基于衰弱风险评估的多维度协同管理对存在衰弱风险的老年T2DM患者血糖控制和健康促进行为的影响

doi:10.3969/j.issn.1003-9198.2026.04.013

摘要/Abstract

摘要： 目的探讨基于衰弱风险评估的多维度协同管理对存在衰弱风险的老年T2DM患者血糖控制和健康促进行为的影响。方法选取2024年1—12月在中国人民解放军东部战区总医院内分泌科治疗的存在衰弱风险的128例老年T2DM患者作为研究对象,采用随机对照设计,将患者分为干预组(n=64)和对照组(n=64)。对照组实施常规糖尿病管理,干预组接受基于衰弱风险评估的多维度协同管理。比较2组干预前、干预3个月后餐后 2 h血糖(2hPG)、FPG、HbA1c、衰弱评分(FP)总分、步速、握力、健康促进行为量表(HPLP-Ⅱ)得分、糖尿病痛苦量表(DDS)评分及糖尿病自我管理行为量表(SDSCA)评分差异。结果 (1)血糖控制:干预前2组2hPG、FPG、HbA1c 差异无统计学意义(P＞0.05),干预后2组2hPG、FPG均降低,且干预组水平更低(P＜0.05);2组干预前后HbA1c差异无统计学意义(P＞0.05)。(2)衰弱情况:干预前2组FP总分、握力、步速差异均无统计学意义(P＞0.05),干预后2组FP总分、握力、步速均较干预前改善,且干预组改善幅度更优(P＜0.05)。(3)健康促进行为:干预前2组HPLP-Ⅱ各维度得分差异均无统计学意义(P＞0.05),干预后2组HPLP-Ⅱ各维度得分均高于干预前,且干预组改善幅度更优(P＜0.05)。(4)糖尿病痛苦及自我管理:干预前2组DDS及SDSCA评分差异无统计学意义(P＞0.05),干预后2组DDS评分降低,SDSCA评分提高,且干预组改善幅度更大(P＜0.05)。结论基于衰弱风险评估的多维度协同管理可有效改善存在衰弱风险的老年T2DM患者的血糖控制,减轻糖尿病相关心理痛苦,增强自我管理能力,并促进健康行为的全面优化。

关键词: 2型糖尿病, 衰弱风险评估, 多维度协同管理, 血糖控制, 健康促进行为, 老年人

Abstract: Objective To investigate the effect of multi-dimensional collaborative management based on frailty risk assessment on blood glucose control and health promotion behavior in elderly patients with type 2 diabetes mellitus(T2DM) complicated with frailty risk. Methods A total of 128 elderly T2DM patients with frailty risk who were treated in the Department of Endocrinology, General Hospital of Eastern Theater Command of Chinese People’s Liberation Army from January to December 2024 were selected as the research subjects. The patients were divided into intervention group (n=64) and control group (n=64) by randomized methods.The 2-hour postprandial plasma glucose (2hPG), fasting blood glucose (FPG), glycosylated hemoglobin (HbA1c), total score of frailty score (FP), pace, grip strength, health promotion behavior scale (HPLP-Ⅱ) score, diabetes distress scale (DDS) and diabetes self-management behavior scale (SDSCA) were compared between the two groups before intervention and 3 months after intervention. Results There were no significant differences in 2hPG, FPG and HbA1c between the two groups before intervention (P>0.05). After intervention, the levels of 2hPG and FPG decreased in both groups, especially in the intervention group(P<0.05). There were no significant differences in total score of FP, grip strength and pace between the two groups before intervention (P>0.05). After intervention, the total score of FP, grip strength and pace of the two groups were improved compared with those before intervention, especially in the intervention group (P<0.05). There were no significant differences in the scores of each dimensions of HPLP-Ⅱ between the two groups before intervention (P>0.05). The scores of each dimensions of HPLP-Ⅱ in the two groups after intervention were higher than those before intervention, especially in the intervention group (P<0.05). There were no significant differences in DDS and SDSCA scores between the two groups before intervention (P>0.05). After intervention, the DDS scores of the two groups decreased, the SDSCA scores increased, especially in the intervention group (P<0.05). Conclusions The multi-dimensional collaborative management based on frailty risk assessment can effectively improve blood glucose control, reduce diabetes-related psychological pain, enhance self-management ability, and promote the comprehensive optimization of health behaviors in elderly patients with T2DM complicated with frailty risk.

Key words: type 2 diabetes mellitus, frailty risk assessment, multi-dimensional collaborative management, blood glucose control, health promotion behavior, aged

中图分类号:

孟寒露, 沈秋月, 陈君君, 陈晨, 徐莉莉, 郭青玉, 陈敏. 基于衰弱风险评估的多维度协同管理对存在衰弱风险的老年T2DM患者血糖控制和健康促进行为的影响[J]. 实用老年医学, 2026, 40(4): 394-399.

