CRD summary

This generally well-conducted review found that community-based complex interventions can prevent the need for nursing home care and reduce the rate of falls in elderly people, helping them to continue living at home. The lack of full duplication during the review process may lead to some uncertainty regarding the reliability of the conclusions.

Authors' objectives

To assess the effectiveness of community-based complex interventions for the preservation of physical function and independence in elderly people.

Searching

The Cochrane CENTRAL Register (to January 2005), MEDLINE and EMBASE (2003 to January 2005), CINAHL (1982 to January 2005), PsycINFO (1972 to January 2005), Web of Science (2004 to 2006), ISI Science Citation Index and Social Sciences Citation Index (1945 to January 2005) were searched without language restrictions. The reference lists of trials and previous reviews were checked and any unfinished trials were followed up for final reports. A sample MEDLINE search strategy was reported in a Web appendix.

Study selection

The only eligible study design for this review was the randomised controlled trial (RCT) with a follow-up of at least 6 months. The community-based complex interventions were defined as multifactorial, providing personalised assessment and the provision of or referral to appropriate specialist medical or social care. The included studies offered a variety of complex interventions: geriatric assessment of elderly people, assessment of elderly people identified as frail, community-based care after hospital discharge, fall prevention, and group education or counselling. This intervention was compared with usual care or a minimal intervention. The population of interest was defined as individuals of at least 65 years of age who were resident at home or preparing for discharge to home. Eligible studies reported on one or more of the following outcomes: living at home, death, nursing home and hospital admissions, falls and physical function.

One reviewer screened titles and abstracts for selection.

Assessment of study quality

Losses to follow-up were used as a marker of study quality and recorded as ≤1%, ≤ 5% or other. The method of randomisation was also assessed and its impact investigated.

One reviewer extracted the data; the data were extracted in duplicate for 64% of the included papers. Any disagreements in the extracted data were resolved by discussion.

Data extraction

Where the data were insufficient for outcome extraction, the results were summarised descriptively. Relative risks (RRs) were calculated for all dichotomous outcomes. 'Not living at home' was extracted rather than 'living at home'; where these data were not available, the sum of deaths and nursing home admissions was used. For physical function, data were extracted as mean differences. If standard deviations had not been reported these were calculated as per Cochrane Handbook recommendations. For all outcomes, scales were recoded to ensure that high values indicated poor physical functioning.

The intensity level of the complex interventions was calculated by summing three measures of intervention intensity: number of disciplines involved, number of scheduled visits and duration of the intervention. Each aspect was scored, giving a maximum overall score of 9. Interventions with a score of 1 to 4 were regarded as low intensity, 5 to 6 as medium intensity and 7 to 9 as high intensity.

One reviewer extracted the data; the data were extracted in duplicate for 64% of the included papers. Any disagreements in the extracted data were resolved by discussion.

Methods of synthesis

Pooled RRs for dichotomous data and standardised mean differences (SMDs) for continuous data, plus 95% confidence intervals (CIs), were calculated using a fixed-effect meta-analysis (Mantel-Haenszel). Heterogeneity was assessed using the I² statistic and, where this was greater than 50%, a random-effects analysis (DerSimonian and Laird) was carried out. Meta-regression was also used. Publication bias was assessed using funnel plots. Sensitivity analyses were used extensively to evaluate the various assumptions and pooling decisions made in the review.

Results of the review

A total of 89 intervention trials were included in this review, all RCTs with a total of 97 984 participants (range: 54 to 43,219).

Randomisation was by individual or household in 80 trials and by cluster in the remaining 9 studies. Losses to follow-up were 1% or less in 40 out of 84 trials with death as an outcome; sensitivity analyses did not find this affected the findings.

Key results are presented below; more detailed results, including those relating to heterogeneity and the various sensitivity analyses, were presented in the original paper.

The risk of not living at home was lower in the intervention group than in the control (60 trials, n=79,578; RR 0.95, 95% CI: 0.93, 0.97). The risk of nursing home admission was reduced in the intervention group compared with the control (54 trials, n=79,575; RR 0.87, 95% CI: 0.83, 0.90), as was the risk of a hospital admission (41 trials, n=20,047; RR 0.94, 95% CI: 0.91, 0.97). There was no difference in the incidence of death (84 trials, n=93,754; RR 1.00, 95% CI: 0.97, 1.02). Physical function was measured using activities of daily living, generic outcomes or the SF-36 scale; all analyses of these outcomes showed an overall benefit for the intervention group, although some heterogeneity was noted.

Authors' conclusions

Complex interventions can prevent the need for nursing home care and reduce the rate of falls in elderly people, which helps them to continue living at home. It is suggested that all elderly people may benefit from assessment and appropriate individualised interventions.

CRD commentary

This review addressed a broad question but clearly specified the limits and details in the selection criteria. The searches included several relevant databases, but the restrictions placed on search dates for MEDLINE and EMBASE and the lack of a specific search for unpublished studies might have resulted in some papers being missed. Although there was no mention of language restrictions in the publication, the authors confirmed that none were applied. The lack of duplication in some parts of the review process may have lead to error and/or bias at various stages (e.g. study selection). Loss to follow-up was used as the indicator of study quality, with the impact of randomisation also being assessed, but there was no consideration of allocation concealment or blinding. It is not possible to ascertain the quality of the included studies from the sparse study details reported in the paper. However, a sample search strategy and multiple tables are available on the Lancet website or from the authors. The analysis was reported clearly and in detail: the complex data set seems to have been dealt with appropriately and sensitivity analyses were used to check assumptions. This was a generally well-conducted review, with some attempts being made to reduce error and bias during the review process. However, given the lack of full duplication throughout the review, there is some question over the reliability of the conclusions.

Implications of the review for practice and research

Practice: The authors stated that the evidence suggests that all elderly people may benefit from assessment and appropriate individualised interventions, particularly in situations where services are less well developed. They also stated that the withdrawal of well-developed services would be inappropriate.

Research: The authors did not state any implications for further research.

Funding

MRC Health Services Research Collaboration.

Bibliographic details

Beswick A D, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. Lancet 2008; 371: 725-735. [PMC free article: PMC2262920] [PubMed: 18313501]

Other publications of related interest

This additional published commentary may also be of interest.

Stott DJ, Langhorne P, Knight PV. Multidisciplinary care for elderly people in the community. Lancet 2008;371:699-700.

Indexing Status

Subject indexing assigned by NLM

MeSH

Activities of Daily Living /classification; Aged; Community Networks /organization & administration /statistics & numerical data; Frail Elderly; Geriatric Assessment /methods /statistics & numerical data; Health Status; Housing for the Elderly /statistics & numerical data; Humans; Mortality; Patient Discharge; Randomized Controlled Trials as Topic; Risk

AccessionNumber

12008008107

Database entry date

03/11/2008

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.