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

BMJ 2024; 384 doi: https://doi.org/10.1136/bmj-2023-077764 (Published 21 March 2024) Cite this as: BMJ 2024;384:e077764

Linked Editorial

Maintaining independence in older adults
  1. Thomas F Crocker, associate professor1,
  2. Joie Ensor, associate professor2 3,
  3. Natalie Lam, research fellow1,
  4. Magda Jordão, research fellow1,
  5. Ram Bajpai, lecturer in biostatistics3,
  6. Matthew Bond, medical statistics research assistant3,
  7. Anne Forster, professor of ageing and stroke research1,
  8. Richard D Riley, professor of biostatistics2 3,
  9. Deirdre Andre, library research support advisor4,
  10. Caroline Brundle, elderly care researcher1,
  11. Alison Ellwood, aged care researcher1,
  12. John Green, rehabilitation research programme manager1,
  13. Matthew Hale, geriatric academic fellow1,
  14. Lubena Mirza, elderly care researcher1,
  15. Jessica Morgan, geriatric medicine doctor5,
  16. Ismail Patel, elderly care researcher1,
  17. Eleftheria Patetsini, ageing research assistant1,
  18. Matthew Prescott, trial manager1,
  19. Ridha Ramiz, ageing research assistant1,
  20. Oliver Todd, clinical lecturer1,
  21. Rebecca Walford, anaesthetics doctor5,
  22. John Gladman, professor of medicine in older people, consultant geriatrician6 7,
  23. Andrew Clegg, professor of geriatric medicine1
  1. 1Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
  2. 2Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
  3. 3Centre for Prognosis Research, School of Medicine, Keele University, Keele, UK
  4. 4Research Support Team, Leeds University Library, University of Leeds, Leeds, UK
  5. 5Geriatric Medicine, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
  6. 6Centre for Rehabilitation and Ageing Research, Academic Unit of Injury, Inflammation and Recovery Sciences, University of Nottingham, Nottingham, UK
  7. 7Health Care of Older People, Nottingham University Hospitals NHS Trust, Nottingham, UK
  1. Correspondence to: T F Crocker medtcro{at}leeds.ac.uk (or @AUASResearch on Twitter/X)
  • Accepted 14 February 2024

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.

Footnotes

  • Contributors: AC, TC, JGl, and RRi conceived of the study. AC, TC, JE, AF, JGl, MJ, NL, EP, and RRi designed the study. DA, TC, and NL developed the search strategy. DA executed the database and trial register searches. TC, JGr, MJ, NL, JM, EP, RRa, and RW selected the studies. RB, CB, TC, JGr, MH, MJ, NL, JM, LM, EP, IP, RRa, OT, and RW extracted data. AC and JGl assessed frailty. AC, TC, AE, AF, JGl, MJ, and NL did intervention grouping. CB, TC, MJ, NL, and MP assessed risk of bias. MJ liaised with patient and public involvement groups. RB, MB, and JE prepared and analysed effectiveness data. JE and RRi supervised the meta-analyses. TC and NL assessed the certainty of the evidence. TC and NL did economic and narrative synthesis. AC, TC, JE, AF, JGl, NL, RRi, and OT interpreted the findings. TC wrote the first draft of the manuscript with input from AC, JE, AF, and JGl. All authors contributed to critically reviewing or revising the manuscript. CB, MB, RB, AC, TC, JE, JGl, JGr, MH, MJ, NL, JM, LM, EP, IP, MP, RRa, OT, and RW collectively accessed and verified the underlying data reported in the manuscript. JE and NL contributed equally. TC is the guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme (NIHR128862) and will be published in full in Health Technology Assessment.176 The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The grant applicants designed the overarching systematic review and network meta-analysis; the funders approved the protocol. The funders have not been involved in any aspect of the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: AC, TC, JE, AF, JGl, MJ, NL, and RRi had financial support from the NIHR Health Technology Assessment Programme for the submitted work; MB had financial support from the PhD Graduate Teaching Fund at the University of Liverpool for the submitted work; DA declares payment made to her employer, University of Leeds Library, from the Academic Unit for Ageing and Stroke Research, Bradford Institute for Health Research, for services that included contributions to the submitted work; TC, AC, and AF received research funding from NIHR Programme Grants for Applied Research; AC and AF also received research funding from NIHR HSDR Programme; AC also received research funding from Health Data Research UK, NIHR ARC Yorkshire and Humber, NIHR Leeds BRC, and Dunhill Medical Trust; AF also declares NIHR Senior Investigator award, National Institute for Health (USA) payment for panel membership in 2021 and 2022, and University of Leeds Governor representative on the Governors Board of Bradford Teaching Hospitals NHS Foundation Trust; MB and MP received NIHR pre-doctoral fellowship funding; RB is supported by matched funding awarded to the NIHR Applied Research Collaboration (West Midlands) and is a member of the data monitoring committee for the Predict and Prevent AECOPD Trial and College of Experts, Versus Arthritis; AC is a member of NIHR HTA Commissioned Research Funding Committee and Dunhill Medical Trust Research Grants Committee; RRi received personal payments for training courses provided in-house to universities (Leeds, Aberdeen, Exeter, LSHTM) and other organisations (Roche), has received personal payments from the BMJ and BMJ Medicine as their statistical editor, is a co-convenor of the Cochrane Prognosis Methods Group and on the Editorial Board of Diagnostic and Prognostic Research, and Research Synthesis Methods, but receives no income for these roles, receives personal payment for being the external examiner of the MSc Medical Statistics, London School of Hygiene and Tropical Medicine, was previously an external examiner for the MSc Medical Statistics at University of Leicester, has written two textbooks for which he receives royalties from sales (Prognosis Research in Healthcare, and Individual Participant Data Meta-analysis), is a lead editor on an upcoming book (Cochrane Handbook for Prognosis Reviews, Wiley, 2025), for which he will receive royalties from sales, has received consulting fees for a training course on IPD meta-analysis from Roche in 2018, the NIHR HTA grant paid for travel to Leeds for one meeting, and is a member of the NIHR Doctoral Research Fellowships grant panel, and a member of the MRC Better Methods Better Research grant panel—for the latter, he receives an attendance fee; MH declares NIHR Academic Clinical Fellowship; OT declares NIHR Academic Clinical Lectureship and Dunhill Medical Trust Doctoral Research Fellowship RTF107/0117; no other relationships or activities that could appear to have influenced the submitted work.

  • Transparency: The lead author (the manuscript's guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: To ensure that we clearly communicate our findings with patients and member of the public, we spent time discussing the intervention components we had identified with Frailty Oversight Group members. Through this work, we developed and refined our descriptions of the components. Frailty Oversight Group members helped to draft and revise the plain language summary of our findings (see appendix 2). This will be included in the final report to be published in Health Technology Assessment,176 as well as on our website. We have produced short video presentations of our work that are also available. Our findings will be publicised on social media and at our regular research engagement events in the local community. As this systematic review was secondary research using aggregated, anonymised data, we do not have any contact details for the participants in the primary research to enable us to share the findings directly with them.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

The data associated with this paper will be openly available indefinitely upon publication under a Creative Commons attribution license from the University of Leeds Data Repository. Summary effect estimates and findings from network meta-analyses: https://doi.org/10.5518/1377; risk of bias judgments: https://doi.org/10.5518/1386.

http://creativecommons.org/licenses/by/4.0/

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.

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