■保持独立对老年人很重要,但是关于实施哪些社区卫生和护理服务的指导不足。
■为了综合根据干预成分分组的老年人的社区服务维持独立的有效性的证据,并检查虚弱是否会减轻影响。
■系统评价和网络荟萃分析。
■研究:随机对照试验或成群随机对照试验。参与者:老年人(平均年龄65岁以上)居住在家里。干预措施:基于社区的复杂干预措施,以维持独立性。比较:常规护理,安慰剂或其他复杂的干预措施。
■住在家里,日常生活的工具活动,日常生活的个人活动,1年的护理安置和服务/经济成果。
■我们搜索了MEDLINE(1946-),Embase(1947-),CINAHL(1972-),PsycINFO(1806-),从成立到2021年8月,中央和试验登记处不受限制,和扫描的参考列表。
■干预被编码,总结和分组。研究人群按虚弱分类。使用随机效应网络荟萃分析。我们评估了试验结果的偏倚风险(CochraneRoB2),网络荟萃分析的不一致性和证据的确定性(建议评估的分级,网络荟萃分析的开发和评估)。
■我们纳入了129项研究(74,946名参与者)。十九个干预部分,包括“多因素行动”(多领域评估和管理/个性化护理计划),在63个组合中确定。除非另有说明,以下结果具有低的确定性。住在家里,与没有干预/安慰剂相比,支持的证据:多因素行动和药物审查审查(比值比1.22,95%置信区间0.93至1.59;中等确定性)多因素行动与药物审查(比值比2.55,95%置信区间0.61至10.60)认知训练,药物审查,营养和运动(比值比1.93,95%置信区间0.79至4.77)和日常生活训练活动,营养和运动(比值比1.79,95%置信区间0.67至4.76)。四种干预组合可能会减少在家生活。对于日常生活的工具性活动,证据支持多因素行动和药物审查审查(标准化平均差0.11,95%置信区间0.00~0.21;中等确定性).两种干预措施可能会减少日常生活的工具性活动。对于日常生活的个人活动,证据支持锻炼,多因素行动和药物审查和自我管理审查(标准化平均差0.16,95%置信区间-0.51至0.82)。对于家庭护理接受者,有证据支持增加多因素行动和药物审查(标准化平均差0.60,95%置信区间0.32~0.88).养老院安置和服务/经济调查结果尚无定论。
■大多数结果的高偏倚风险和不精确的估计意味着大多数证据的确定性较低或非常低。很少有研究对每次比较做出了贡献,阻碍对不一致和脆弱的评价。研究多种多样;研究结果可能不适用于所有情况。
■评估的许多干预组合的结果在很大程度上是小且不确定的。然而,最有可能维持独立性的组合包括多因素作用,药物审查和患者的持续审查。一些组合可能会降低独立性。
■需要进一步的研究来探索行动机制以及与上下文的互动。证据合成的不同方法可能会进一步阐明。
■本研究注册为PROSPEROCRD42019162195。
■该奖项由美国国家卫生与护理研究所(NIHR)卫生技术评估计划(NIHR奖参考:NIHR128862)资助,并在《卫生技术评估》中全文发表;卷。28号48.有关更多奖项信息,请参阅NIHR资助和奖励网站。
由于缺乏有力的证据,大多数类型的社区服务对老年人的益处和风险尚不清楚.个性化护理计划,在调整药物治疗和定期随访的地方,可能有助于人们留在家里。有许多种类的老年人社区服务。例如,在某些服务中,每个人都得到锻炼和饮食建议或个性化护理计划。这些通常旨在帮助老年人独立衰老。在以后的生活中保持独立是很重要的。我们想找出哪些社区服务效果最好:帮助人们留在家里,独立做日常活动。我们回顾了以前测试老年人不同社区服务的研究结果。我们结合了这些发现,并相互比较了不同类型的服务。我们评价了我们对证据的信心。我们发现了129项研究,涉及74,946人。我们发现已经研究了63种不同的服务。这些研究是在世界各地的不同人群中进行的。个性化护理计划,在调整药物治疗和定期随访的地方,可以帮助人们独立衰老。这可能会稍微增加呆在家里的机会。它也可以帮助做日常活动非常轻微。锻炼和饮食建议也可以帮助人们留在家里。然而,有一些证据表明,某些服务可能会降低独立性。我们不知道大多数服务会产生什么影响。我们通常对证据缺乏信心,因为研究规模很小,信息丢失了.证据是截止到2021年8月的。
UNASSIGNED: Sustaining independence is important for older people, but there is insufficient guidance about which community health and care services to implement.
UNASSIGNED: 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.
UNASSIGNED: Systematic review and network meta-analysis.
UNASSIGNED: 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.
UNASSIGNED: Living at home, instrumental activities of daily living, personal activities of daily living, care-home placement and service/economic outcomes at 1 year.
UNASSIGNED: 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.
UNASSIGNED: 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).
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: 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.
UNASSIGNED: Further research is required to explore mechanisms of action and interaction with context. Different methods for evidence synthesis may illuminate further.
UNASSIGNED: This study is registered as PROSPERO CRD42019162195.
UNASSIGNED: 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.
Due to a lack of robust evidence, the benefits and risks of most types of community services for older people are unclear. Individualised care planning, where medication is adjusted and there are regular follow-ups, probably helps people stay living at home. 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. 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. 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. We generally had little confidence in the evidence because studies were small, and information was missing. The evidence is up to date to August 2021.