Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
Centre for Prognosis Research, Keele School of Medicine, Keele University, Keele, Staffordshire, UK.
Health Technol Assess. 2024 Aug;28(48):1-194. 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). Two interventions may reduce instrumental activities of daily living. For personal activities of daily living, evidence favoured exercise, multifactorial-action and review with medication-review and self-management (standardised mean difference 0.16, 95% confidence interval -0.51 to 0.82). For homecare recipients, evidence favoured the addition of multifactorial-action and review with medication-review (standardised mean difference 0.60, 95% confidence interval 0.32 to 0.88). Care-home placement and service/economic findings were inconclusive.
High risk of bias in most results 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. Studies were diverse; findings may not apply to all contexts.
Findings for the many intervention combinations evaluated were largely small and uncertain. However, the combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Some combinations may reduce independence.
Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.
This study is registered as PROSPERO CRD42019162195.
This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128862) and is published in full in ; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.
维持独立性对老年人很重要，但对于应实施哪些社区卫生和保健服务，缺乏足够的指导。
根据干预措施的组成部分，综合评估维持老年人独立性的社区服务的有效性证据，并检验衰弱是否会调节效果。
系统评价和网络荟萃分析。
研究：随机对照试验或整群随机对照试验。参与者：居住在家中的老年人（平均年龄 65 岁以上）。干预措施：以社区为基础的复杂干预措施，以维持独立性。对照：常规护理、安慰剂或其他复杂干预。
1 年时居家生活、工具性日常生活活动、个人日常生活活动、入住养老院和服务/经济结局。
我们检索了 MEDLINE（1946 年-）、Embase（1947 年-）、CINAHL（1972 年-）、PsycINFO（1806 年-）、CENTRAL 和试验注册处，检索时间从建库至 2021 年 8 月，无限制，并扫描了参考文献列表。
对干预措施进行编码、总结和分组。根据衰弱情况对研究人群进行分类。采用随机效应网络荟萃分析。我们评估了试验结果的偏倚风险（Cochrane RoB 2）、网络荟萃分析不一致性和证据确定性（网络荟萃分析的 Grading of Recommendations Assessment, Development and Evaluation）。
我们纳入了 129 项研究（74946 名参与者）。确定了 19 个干预组成部分，包括“多因素行动”（多领域评估和管理/个体化护理计划），并将其分为 63 种组合。除非另有说明，否则以下结果的确定性较低。对于居家生活，与无干预/安慰剂相比，证据支持：多因素行动和药物审查与药物审查的回顾（比值比 1.22，95%置信区间 0.93 至 1.59；中度确定性）多因素行动与药物审查（比值比 2.55，95%置信区间 0.61 至 10.60）认知训练、药物审查、营养和运动（比值比 1.93，95%置信区间 0.79 至 4.77）以及日常生活活动训练、营养和运动（比值比 1.79，95%置信区间 0.67 至 4.76）。四种干预组合可能会降低居家生活。对于工具性日常生活活动，证据支持多因素行动和药物审查与药物审查的回顾（标准化均数差 0.11，95%置信区间 0.00 至 0.21；中度确定性）。两种干预措施可能会降低工具性日常生活活动。对于个人日常生活活动，证据支持运动、多因素行动和药物审查与药物审查和自我管理（标准化均数差 0.16，95%置信区间-0.51 至 0.82）。对于家庭护理接受者，证据支持在多因素行动和药物审查与药物审查的基础上增加（标准化均数差 0.60，95%置信区间 0.32 至 0.88）。家庭护理和服务/经济结果的发现尚无定论。
大多数结果存在高偏倚风险，估计值不精确，意味着大多数证据的确定性较低或非常低。很少有研究对每项比较做出贡献，这阻碍了对不一致性和衰弱的评估。研究具有多样性；研究结果可能不适用于所有情况。
评估的许多干预组合的结果大多较小且不确定。然而，最有可能维持独立性的组合包括多因素行动、药物审查和患者的持续审查。一些组合可能会降低独立性。
需要进一步研究探索作用机制和与环境的相互作用。不同的证据综合方法可能会提供更多的启示。
本研究是由英国国家卫生与保健优化研究所（NIHR）卫生技术评估计划（NIHR 奖 REF：NIHR128862）资助的，并在完整版本中发表；第 28 卷，第 48 期。有关进一步的奖励信息，请访问 NIHR 资助和奖励网站。
