以社区为基础的老年痴呆合作式阶梯管理模式研究

An effective and feasible community-based dementia management strategy is urgently needed in China, because most Chinese patients with dementia receive no professional management in communities. Researchers of this study adapted the Collaborative Care Model for Mental Disorders in Western countries and modified it based on available services resources in Chinese communities. A Collaborative Care Model for dementia was developed, which integrated psychogeriatric and primary care health services and community services provided by the Disabled People's Federation (DPF), and assigned services resources according to the principal of stepped care. This Community-based Collaborative Stepped Care Model for Dementia (CCSCMD) was finalized after Delphi consultation and pilot testing. Using cluster randomized controlled trial design, an empirical study was proposed to provide CCSCMD services to 120 dementia patients of 10 communities for 30 months, and a sample of 120 dementia patients from another 10 communities receiving usual care were included as controls. Implementation of the intervention was divided into 2 stages: capacity building to form the cooperation team and continuous follow up and support for caring technologies. By comparing cognitive function, behavioral and psychological symptoms of dementia, caregiver burden, and costs of care between intervention and control groups, we explored the feasibility and cost-effectiveness of this novel way to provide community mental health services for dementia patients on the basis of China's limited specialist resources and easily accessible primary care health services and DPF social services. Our findings will facilitate the establishment of a replicable “Dementia-Community-Specialist" management model that is suited for Chinese communities.

因专科医疗资源匮乏，目前我国大多数老年痴呆患者未得到有效管理，急需有效可行的社区痴呆管理策略。研究者根据国情对发达国家的精神障碍协作式管理模式进行了本土化，构建了老年精神专科、基层医疗和残疾人联合会（残联）的社区服务为一体的痴呆合作式管理模式，并采用阶梯式照护原则分配服务资源。研究通过特尔菲专家咨询和预试验以形成正式的“以社区为基础的老年痴呆合作式阶梯管理模式”。实证研究用整群随机对照设计对10个社区的120例痴呆患者进行30个月的模式干预，并与无干预的10个社区的120例痴呆患者进行对照，干预实施分为协作团队能力建设和连续性照护技术支持两个阶段。通过比较两组患者认知功能、精神行为症状、照料者负担和成本效果的差异阐明将有限的专科资源与便利可及的基层医疗资源及残联社区服务结合以提供痴呆社区管理服务的可行性和有效性。研究发现将有助于建立国内第一个可推广的符合国情的“痴呆-社区-专科“管理模式。

目前中国尚没有开展老年痴呆的社区管理，老年痴呆的社区慢病管理策略是值得研究的重大课题。本研究结合中国社区实际、参考慢病的协作式管理理论，整合了老年精神专科、社区基层医疗和包括残联在内的其他社区服务资源，采用阶梯式照护原则分配服务资源，成功构建了“以社区为基础的老年痴呆合作式阶梯式管理模式”（CCSCMD）以为老年居家的痴呆患者及其照料者提供可及的专业的精神卫生服务。研究显示CCSCMD充分利用了社区现有的服务资源，通过以个案管理者为核心抓手，实现专科资源和社区家庭资源的联动，以痴呆患者为中心，为痴呆患者提供多层面的专业照护服务，是适合于与武汉市城乡条件接近的中国社区的老年痴呆管理模式，具有良好的科学性和可行性。实证研究数据分析显示CCSCMD干预有效延缓了痴呆的进展、减少精神行为症状的发生、减轻了照料者负担和急诊治疗率。研究发现有助于建立国内可推广的符合国情的“痴呆-社区-专科”管理模式。