基层医疗视角下老年多病共存患者治疗负担的识别与减轻策略研究进展

Research Progress on the Identification and Mitigation Strategies of Treatment Burden in Older Adults with Multimorbidity from a Primary Care Perspective

摘要: 随着人口老龄化和慢性病长期化进程加快，老年多病共存已成为基层医疗卫生服务中常见而复杂的管理问题。老年多病共存患者常同时面对多种疾病诊疗、长期用药、定期复诊、检查监测、生活方式调整和家庭照护安排。治疗措施本身具有必要性，但当多项治疗任务持续叠加，并超过患者身体功能、认知能力、经济条件和家庭支持能力时，治疗过程可能转化为新的负担。治疗负担强调患者为完成疾病治疗和健康管理所承担的工作量，以及这些工作量对其日常生活、心理状态、社会功能和生活质量造成的影响。现有治疗负担相关理论和评估工具多来源于复杂慢性病患者、多病共存患者或一般慢性病患者研究，可为老年多病共存患者管理提供重要参考；但在基层应用时，还需结合老年患者衰弱、认知功能下降、多重用药和照护依赖等特点进行理解。本文围绕老年多病共存患者治疗负担的概念、主要表现、形成原因、识别与评估方法及基层减轻策略进行综述，并在此基础上初步构建适用于中国基层医疗环境的治疗负担识别–评估–干预整合框架，以期为全科医生和家庭医生团队开展个体化、连续性慢病管理提供参考。

Abstract: With the acceleration of population ageing and the long-term management of chronic diseases, multimorbidity among older adults has become a common and complex challenge in primary health care. Older adults with multimorbidity often face multiple disease-related treatments, long-term medication use, regular follow-up visits, examinations and monitoring, lifestyle modification, and family caregiving arrangements. Although these therapeutic measures are necessary, the continuous accumulation of treatment-related tasks may become a new source of burden when they exceed patients’ physical function, cognitive capacity, financial resources, and family support. Treatment burden refers to the workload that patients undertake to manage their diseases and health care, as well as the impact of this workload on their daily life, psychological status, social functioning, and quality of life. Existing theories and assessment tools related to treatment burden are mostly derived from studies of patients with complex chronic conditions, multimorbidity, or chronic diseases in general. These findings provide important references for the management of older adults with multimorbidity; however, their application in primary care should take into account age-related characteristics, such as frailty, cognitive decline, polypharmacy, and care dependence. This review summarizes the concept, main manifestations, contributing factors, identification and assessment methods, and primary care-based mitigation strategies of treatment burden in older adults with multimorbidity. On this basis, it proposes a preliminary integrated framework for the identification, assessment, and intervention of treatment burden in Chinese primary care settings, with the aim of informing individualized and continuous chronic disease management by general practitioners and family doctor teams.