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. 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: ; risk of bias judgments: .

中文翻译：

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基于社区的复杂干预措施以维持老年人的独立性：系统评价和网状荟萃分析


目的 综合基于社区的复杂干预措施的有效性证据，根据其干预组成部分进行分组，以维持老年人的独立性。设计 系统评价和网络荟萃分析。数据来源 Medline、Embase、CINAHL、PsycINFO、CENTRAL、clinicaltrials.gov 和国际临床试验注册平台，从建库到 2021 年 8 月 9 日，以及纳入研究的参考文献列表。资格标准 随机对照试验或整群随机对照试验，随访 ≥24 周，研究基于社区的复杂干预措施，以维持居家老年人（平均年龄 ≥65 岁）的独立性，以常规护理、安慰剂或其他复杂干预措施作为对照。主要结局 12 个月时居家生活、日常生活活动（个人/工具）、护理院安置和服务/经济结局。数据综合 干预措施根据专门开发的类型进行分组。随机效应网络荟萃分析估计了比较效应;Cochrane 修订工具 （RoB 2） 结构化偏倚风险评估。建议分级评估、开发和评价 （GRADE） 网络荟萃分析结构化确定性评估。结果 本综述纳入了 129 项研究 （74 946 名研究对象）。在 63 种组合中确定了 19 个干预组成部分，包括“来自个体化护理计划的多因素行动”（导致定制行动的多领域评估和管理过程）。对于居家生活，与无干预/安慰剂相比，证据支持个体化护理计划的多因素行动，包括药物审查和定期随访（常规审查）（比值比 1.22,95% 置信区间 0.93 至 1。59;中等质量证据）;个体化护理计划的多因素行动，包括无定期随访的药物审查（2.55,0.61 至 10.60;低质量证据）;结合认知训练、药物审查、营养支持和运动（1.93,0.79 至 4.77;低质量证据）;以及日常生活训练、营养支持和锻炼的联合活动 （1.79， 0.67 至 4.76;低质量证据）。风险筛查或在个体化护理计划和常规审查与药物审查的多因素行动中加入教育和自我管理策略可能会降低居家生活的几率。对于日常生活中的工具性活动，证据支持个体化护理计划和常规审查与药物审查的多因素行动（标准化均数差 0.11,95% 置信区间 0.00 至 0.21;中等质量）。两种干预措施可能会减少日常生活中的工具性活动：日常生活训练、辅助工具和锻炼的联合活动;以及日常生活训练、辅助、教育、锻炼和多因素行动的结合活动，包括个体化护理计划和常规审查与药物审查和自我管理策略。对于个人日常生活活动，证据支持联合锻炼、个体化护理计划的多因素行动以及药物审查和自我管理策略的常规审查（0.16，-0.51 至 0.82;低质量证据）。对于家庭护理接受者，证据支持从个体化护理计划和常规审查和药物审查中增加多因素行动（0.60、0.32 至 0.88;低质量）。高偏倚风险和不精确的估计意味着大多数证据质量低或极低。 很少有研究对每项比较做出贡献，阻碍了对不一致和脆弱性的评估。结论 最有可能维持独立性的干预措施是个体化护理计划，包括药物优化和定期随访审查，从而采取多因素行动。家庭护理接受者可能特别受益于这种干预。出乎意料的是，某些组合可能会降低独立性。需要进一步的研究来调查哪些干预措施组合最适合不同的受试者和背景。注册 PROSPERO CRD42019162195.与本文相关的数据将在利兹大学数据存储库的 Creative Commons 署名许可下无限期地公开提供。网络荟萃分析的总结效应估计和结果： ;偏倚风险判断： .