Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis

Abstract

Objective: To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people.

Design: Systematic review and network meta-analysis.

Data sources: Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies.

Eligibility criteria: Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks' follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators.

Main outcomes: Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months.

Data synthesis: Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane's revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment.

Results: The review included 129 studies (74 946 participants). Nineteen intervention components, including "multifactorial action from individualised care planning" (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine review with medication review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, -0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty.

Conclusions: The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts.

Registration: PROSPERO CRD42019162195.

Fig 1

PRISMA flow diagram showing identification, selection, and inclusion of studies from databases, registers, and other sources. ICTRP=International Clinical Trials Registry Platform

Fig 2

Network plots for analyses of main outcomes in medium term (~12 months) that yielded ≥1 finding of at least low certainty. AC indicates network including available care; hmcr indicates network including formal homecare. Each node is labelled with intervention group abbreviation and number of participants. Node size is proportionate to number of participants; edge thickness is proportionate to number of comparisons. Intervention and control group abbreviations are combination of: ADL=activities of daily living training; aids=provision of aids and adaptations; cgn=cognitive training; comm=technology for communication and engagement; educ=health education; eng=engagement in meaningful activities; exrc=physical exercise; hmcr=formal homecare; hmnt=alternative medicine; med=medication review; mfa=multifactorial action; mfar=multifactorial action and follow-on routine review; mntr-mfa=monitoring, which may trigger multifactorial action; ntr=nutritional support; psyc=psychological therapy; rsk-mfa=risk screening, which may trigger multifactorial action; sst=social skills training; vchr=care voucher provision; wlfr=welfare rights advice; w/med=with medication-review; w/slfm=with self-management strategies

Fig 3

Summary of moderate and low certainty evidence for main outcomes synthesised with network meta-analysis. *In comparison with reference comparator. For intervention groups including homecare, reference comparator is homecare; for all other intervention groups, reference comparator is available care. Living at home (+ favoured); instrumental ADL (+ favoured); personal ADL (+ favoured); hospital admission (– favoured); care home placement (– favoured). ADL=activities of daily living; T1=short term timeframe (24 weeks to 9 months); T2=medium term timeframe (>9 months to 18 months; T3=long term timeframe (>18 months); +++++=very large increase; ++++=large increase; +++=moderate increase; ++= slight increase; +=very slight increase; ~=little to no difference; -=very slight reduction;--=slight reduction; ---=moderate reduction; ----=large reduction; -----=very large reduction. Blue shades indicate possible benefit; orange shades indicate possible harm; bold indicates moderate certainty evidence

Fig 4

Living at home in medium term: comparisons with available care summary of findings table. Summary of findings table shows relative effects and anticipated absolute effects of each community based complex intervention type compared with available care (ac) for living at home outcome in medium term. Living at home is binary outcome, alternative outcome being either care home placement or death. Relative effects are odds ratio (OR) from network meta-analysis (NMA) and risk ratio (RR) calculated from odds ratio. OR>1 (or RR>1) favours listed community based complex intervention; OR<1 favours available care. Intervention types are ordered by certainty of evidence (high to very low) and ranking (highest to lowest). NMA included 21 studies, 14 nodes, and 16 937 participants in total. Follow-up ranged from 12 to 18 months. Heterogeneity was estimated as τ=8.56×10^-2. Consistency assumption held. Mean rank of available care was 9.9 (95% CI 7 to 12). *Calculated from OR and assumed comparator risk of 0.935, median available care risk among these studies. †Serious concerns about imprecision as confidence interval (CI) crosses no effect line and includes substantial benefit. CI for absolute effect with high risk population also includes pre-specified definition of very small harm, but given that this was marginal and in light of small lower CI for RR (0.9955), this was not judged as very serious. Downgrade once. ‡Very serious concerns about imprecision as CI includes substantial benefit and substantial harm. Downgrade twice. §Very serious concerns about risk of bias owing to exclusion of participants in per protocol analysis and missing outcome data in indirect evidence via homecare and multifactorial action and review versus available care comparison. Downgrade twice. ¶Very serious concerns about imprecision as CI is very wide, no closed loop exists, and direct comparison is based on indirect evidence from 122 people in homecare and multifactorial action and review and 81 people in homecare and multifactorial action and review with self-management, which does not meet optimal information size. Already downgraded twice for risk of bias; downgrade once. **Very serious concerns about risk of bias owing to exclusion of participants in per protocol analysis and missing outcome data. Downgrade twice. ††Very serious concerns about imprecision as CI is very wide, no closed loop exists, and direct comparison is based on indirect evidence from 122 people in homecare and multifactorial action and review, which does not meet optimal information size. Already downgraded twice; downgrade once. ‡‡Serious concerns about risk of bias owing to missing outcome data. Downgrade once. §§Serious concerns about risk of bias owing to recruitment process of participants and missing outcome data in one study. Downgrade once. ¶¶Very serious concerns about risk of bias owing to randomisation process and missing outcome data. Already downgraded twice; downgrade once