MENG Hanlu, SHEN Qiuyue, CHEN Junjun, CHEN Chen, XU Lili, GUO Qingyu, CHEN Min. Effect of multi-dimensional collaborative management based on frailty risk assessment on blood glucose control and health promotion behavior in elderly patients with T2DM complicated with frailty risk[J]. Practical Geriatrics, 2026, 40(4): 394-399.

参考文献

[1] 张怡, 杨波, 李茂, 等. 2018—2022年成都地区体检人群2型糖尿病流行病学特征及影响因素分析[J]. 现代预防医学, 2024, 51(17):3157-3162, 3179.
[2] ARIF E, ELLABAN M M, SHAAT M M.Frailty and nutritional status in Egyptian diabetic seniors at Ain Shams Geriatrics Hospital; a cross-sectional study[J]. Egypt J Intern Med,2025,37(1):111.
[3] OKAB A A, AL-GANMI A H A, JAWAD A K, et al. Nutritional status and frailty amongst elderly people with diabetes at endocrine and diabetes centres in Baghdad City, Iraq[J]. Niger Postgrad Med J, 2025, 32(3):165-170.
[4] CEMALI M, ÖZTÜRK D, SARI M, et al. Assessment of pain, frailty, fear of falling, and kinesiophobia in older adults with and without type 2 diabetes mellitus[J]. J Aging Phys Act, 2025, 34(1):51-60.
[5] GU Y, HAN X, LIU J, et al. Frailty and incident diabetes among middle-aged and older adults:evidence from a large prospective cohort in China[J]. Nutr Metab Cardiovasc Dis, 2025, 35(10):104114.
[6] 谢艳红, 杨晓红, 段彦霞, 等. LEARNS护理模式结合短视频健康教育在老年2型糖尿病患者中的应用效果[J]. 中国健康教育, 2024, 40(12):1133-1137.
[7] 唐青峰, 汪晶晶, 赵海燕, 等. 老年糖尿病病人衰弱风险预测模型的建立与验证[J]. 护理研究, 2024, 38(17):3065-3071.
[8] 陈露, 徐李华, 陈文秀, 等. 多维度协同护理在老年髋部骨折患者术后疼痛管理中的应用[J]. 护理实践与研究, 2025, 22(3):423-428.
[9] 《中国老年型糖尿病防治临床指南》编写组. 中国老年2型糖尿病防治临床指南(2022年版)[J]. 中国糖尿病杂志, 2022, 30(1):2-51.
[10] 杨柳, 王晓云, 闫慧楠. 八段锦联合认知训练对老年糖尿病患者认知衰弱干预的临床研究[J]. 中国全科医学, 2023, 26(23):2848-2853.
[11] 应巧燕, 刘华平, 郭欣颖, 等. 老年人衰弱筛查和评估的证据总结[J]. 护理学杂志, 2017, 32 (1):95-98.
[12] KAMALI A S, SADEGHI R, TOL A,et al. Reliability and validity of kurdish language version of health promoting lifestyle profile llamong kurdish healthcare providers kurdish version of HPLP-Ⅱ[J].Arch lran Med,2016,19(12):824-831.
[13] 杨青, 刘雪琴. 中文版糖尿病痛苦量表信效度评价[J]. 护理学报, 2010, 17(17):8-10.
[14] 华丽, 朱伟萍. 中文版《糖尿病自我管理行为量表》的信效度验证[J]. 解放军护理杂志, 2014, 31(16):5-8.
[15] 吴艳萍, 雷园园, 申晋波, 等. 不同运动方式对T2DM患者血糖控制及并发症危险因素的影响[J]. 中国老年学杂志, 2022, 42(9):2165-2169.
[16] 胡遴, 封海霞, 韩晶, 等. 基于COM-B模型的弹力带抗阻训练方案对衰弱前期老年2型糖尿病患者的干预研究[J]. 中国医学前沿杂志:电子版, 2025, 17(4):91-98.
[17] 张爽, 陈影, 孙娜雅, 等. 综合运动训练对老年糖尿病患者衰弱和躯体功能的影响[J]. 中华护理杂志, 2020, 55(10):1445-1451.
[18] 王英杰, 刘薇, 朱宏伟, 等. 老年衰弱患者肌力训练干预方案的构建及应用研究[J]. 中华护理杂志, 2024, 59(14):1669-1677.
[19] PEÑA-LONGOBARDO L M, OLIVA-MORENO J, ZOZAYA N, et al. Economic evaluation of a multimodal intervention in pre-frail and frail older people with diabetes mellitus:the MID-FRAIL project[J]. Expert Rev Pharmacoecon Outcomes Res, 2021, 21(1):111-118.
[20] WU P, LIAO L. A theory-based nursing intervention to improve self-management behavior and health status in older adults with type 2 diabetes and frailty[J]. Res Gerontol Nurs, 2024, 17(6):293-306.
[21] 王雪, 聂恒卓, 刘海平. OTO模式对社区老年2型糖尿病患者血糖控制水平及自我管理行为能力的影响[J]. 中国全科医学, 2023, 26(1):74-81.