HEC, Paris, France.
Oliba, Via Federico Cesi 30, 00193, Rome, Italy.
Aging Clin Exp Res. 2020 Jul;32(7):1353-1358. doi: 10.1007/s40520-020-01533-z. Epub 2020 Apr 10.
Due to the increase in the older population in Europe and associated rise in the absolute number of persons with Non-Communicable Diseases (NCDs), it is becoming increasingly important to find ways to promote healthy ageing, which is defined as the process of developing and maintaining the functional ability that enables well-being in older age. Older persons with NCDs can have complex care needs due to the increased risk of frailty, multimorbidity, and polypharmacy. However, current health systems in Europe often provide fragmented care for older people with NCDs; many receive disjointed care from numerous specialists or via different levels of care. In the current article, we discuss barriers and challenges in implementing integrated care models in European settings for older NCD patients. Specifically, we discuss the need for greater use of case managers in the care and treatment persons with complex care needs as well as the lack of training and education in healthcare professionals on topics related to multimorbidity, frailty, and polypharmacy. We discuss the limitations that arise from the current focus on disease-specific guidelines and care models that do not take comorbid conditions into account, and the lack of good quality evidence that evaluates the effectiveness of integrated care interventions, especially in European health settings. We highlight the importance of evaluating and monitoring mental health in conjunction with somatic symptoms in NCD patients and discuss the integral role of information and communication technology in healthcare to streamline integrated care processes and help to achieve better outcomes for patients.
由于欧洲老年人口的增加以及与非传染性疾病（NCDs）相关的绝对人数的增加，寻找促进健康老龄化的方法变得越来越重要。健康老龄化是指发展和保持功能能力的过程，使老年人能够在晚年保持幸福。患有 NCD 的老年人由于衰弱、多病共存和多药治疗的风险增加，可能有复杂的护理需求。然而，欧洲目前的卫生系统通常为患有 NCD 的老年人提供碎片化的护理；许多人从众多专科医生或通过不同级别的护理接受脱节的护理。在当前的文章中，我们讨论了在欧洲环境中为老年 NCD 患者实施综合护理模式的障碍和挑战。具体来说，我们讨论了在护理和治疗复杂护理需求的人方面更需要使用个案经理，以及医疗保健专业人员在多疾病共存、衰弱和多药治疗相关主题方面缺乏培训和教育。我们讨论了当前关注特定疾病的指南和护理模式的局限性，这些指南和模式没有考虑到合并症，并且缺乏评估综合护理干预效果的高质量证据，特别是在欧洲卫生环境中。我们强调了在评估和监测 NCD 患者躯体症状的同时评估和监测心理健康的重要性，并讨论了信息和通信技术在医疗保健中的重要作用，以简化综合护理流程并帮助患者获得更好的结果。
