Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis
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 
Published: March 2023

Background
Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement.

Objectives
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.

Review design
Systematic review and network meta-analysis.

Eligibility criteria
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.

Main outcomes
Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year.

Data sources
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.

Review methods
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).

Results
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.

Limitations
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.

Conclusions
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.

Future work
Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.

Study registration
This study is registered as PROSPERO CRD42019162195.

Funding
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 Health Technology Assessment; Vol. 28, No. 48. See the NIHR Funding and Awards website for further award information.