本文由小咖机器人翻译整理

期刊来源：BMJ

原文链接：https://doi.org/10.1136/bmj-2023-077764

摘要内容如下：

客观

综合以社区为基础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

系统综述和网络荟萃分析。

数据源

MEDLINE、EMBASE、CINAHL、PsycInfo、Central、ClinicalTrials.gov和国际临床试验注册平台（从开始到2021年8月9日）以及纳入研究的参考文献列表。

资格标准

随机对照试验或随访≥24周的整群随机对照试验，研究基于社区的综合干预措施对居家老年人（平均年龄≥65岁）维持独立性的影响，以常规护理、安慰剂或其他综合干预措施作为对照。

主要成果

12个月时的居家生活、日常生活活动（个人/工具性）、护理之家安置和服务/经济结果。

数据综合

干预措施根据专门制定的类型学进行分组。随机效应；网络元分析；估计比较效应；Cochrane修订工具（ROB 2）结构化偏倚风险评估。建议评估的分级，开发和评估（GRADE）网络元分析结构化确定性评估。

结果

该综述包括129项研究（74946名参与者）。在63个组合中确定了19个干预组成部分，包括“个性化护理计划的多因素行动”（一种多领域评估和管理过程，导致量身定制的行动）。对于在家生活，与无干预/安慰剂相比，有证据支持个体化护理计划的多因素作用，包括药物审查和定期随访（常规审查）（优势比1.22，95%置信区间0.93至1.59；中等确定性）；个体化护理计划的多因素作用，包括无定期随访的药物审查（2.55，0.61至10.60；低确定性）；联合认知训练、药物检查、营养支持和运动（1.93，0.79至4.77；低确定性）；日常生活训练、营养支持和运动的综合活动（1.79，0.67至4.76；低确定性）。风险筛查或将教育和自我管理策略添加到个体化护理计划的多因素行动和药物审查的常规审查中，可能会降低居家生活的几率。对于日常生活的工具性活动，来自个体化护理计划和药物审查的常规审查的证据支持多因素作用（标准化平均差异0.11，95%置信区间0.00至0.21；中等确定性）。两种干预措施可以减少工具性日常生活活动：日常生活活动综合训练、辅助工具和锻炼；将日常生活训练、辅助工具、教育、锻炼和多因素行动相结合，从个体化护理计划和常规审查到药物审查和自我管理策略。对于日常生活的个人活动，有证据支持联合运动、个体化护理计划的多因素作用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；低确定性）。对于家庭护理接受者，证据支持从个体化护理计划和药物审查的常规审查中增加多因素行动（0.60，0.32至0.88；低确定性）。偏倚和不精确估计的高风险意味着大多数证据的确定性很低或非常低。很少有研究有助于每一项比较，阻碍了对不一致性和脆弱性的评估。

结论

最有可能维持独立性的干预措施是个性化护理计划，包括药物优化和定期随访审查，从而导致多因素行动。家庭护理接受者可能特别受益于这种干预。出乎意料的是，一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的组合对不同的参与者和环境最有效。

注册

普洛斯彼罗CRD42019162195。

英文原文如下：

Abstracts

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.

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