Abstract: Objective: To evaluate intervention effect of case management on blood sugar control level and the ability of self-management of elderly outpatient with type 2 diabetes.  Methods: 100 cases were randomly divided into intervention group (n=50) and control group (n=50) and were treated by a team of endocrinologist, dietician, diabetes specialist nurses. The patients of intervention group accepted the case management and follow-up of 6 months, the patients in control group accepted routine outpatient guidance, big lecture activities on a regular basis. Using repetitive measure analysis of variance, the patients’ blood sugar, glycosylated hemoglobin (HbA1c), blood lipid and self management level, the indicators of psychological anxiety of all patients were compared between two groups before intervention, after intervention 6 months.  Results: After case management, the 2h postprandial blood glucose, fasting glucose, HbA1c, blood lipid in the intervention group were superior to that of control group significantly (P<0.01), the self management ability (including reasonable diet, exercise and blood sugar monitoring, according to medical medicine, foot care knowledge) and psychological anxiety was also better (P<0.01).Conclusion:  The case management for elderly patients with type 2 diabetes can improve metabolism, help to reduce blood sugar, promote self management behavior, master a healthy diet and sports science, ease anxiety effectively.

Key words: Elderly patients with type 2 diabetes, Case management, Blood sugar

摘要： 目的:评价个案管理对门诊老年2型糖尿病患者血糖控制水平及自我管理能力的干预效果。方法:由内分泌科医生、营养科医生、糖尿病专科护士组成团队合作，采用随机对照试验研究设计，将门诊100例老年2型糖尿病患者随机分为干预组和对照组各50例。干预组接受6个月的个案管理和随访，对照组接受门诊常规指导，定期参加大讲课活动。采用重复测量方差分析，比较干预前、干预6个月后两组患者血糖、糖化血红蛋白（HbA1c）、血脂和自我管理水平、心理焦虑的各项指标，并进行比较。结果:接受个案管理后，干预组患者的空腹血糖、餐后2 h血糖、糖化血红蛋白、血脂值均较对照组降低（均P＜0.01）。干预组在自我管理能力（包括饮食合理、运动锻炼、血糖监测、遵医用药、足部护理知识）认识上的差异有统计学意义（P<0.01），干预组优于对照组。干预组心理焦虑状况较对照组明显降低（P<0.01）。结论:个案管理对门诊老年2型糖尿病患者的血糖代谢水平有一定改善，帮助患者降低血糖，促进患者自我管理行为的建立与提高，掌握健康饮食和科学运动，有效缓解老年糖尿病患者的心理焦虑状况。

关键词: 老年2型糖尿病, 个案管理, 血糖