Challenges in Synthesizing and Interpreting the Evidence from a Systematic Review of Multifactorial Interventions to Prevent Functional Decline in Old

The U.S. Preventive Services Task Force (USPSTF) has been working to improve its methods and processes for the preventive needs of older adults. Traditional methods for systematic reviews and evidence-based recommendations for prevention of cancer or chronic disease may fall short in addressing many geriatric conditions. This deficit is because of these conditions' multifactorial risk factors and/or broad interventions aimed at improving multiple related health outcomes. The multidimensional nature of geriatric care presents unique challenges to thoughtfully interpreting the evidence base for many geriatric topics. Clinical care and research in older adults have, in part, reflected this multidimensional nature by developing comprehensive geriatric assessments-a multidisciplinary diagnostic process intended to determine an older adult's medical, psychosocial, and functional abilities/limitations in order to develop an overall plan for management. Over the past two decades, there has been a large body of international research evaluating different interventions that incorporate both inpatient and outpatient geriatric assessment approaches aimed at improving various health, quality of life, and clinical care outcomes. In 2010, the USPSTF posted for public comment a draft recommendation statement based on a commissioned systematic review that found that exercise and physical therapy interventions and vitamin D supplementation reduced falling in community-dwelling older adults. However, other interventions (notably, multifactorial assessment and management interventions) did not appear to reduce risk for falling. Because this previous review focused on interventions whose primary aim was to prevent falls, the USPSTF commissioned a second review to more broadly address the net benefit of these types of assessment and management interventions in older adults. This second review presented the opportunity to test methods around evidence synthesis and evidence-based recommendations for highly related bodies of evidence (i.e., multifactorial interventions to prevent falls and/or functional decline), as well as methods for reviewing complex interventions and multiple interrelated health outcomes. This review was designed to answer two key questions: 1) Can outpatient multifactorial assessment and management interventions improve health-related quality of life (HRQL) or reduce hospitalization, institutionalization, disability, or mortality in community-dwelling older adults? and 2) What are the adverse effects associated with these multifactorial assessment and management interventions? This report briefly summarizes our review findings and focuses on the methodological challenges we encountered and methods we used in study design, reporting, and analysis.