Research On Chronic Disease Management Of Community Senior Citizens Based On Comprehensive Assessment Of The Elderly

Objectives:Through a comprehensive assessment of the health of the elderly,to understand the health status of the elderly,the elderly's understanding of the prevention and treatment of chronic disease,and the management of chronic disease,to explore the old chronic disease management model suitable for China's national conditions(family-community-hospital And the need to apply a comprehensive assessment of geriatrics(CGA)for health management guidance for the elderly.Methods:Among the elderly patients who were discharged from a top-three hospital in2015-2017,100 elderly people aged 70-85 years were selected according to the criteria for the study,and the chronic diseases and chronic diseases were discharged from the elderly.The management situation was investigated and analyzed,and the results of the comprehensive evaluation of the elderly at the time of discharge from the elderly were analyzed,and the related factors were analyzed,and a feasible rehabilitation intervention method for elderly chronic diseases was developed.The content of the comprehensive assessment of the elderly is mainly: physical condition,nutritional status,comorbidity,multiple medication,functional status,psychological situation,social environment,etc.The scale used is FIM\MNA\GDS\MORSE\MMSE,etc.The potential diseases of the elderly are carried out by community health care workers for health guidance,rational medication guidance,prevention of complications,functional exercise,and home care guidance for the elderly.After one year of follow-up observation,the improvement of senile syndrome after the implementation of intervention measures,as well as the acute exacerbation of chronic diseases in the elderly,and the degree of understanding of the management of chronic diseases and the satisfaction of their own health status were investigated.Results:1)100 elderly people,53 males and 47 females,with an average age of 77.63±4.58 years old.2)elderly patients with multiple diseases coexist.The chronic diseases of elderly patients are mainly hypertension,coronary heart disease,diabetes,COPD,cerebral infarction,Peptic ulcer,chronic gastritis,chronic renal insufficiency,malignant tumors,etc.;3)Depression,insomnia,audio-visual impairment and other symptoms in the elderly,and often accompanied by osteoporosis and joint pain.4)The elderly are mainly at home.There are many problems in the management of chronic diseases in the elderly at home.Almost every elderly person has these problems: poor drug compliance,random inactivity or unauthorized drug use,frequent adverse drug reactions,and inability to seek medical treatment in time when the disease changes.Rehabilitation exercise compliance and potential disease risk factors are not well understood.5)In the analysis of the results of the FIM\MNA\GDS\MORSE\MMSE rating scale,the scores of each scale have little relationship with age,which indicates that the functional status of the body is low,malnutrition,depression,falls,cognitive impairment,etc.are the elderly.Common common problems.However,it is closely related to gender,education level,spouse status,old-age care style,chronic disease understanding,and medication type.6)After CGA intervention,the quality of life of the elderly has improved and their satisfaction with themselves is higher.The awareness rate of chronic disease management is significantly higher in the elderly,and the acute attack rate of chronic diseases is lower in the elderly.Unsafe factors such as falls and aspirations.The incidence of suffocation and falling bed is lower than that of hospitals.Conclusions:According to the results of the comprehensive evaluation of the elderly,management interventions on the elderly in the community chronic disease management can effectively control the acute episodes of chronic diseases,reduce the occurrence of adverse events,improve the quality of life of patients,and have positive effects in the management of chronic diseases in the elderly.The meaning.Suggestions:(1)In the management of chronic disease in the elderly,carry out comprehensive evaluation of the elderly,conduct chronic disease analysis,guide the elderly to rational use of drugs,functional rehabilitation,etc.,and also need the guidance of multidisciplinary teams when the disease needs.(2)In the old-age care model based on home-based care,the establishment of“family-community-hospital” three-level linkage chronic disease management has a positive significance in meeting the needs of the elderly for medical services and effectively managing the elderly with chronic diseases.(3)Rationalize the allocation of geriatric professionals to the grassroots level.