【摘要】 骨质疏松症是我国老年人群的重要健康问题，会导致脆性骨折、失能，给患者、家庭和社会带来沉重负担。传统骨质疏松管理以疾病为中心，缺乏整体观。老年骨质疏松患者常常存在多种疾病共存、合并躯体功能下降、跌倒、疼痛、衰弱、肌少症、营养不良、焦虑抑郁等老年综合征、依从性不佳等现状，需综合评估全程管理干预。老年综合评估（comprehensive geriatric assessment, CGA）是老年医学的核心技术，可以改善老年人的功能状况和健康结局。本文探索基于CGA的骨质疏松管理模式，阐述本模式资源配置、管理流程、评价指标，在实践中对本模式进行优化改进，以期为我国骨质疏松及老年慢病管理提供参考，促进健康老龄化。更多还原

【Abstract】 Osteoporosis is an important health problem for elderly in our country, which can lead to fragility fractures and disability and cause heavy burden to patients, families and society. The traditional management of osteoporosis focuses on the disease and lacks a holistic view. The elderly patients with osteoporosis often have many conditions, such as coexistence of multiple diseases, physical function decline, fall, pain, frailty, sarcopenia, malnutrition, anxiety and depression. Therefore, comprehensive assessment and whole-process management intervention are needed. Geriatric comprehensive assessment(CGA) is a core technology in geriatric medicine, which can improve the functional status and health outcomes of the elderly. This article introduces the management model of osteoporosis based on CGA we established, including the resource allocation, management process, evaluation indicators and quality improvement, in order to provide reference for the management of osteoporosis and chronic diseases of the elderly in China, and to promote healthy aging.更多还原