Complex interventions for improving independent living and quality of life amongst community-dwelling older adults: a systematic review and meta-analysis

Abstract

Background community-based complex interventions for older adults have a variety of names, including Comprehensive Geriatric Assessment, but often share core components such as holistic needs assessment and care planning. Objective to summarise evidence for the components and effectiveness of community-based complex interventions for improving older adults’ independent living and quality of life (QoL). Methods we searched nine databases and trial registries to February 2022 for randomised controlled trials comparing complex interventions to usual care. Primary outcomes included living at home and QoL. Secondary outcomes included mortality, hospitalisation, institutionalisation, cognitive function and functional status. We pooled data using risk ratios (RRs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs). Results we included 50 trials of mostly moderate quality. Most reported using holistic assessment (94%) and care planning (90%). Twenty-seven (54%) involved multidisciplinary care, with 29.6% delivered mainly by primary care teams without geriatricians. Nurses were the most frequent care coordinators. Complex interventions increased the likelihood of living at home (RR 1.05; 95% CI 1.00–1.10; moderate-quality evidence) but did not affect QoL. Supported by high-quality evidence, they reduced mortality (RR 0.86; 95% CI 0.77–0.96), enhanced cognitive function (SMD 0.12; 95% CI 0.02–0.22) and improved instrumental activities of daily living (ADLs) (SMD 0.11; 95% CI 0.01–0.21) and combined basic/instrumental ADLs (SMD 0.08; 95% CI 0.03–0.13). Conclusions complex interventions involving holistic assessment and care planning increased the chance of living at home, reduced mortality and improved cognitive function and some ADLs.

Preventive interventions to improve older people’s health outcomes: systematic review and meta-analysis

“…The impact of complex interventions set in primary care on older people’s outcomes has been extensively researched in recent decades. Findings from previous reviews have been mixed overall on admissions to hospital, 8 – 13 , 56 ARC placement, 8 – 10 , 12 , 13 , 18 functional ability, 8 , 9 , 12 – 16 and QoL. 11 – 14 , 18 In the present review, an intervention benefit to older people’s SRH and functional ability was found.…”

“…Many intervention trials set in primary care have tested the effectiveness of preventive rather than disease-specific approaches relating to the care of older people, and numerous systematic reviews related to this topic have been published. Previous reviews have found mixed effects on older people’s admissions to hospital 8 – 13 and aged residential care (ARC), 8 – 10 , 12 , 13 functional ability, 8 , 9 , 12 – 16 and QoL. 11 – 14 These reviews often report effects according to the primary intervention focus or what is thought to be its active ingredient — for example, multidimensional assessment and subsequent management; 8 , 9 , 14 , 17 health promotion and disease prevention programmes; 15 , 16 , 18 or preventive home visiting.…”

How can we improve Comprehensive Geriatric Assessment for older people living with frailty in primary care and community settings? A qualitative study

“…However, evidence shows variation in the role in different studies in terms of duration and frequency of home visits and HCPs who coordinated the care. 11 38 39 Further research needs to identify who could best coordinate care in older people and what the best approach may be.…”

“…3 9 However, the effectiveness of CGA for older people with frailty in primary care and community settings is mixed. 8 10 11 Ho et al reported benefits in terms of the likelihood of living at home, reduced mortality, improved cognition and activities of daily living, but with uncertain benefits on quality of life, 11 whereas Briggs et al found no difference in mortality, activities of daily living, quality of life and care home admissions. 8 Descriptions of CGA components often lack detail, including the delineation of staff involved in delivery, and an understanding about factors that affect implementation are limited.…”

“…3 For example, while telemedicine can beneficial, cost-effective and acceptable to older people, 13 there are concerns about digital exclusion 14 and risks that important signs and symptoms could be missed. 15 Improving the effectiveness and efficiency of CGA 11 requires exploration of how individual components may work and how the overall intervention can be enhanced. The Digital and Remote Enhancement for the Assessment and Management of Older People with Frailty project aimed to develop a community-based model of CGA that incorporated technology.…”