promote the health management of elderly multimorbidity in China.


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  • [1]
    WHITTY C J M, MACEWEN C, GODDARD A, et al. Rising to the challenge of multimorbidity[J]. BMJ, 2020, 368: l6964. DOI: 10.1136/bmj.l6964.
    KING D E, XIANG J, PILKERTON C S. Multimorbidity trends in United States adults, 1988-2014[J]. J Am Board Fam Med, 2018, 31(4): 503-513. doi: 10.3122/jabfm.2018.04.180008
    MAKOVSKI T T, SCHMITZ S, ZEEGERS M P, et al. Multimorbidity and quality of life: Systematic literature review and meta-analysis[J]. Ageing Res Rev, 2019, 53: 100903. DOI: 10.1016/j.arr.2019.04.005.
    KUZUYA M. Era of geriatric medical challenges: Multimorbidity among older patients[J]. Geriatr Gerontol Int, 2019, 19(8): 699-704. doi: 10.1111/ggi.13742
    BAO X Y, XIE Y X, ZHANG X X, et al. The association between multimorbidity and health-related quality of life: A cross-sectional survey among community middle-aged and elderly residents in southern China[J]. Health Qual Life Outcomes, 2019, 17(1): 107. doi: 10.1186/s12955-019-1175-0
    NGUYEN T N, NGANGUE P, HAGGERTY J, et al. Multimorbidity, polypharmacy and primary prevention in community-dwelling adults in Quebec: A cross-sectional study[J]. Fam Pract, 2019, 36(6): 706-712. doi: 10.1093/fampra/cmz023
    WILLADSEN T G, SIERSMA V, NICOLAISDOTTIR D R, et al. Symptom burden in multimorbidity: A population-based combined questionnaire and registry study from Denmark[J]. BMJ Open, 2021, 11(4): e041877. DOI: 10.1136/bmjopen-2020-041877.
    CHEN P, LI F, HARMER P. Healthy China 2030: Moving from blueprint to action with a new focus on public health[J]. Lancet Public Health, 2019, 4(9): e447. DOI: 10.1061/S2468-2667(19)30160-4.
    FEINSTEIN A R. The pre-therapeutic classification of co-morbidity in chronic disease[J]. J Chronic Dis, 1970, 23(7): 455-468. doi: 10.1016/0021-9681(70)90054-8
    BRANDLMEIER P. Multimorbidity among elderly patients in an urban general practice[J]. ZFA(Stuttgart), 1976, 52(25): 1269-1275.
    ORGANIZATION W H. The world health report 2008: Primary health care now more than ever[J]. World Health Organization, 2008, 25(7): 617.
    HARRISON J E, WEBER S, JAKOB R, et al. ICD-11: An international classification of diseases for the twenty-first century[J]. BMC Med Inform Decis Mak, 2021, 21(Suppl 6): 206.
    CHEN T, DREDZE M, WEINER J P, et al. Identifying vulnerable older adult populations by contextualizing geriatric syndrome information in clinical notes of electronic health records[J]. J Am Med Inform Assoc, 2019, 26(8-9): 787-795. doi: 10.1093/jamia/ocz093
    QUAH J H M, WANG P, NG R R G, et al. Health-related quality of life of older Asian patients with multimorbidity in primary care in a developed nation[J]. Geriatr Gerontol Int, 2017, 17(10): 1429-1437. doi: 10.1111/ggi.12881
    MITSUTAKE S, ISHIZAKI T, TERAMOTO C, et al. Patterns of co-occurrence of chronic disease among older adults in Tokyo, Japan[J]. Prev Chronic Dis, 2019, 16: E11. DOI: 10.5888/pcd16.180170.
    KINGSTON A, ROBINSON L, BOOTH H, et al. Projections of multi-morbidity in the older population in England to 2 035: Estimates from the Population Ageing and Care Simulation (PACSim) model[J]. Age and ageing, 2018, 47(3): 374-380. doi: 10.1093/ageing/afx201
    钱焊森, 马爱霞. 我国中老年人共病现状及其影响因素分析[J]. 中国药物评价, 2017, 34(6): 476-480. https://www.cnki.com.cn/Article/CJFDTOTAL-YAPJ201706025.htm

    QIAN H S, MA A X. Multimorbidity status and its riskfactors to multimorbidity in middle-agedpeople in China[J]. Chinese Journal of Drug Evaluation, 2017, 34(6): 476-480. https://www.cnki.com.cn/Article/CJFDTOTAL-YAPJ201706025.htm
    张家泳, 丛守婧, 麦勇强, 等. 广东省中山市中老年人慢性病共病现状调查及流行病学分析[J]. 现代医药卫生, 2018, 34(9): 1320-1323. https://www.cnki.com.cn/Article/CJFDTOTAL-XYWS201809014.htm

