Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis

• Published in: Health technology assessment (Winchester, England) England), 2024-08, Vol.28 (48), p.1-194
• Main Authors: Crocker, Thomas Frederick, Lam, Natalie, Ensor, Joie, Jordão, Magda, Bajpai, Ram, Bond, Matthew, Forster, Anne, Riley, Richard D, Andre, Deirdre, Brundle, Caroline, Ellwood, Alison, Green, John, Hale, Matthew, Morgan, Jessica, Patetsini, Eleftheria, Prescott, Matthew, Ramiz, Ridha, Todd, Oliver, Walford, Rebecca, Gladman, John, Clegg, Andrew
• Format: Article
• Language: English
• Subjects: Activities of Daily Living; Aged; Aged, 80 and over; ageing well in place; community dwelling older person; community dwelling person; Community Health Services - organization & administration; comprehensive geriatric assessment; Frail Elderly; Frailty; Humans; Independent Living; multicomponent package of care; Network Meta-Analysis; preventive health services; primary health care practice; Quality of Life; Randomized Controlled Trials as Topic; reablement rehabilitation therapy; rehabilitation therapy; resilience; systematic review with network meta analysis
• ISSN: 2046-4924; 1366-5278; 2046-4924
• DOI: 10.3310/HNRP2514

Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement. To synthesise evidence of the effectiveness of community services to sustain independence for older people grouped according to their intervention components, and to examine if frailty moderates the effect. Systematic review and network meta-analysis. Studies: Randomised controlled trials or cluster-randomised controlled trials. Participants: Older people (mean age 65+) living at home. Interventions: community-based complex interventions for sustaining independence. Comparators: usual care, placebo or another complex intervention. Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year. We searched MEDLINE (1946-), Embase (1947-), CINAHL (1972-), PsycINFO (1806-), CENTRAL and trial registries from inception to August 2021, without restrictions, and scanned reference lists. Interventions were coded, summarised and grouped. Study populations were classified by frailty. A random-effects network meta-analysis was used. We assessed trial-result risk of bias (Cochrane RoB 2), network meta-analysis inconsistency and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation for network meta-analysis). We included 129 studies (74,946 participants). Nineteen intervention components, including 'multifactorial-action' (multidomain assessment and management/individualised care planning), were identified in 63 combinations. The following results were of low certainty unless otherwise stated. For living at home, compared to no intervention/placebo, evidence favoured: multifactorial-action and review with medication-review (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty) multifactorial-action with medication-review (odds ratio 2.55, 95% confidence interval 0.61 to 10.60) cognitive training, medication-review, nutrition and exercise (odds ratio 1.93, 95% confidence interval 0.79 to 4.77) and activities of daily living training, nutrition and exercise (odds ratio 1.79, 95% confidence interval 0.67 to 4.76). Four intervention combinations may reduce living at home. For instrumental activities of daily living, evidence favoured multifactorial-action and review with medication-review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty)