Which community services are best for helping older people to be independent?

Key findings
• Individualised care planning, where medication is adjusted and there are regular follow-ups, probably helps people stay living at home.
• Due to a lack of robust evidence, the benefits and risks of most types of community services for older people are unclear.

What are community services for older people?

There are many kinds of community services for older people. For example, in some services, everyone is given exercise and dietary advice or an individualised care plan. These often aim to help older people age independently.

What was the study about?
Maintaining independence is important in later life.
We wanted to find out which community services work best:
• to help people stay living at home, and
• to do day-to-day activities independently.
We reviewed findings from previous studies that have tested different community services for older people. We combined these findings and compared different types of service with one another. We rated our confidence in the evidence.

What is already known on this topic
Older people prioritise maintenance of independence.
Previous research has suggested that these services may help older people age independently, but it is unclear which work best.

What did we find?
We found 129 studies with 74,946 people. We found 63 different kinds of service have been studied. The studies were carried out in diverse populations around the world. Individualised care planning, where medication is adjusted and there are regular follow-ups may help people age independently. It probably increases the chance of staying at home slightly. It may also help with doing day-to-day activities very slightly. Exercise and dietary advice may also help people stay living at home. However, there was some evidence that some services may reduce independence. We do not know what effect most services have.

What are the limitations of the evidence?
We generally had little confidence in the evidence because studies were small, and information was missing.

How current is the evidence?
The evidence is up to date to August 2021.

Crocker TF, Lam N, Ensor J, et al. Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis. Health Technol Assess in press.

Background

Background
The number of older people in the UK is increasing. While there is growth in life expectancy, healthy life expectancy is not keeping pace.

The 2023 Chief Medical Officer’s Report on Health in an Ageing Society identifies maximising independence for older people as a policy priority for England. The report highlights an evidence gap regarding the effectiveness of complex interventions. Previous systematic reviews have indicated that, overall, such interventions probably have small but positive effects, despite some limitations in the underlying evidence. However, an important problem is that we do not have good evidence for how community services for older people, including people living with frailty, should be organised and provided.

In this project we reviewed findings from previous research studies (clinical trials) that tested different community services for older people living at home, including people living with frailty. We combined information from the previous research studies to try and find out which community services are most effective. We aimed to help people who run the NHS and social care to decide precisely which services should be offered and who should get them. In turn this should help older people to live longer in their own homes with fewer problems.

Methods
We used a method called network meta-analysis to allow us to compare different kinds of services for older people with each other. This is a major improvement on previous reviews, where usually we only find out if each service is better than not having the service at all. We also looked at whether some services are better suited to people with frailty and others are better suited to the general older population.

We looked at which service is most effective at helping people to stay living at home. We also looked at how different services improve independence and mental health. We looked at whether different services reduce falls, hospital admission and nursing home admissions for older people. We also looked at how much different services cost and if they are cost-effective.

This work has provided important and robust information to providers of services so they can deliver the NHS Long Term Plan and improve health and wellbeing in later life.

Searching for studies
We identified studies from five databases and two trial registers, last searched 9 August 2021, and the reference lists of included study reports. We included studies if they were randomised controlled trials or cluster randomised controlled trials with follow-up of at least 24 weeks, including older people (mean age ≥65 years) living at home, and evaluating community based complex interventions for sustaining independence compared with usual care, placebo, or another complex intervention.

Study answer and limitations
The study included 129 trials with 74,946 participants and 63 different types of intervention. Moderate certainty evidence suggested that individualised care planning including medicines optimisation and regular follow-up reviews increases the odds of staying at home slightly (odds ratio 1.22, 95% confidence interval 0.93 to 1.59) and increases the independent performance of instrumental ADLs very slightly (standardised mean difference 0.11, 0.00 to 0.21) compared with no intervention/placebo. For homecare recipients, adding the same intervention combination may moderately increase independent performance of personal ADLs (standardised mean difference 0.60, 0.32 to 0.88; low certainty). Care home placement and service/economic findings were inconclusive. Unexpectedly, some combinations of intervention components may reduce independence. Most findings were low or very low certainty owing to risk of bias in the primary evidence, small sample sizes, or confidence intervals that included benefit and harm.

What this study adds
Individualised care planning with tailored actions, including medicines optimisation and regular follow-ups, probably helps to sustain independence in older people. Although some complex interventions may sustain independence, others may reduce independence. Further evidence is needed about who benefits most from which kinds of interventions, which may be provided by individual participant data meta-analysis

Figure: Network plots for the analyses of living at home in the medium term (around 12 months).
AC indicates the network including available care (no intervention/placebo); hmcr indicates the network including formal homecare.
Each node is labelled with the intervention group abbreviation and number of participants. Node size is proportionate to number of participants; edge thickness is proportionate to number of comparisons.
Intervention and control group abbreviations are a combination of the following:- ADL: activities of daily living training; cgn: cognitive training; educ: health education; exrc: physical exercise; hmcr: formal homecare; med: medication-review; mfa: multifactorial-action; mfar: multifactorial-action and follow-on routine review; ntr: nutritional support; rsk-mfa: risk screening, which may trigger multifactorial-action; w/med: with medication-review; w/slfm: with self-management.

Systematic review registration
This systematic review was prospectively registered on PROSPERO: CRD42019162195

Aims & Objectives

To synthesise evidence on the effectiveness of community-based complex interventions to sustain independence for older people, including the effect of frailty and pre-frailty, and group interventions to identify the best configurations.

Research questions:

  • Do community-based complex interventions for older people increase living at home, independence and health-related quality of life?
  • Do community-based complex interventions for older people reduce home care requirement, depression, loneliness, falls, hospitalisation, care home admission, costs and mortality?
  • How should interventions be grouped for network meta-analysis (NMA)?
  • What is the optimal configuration of community-based complex interventions for older people?
  • Do intervention effects differ by frailty level (not frail; pre-frailty; frailty)?

Methods

Systematic review with NMA, following Cochrane methods, GRADE NMA guidance to evaluate quality of evidence, and PRISMA NMA reporting guidance.

Eligible studies are randomised controlled trials (RCTs) and cluster RCTs of community-based complex interventions for older people living at home (mean age 65+), compared with usual care or another complex intervention. The primary outcome is living at home.

Interventions will be grouped in a three-stage process: summarising using TIDieR, content analysis, and nominal group consensus process with expert reference panel.

In addition, meta-analysis results will be presented by different levels of frailty (not frail; pre-frailty; frailty), and by extending the standard and network meta-analyses to a meta-regression.

Impact and dissemination

Potential for major impact, supporting delivery of the NHS Long Term Plan, with dissemination to policymakers, commissioners, health/social care professionals, older people and researchers.

Outputs

Main findings:
Crocker TF, Ensor J, Lam N, Jordão M, Bajpai R, Bond M, Forster A, Riley RD, Andre D, Brundle C, Ellwood A, Green J, Hale M, Mirza L, Morgan J, Patel I, Patetsini E, Prescott M, Ramiz R, Todd O, Walford R, Gladman J, Clegg A. Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis. The BMJ 2024;384:e077764. https://doi.org/10.1136/bmj-2023-077764

Protocol:
Crocker TF, Clegg A, Riley RD, Lam N, Bajpai R, Jordão M, Patetsini E, Ramiz R, Ensor J, Forster A, Gladman JRF. Community-based complex interventions to sustain independence in older people, stratified by frailty: a protocol for a systematic review and network meta-analysis. BMJ Open 2021;11(2):e045637. https://doi.org/10.1136/bmjopen-2020-045637

Sub-study about using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB 2):
Crocker TF, Lam N, Jordão M, Brundle C, Prescott M, Forster A, Ensor J, Gladman J, Clegg A. Risk-of-bias assessment using Cochrane’s revised tool for randomized trials (RoB 2) was useful but challenging and resource-intensive: observations from a systematic review. Journal of Clinical Epidemiology 2023;161:39-45. https://doi.org/10.1016/j.jclinepi.2023.06.015

Datasets:
Crocker TF, Lam N, Ensor J, Jordão M, Bajpai R, Bond M, Forster A, Riley R, Andre D, Brundle C, Green J, Hale M, Morgan J, Patetsini E, Prescott M, Ramiz R, Walford R, Gladman J, Clegg A. Community-based complex interventions to sustain independence in older people systematic review and network meta-analysis: effect estimates and findings dataset. University of Leeds 2024. [Dataset] https://doi.org/10.5518/1377

Crocker TF, Lam N, Jordão M, Brundle C, Prescott M, Forster A, Ensor J, Gladman J, Clegg A. Community-based complex interventions to sustain independence in older people systematic review and network meta-analysis: risk-of-bias dataset. University of Leeds 2023. [Dataset] https://doi.org/10.5518/1386

In press:
Crocker TF, Jordão M, Lam N, et al. Development of a typology of community-based complex interventions to sustain independence in older people (CII-OP): a qualitative synthesis of interventions in randomised controlled trials. Age and Ageing in press.

Crocker TF, Lam N, Ensor J, et al. Community-based complex interventions to sustain independence in older people, stratified by frailty: a systematic review and network meta-analysis. Health Technology Assessment in press.

Partners & Collaborators

Investigators

Professor Andrew Clegg, Dr Tom Crocker, Dr Joie Ensor, Professor Anne Forster, Professor John Gladman, Professor Richard Riley

Collaborators

Bradford Institute for Health Research, Keele University, University of Leeds, University of Nottingham

Our established Frailty Oversight Group (FOG), made up of patients and public, worked with us to produce plain English summaries. To ensure that we clearly communicate our findings with patients and member of the public, we spent time discussing the intervention components we had identified with Frailty Oversight Group members. Through this work, we developed and refined our descriptions of the components. Frailty Oversight Group members helped to draft and revise the plain language summary of our findings.

Timescales

01/12/2019 – 31/03/2022

Funding agency

National Institute for Health and Care Research (NIHR)

Further information

For further information contact:

Professor Andrew Clegg  telephone: 01274 383440.

Tom Crocker telephone: 01274 383903.

This Research is funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme. Frailty Themed Call (Evidence Synthesis) NIHR128862. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.