    ZHANG J Y, CONG S J, MAI Y Q, et al. Investigation and epidemiology analysis of chronic disease common diseases in elderly people in Zhongshan city[J]. Journal of Modern Medicine & Health, 2018, 34(9): 1320-1323. https://www.cnki.com.cn/Article/CJFDTOTAL-XYWS201809014.htm
    MASNOON N, SHAKIB S, KALISCH-ELLETT L, et al. What is polypharmacy?A systematic review of definitions[J]. BMC geriatrics, 2017, 17(1): 1-10. doi: 10.1186/s12877-016-0400-5
    MAIR A, WILSON M, DREISCHULTE T. Addressing the challenge of polypharmacy[J]. Annu Rev Pharmacol Toxicol, 2020, 60: 661-681. DOI: 10.1146/annurev-pharmtox-010919-023508.
    ZHAO Y W, HAREGU T N, HE L, et al. The effect of multimorbidity on functional limitations and depression amongst middle-aged and older population in China: A nationwide longitudinal study[J]. Age and ageing, 2021, 50(1): 190-197. doi: 10.1093/ageing/afaa117
    MARTINEZ-GOMEZ D, GUALLAR-CASTILLON P, GARCIA-ESQUINAS E, et al. Physical activity and the effect of multimorbidity on all-cause mortality in older adults[J]. Mayo Clin Proc, 2017, 92(3): 376-382. doi: 10.1016/j.mayocp.2016.12.004
    KUIPERS S J, NIEBOER A P, CRAMM J M. The need for co-creation of care with multi-morbidity patients-a longitudinal perspective[J]. Int J Environ Res Public Health, 2020, 17(9): 3201. doi: 10.3390/ijerph17093201
    陈阳希, 张兴虎, 杨翔, 等. Charlson共病指数与慢性心力衰竭患者预后的相关性研究[J]. 东南国防医药, 2020, 22(2): 124-128. doi: 10.3969/j.issn.1672-271X.2020.02.003

    CHEN Y X, ZHANG X H, YANG X, et al. The correlation between Charlson comorbidity index and clinical outcome in patients with chronic heart failure[J]. Military Medical Journal of Southeast China, 2020, 22(2): 124-128. doi: 10.3969/j.issn.1672-271X.2020.02.003
    高超, 于普林. 老年医学多学科整合团队工作模式的进展[J]. 中华老年医学杂志, 2020, 39(2): 238-240. doi: 10.3760/cma.j.issn.0254-9026.2020.02.026

    GAO C, YU P L. Progress on the geriatric interdisciplinary team work model[J]. Chinese Journal of Geriatrics, 2020, 39(2): 238-240. doi: 10.3760/cma.j.issn.0254-9026.2020.02.026
    QU Z, PARRY M, LIU F, et al. Self-management and blood pressure control in China: A community-based multicentre cross-sectional study[J]. BMJ Open, 2019, 9(3): e025819. DOI: 10.1136/bmjopen-2018-025819.
    王凌霄, 陈善萍, 沈静, 等. 住院老年共病患者多学科延续性管理模式研究[J]. 中华老年医学杂志, 2020, 39(2): 204-208. doi: 10.3760/cma.j.issn.0254-9026.2020.02.019

    WANG L X, CHEN S P, SHEN J, et al. Study on a multidisciplinary continuing management model for hospitalized elderly patients with multimorbidity[J]. Chinese Journal of Geriatrics, 2020, 39(2): 204-208. doi: 10.3760/cma.j.issn.0254-9026.2020.02.019
    王春燕, 张学平. 焦点解决模式对老年焦虑障碍共病高血压患者的心理护理作用[J]. 中华全科医学, 2020, 18(10): 1779-1782. doi: 10.16766/j.cnki.issn.1674-4152.001617

    WANG C Y, ZHANG X P. Psychological nursing effect of the solution-focused model on elderly patients with hypertension and generalized anxiety disorder[J]. Chinese Journal of General Practice, 2020, 18(10): 1779-1782. doi: 10.16766/j.cnki.issn.1674-4152.001617
    GIULIANTE M M, GREENBERG S A, MCDONALD M V, et al. Geriatric interdisciplinary team training 2.0: A collaborative team-based approach to delivering care[J]. J Interprof Care, 2018, 32(5): 629-633. doi: 10.1080/13561820.2018.1457630
    路云, 颜俊娴, 华娟. 老年人共病管理的研究现状及经验探究[J]. 卫生经济研究, 2017(7): 58-61. DOI: 10.14055/j.cnki.33-1056/f.20170705.003.

    LU Y, YAN J X, HUA J. Research status and experience of comorbidity management in the elderly[J]. Health Economics Research, 2017(7): 58-61. DOI: 10.14055/j.cnki.33-1056/f.20170705.003.
    SALISBURY C, MAN M-S, BOWER P, et al. Management of multimorbidity using a patient-centred care model: A pragmatic cluster-randomised trial of the 3D approach[J]. Lancet, 2018, 392(10141): 41-50. doi: 10.1016/S0140-6736(18)31308-4
    陈旭娇, 严静, 王建业, 等. 中国老年综合评估技术应用专家共识[J]. 中华老年病研究电子杂志, 2017, 4(2): 1-6. https://www.cnki.com.cn/Article/CJFDTOTAL-LNBY201702001.htm

    CHEN X J, YAN J, WANG J Y, et al. Expert Consensus on the application of comprehensive geriatric assessment technology in China[J]. Chinese Journal of Senile Diseases Research (Electronic Edition), 2017, 4(2): 1-6. https://www.cnki.com.cn/Article/CJFDTOTAL-LNBY201702001.htm
    马建新, 刘丽丽, 张金萍, 等. 老年综合评估管理模式对老年共病患者运动耐量及生活质量的影响[J]. 华南国防医学杂志, 2020, 34(8): 539-542. https://www.cnki.com.cn/Article/CJFDTOTAL-HNGY202008005.htm

    MA J X, LIU L L, ZHANG J P, et al. Effects of comprehensive geriatric assessment comprehensive management on exercise tolerance and quality of life in elderly multimorbidity patients[J]. Military Medical Journal of South China, 2020, 34(8): 539-542. https://www.cnki.com.cn/Article/CJFDTOTAL-HNGY202008005.htm
    2019 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults[J]. J Am Geriatr Soc, 2019, 67(4): 674-694. https://www.cnki.com.cn/Article/CJFDTOTAL-AHND202203006.htm
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