Purpose: 1) To summarize the results of a systematic review of multifactorial assessment and management interventions to prevent functional decline in older adults for the U.S. Preventive Services Task Force and 2) to describe the methodological challenges in synthesizing and interpreting the review’s findings.
Data Sources: We used two existing systematic reviews to identify trials published through January 2005 and then searched MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature from 2004 through June 3, 2010. We supplemented searches with suggestions from experts and citations from other publications.
Study Selection: Two investigators independently reviewed 5,553 abstracts and 208 articles against a set of a priori inclusion and quality criteria. Discrepancies were resolved by consensus. In total, we included 70 fair- to good-quality trials.
Data Extraction: One investigator abstracted data into evidence tables and a second reviewer checked these data. Activities of daily living (ADLs), instrumental activities of daily living (IADLs), falls, hospitalizations, and mortality were combined using a random effects model; institutionalizations were combined using a fixed effects model. We grouped trials based on the purpose of the trial and country in which the trial was conducted after an extensive investigation of important population, setting, and intervention characteristics.
Data Synthesis: A subset of rigorous randomized, controlled trials suggests that outpatient multifactorial assessment and management interventions have a statistically significant, albeit small, beneficial effect on measures of functional ability, such as ADL and IADL. However, we were unable to determine the clinical significance of this effect and the overall net benefit of these types of interventions due to heterogeneity amongst studies, including: older adults studied, the broad spectrum and multifactorial nature of interventions evaluated, the suboptimal and inconsistent use of outcomes measured, and the inconsistent and inadequate reporting of data that might allow comparison of populations, interventions, and outcomes across studies.
Conclusions: This review process illustrated the complexities encountered when synthesizing and interpreting the evidence in geriatric research and methods around reviewing complex interventions and multiple interrelated health outcomes. Based on the methodological challenges of this review, we offer suggestions to researchers on the design, reporting, and analysis of trials that would help address these challenges and allow for better interpretation of evidence in the future.