Interventions Addressing Symptoms in Older Adults with Multimorbidity: An Umbrella Review

Figures & data

Table 1 Academic Search Approach

Search Concepts	Terms
Symptom intervention	Symptoms or signs or characteristics or presentation or symptomatology And interventions or strategies or best practices or treatment or therapy or program or management
Older adults	Older adults or elderly or geriatric or geriatrics or aging or senior or seniors or older people or aged 60 or 60+
Chronic health conditions	Multimorbidity, or multiple comorbidity, or multiple chronic conditions, disease
Literature reviews	Systematic review with or without a meta-analysis

Table 2 Inclusion and Exclusion Criteria

Criteria	Inclusion	Exclusion
Participants	Old adults (aged 60+) with multimorbidity.	Children, adolescents, and adults under the age of 60 years old.
Setting	All settings were included.
Intervention	The intervention included understanding signs and symptoms of multimorbidity, monitoring symptoms, and self-care of symptoms.	The intervention is from a medical treatment aspect, such as drugs; Complementary medicine or therapy.
Outcomes	Health-related outcomes, cost-effectiveness, patient preferences	Outcomes from a medical treatment aspect; Outcomes solely on the economic aspect.
Design	Systematic reviews with or without a meta-analysis	Primary studies, commentaries, editorials, conference papers, etc.
Language	English or Chinese	Other than English or Chinese

Figure 1 Flow diagram of publication selection.

Table 3 Key Characteristics of Included Reviews

Citations	Aim	Setting & Sample	Multimorbidity	Year of Search, Studies Included	Key Findings	Quality Assessment
Crowe et al (2016)^Citation22	To evaluate the clinical effects of transdiagnostic health management interventions for older adults with multimorbidity.	Home care; 10,393 participants included; Participants had 2–7.1 conditions, mean ages range from 65–78.5 yr.	More than 1 long-term condition; Arthritis, Respiratory conditions, hypertension, and diabetes were common conditions.	From 1999 to 2014; RCTs (n =5), open-label studies (n =4), concurrent controlled cohort study (n = 1), case–control study (n = 1), and quasi-experimental study (n = 1).	Transdiagnostic health management interventions might be effective for older people with multimorbidity.	10
Kastner et al (2018)^Citation23	To evaluate the effects of interventions for managing multimorbidity in older adults.	Primary care (n = 8), home (n = 7), outpatient clinics (n = 5), hospitals (n = 3), and nursing homes (n = 2); 12,579 participants included, mean age 67.3 yr, range 61–86 yr.	Two and more high-burden chronic diseases; Diabetes, depression, heart failure, and COPD were common conditions.	From 1990 to 2017; RCTs (n = 15), cluster RCTs (n = 6), mixed-methods (n = 3), and uncontrolled (n = 1).	Care coordination interventions with one or a combination of interventions might be effective for older adults with multimorbidity.	10
Goehner et al (2019)^Citation24	To identify the effects of trained volunteers in supporting older adults with multimorbidity and present the characteristics of the volunteers for further practice.	Homecare following a hospital stay; 3379 participants included mean age = 77.0 yr, range 67.3–82.8 yr.	At least 1 chronic condition; Frail and cancer were common conditions.	From 2002 to 2017; RCTs (n = 5), clinical controlled trials (n = 2), pre-post study (n = 5).	The effects of trained volunteer-supporting programs for older adults with multimorbidity were inconsistent.	10
Parker et al (2020)^Citation25	To identify the effects of transitional care for older people living with dementia and multimorbidity, and their caregivers.	Setting unspecific; 1861 participants included mean age = 80 yr.	Dementia and multimorbidity.	From 2000 to 2018; RCTs (n = 8), quasi-experimental (n = 2), and case series studies (n=1).	The implementation of transitional care coordination might help to reduce the impacts of older adults with multimorbidity.	9
Kennedy et al (2021)^Citation26	To evaluate the effects of interventions led by community health workers on clinical outcomes in older adults with multimorbidity.	Setting unspecific; 2051 participants included, aged range 69–80 yr.	Having complex conditions such as multimorbidity, frailty, disability, or high utilization; Depression, anxiety, disability, hypertension, cardiovascular disease, and congestive heart failure were common conditions.	From inception to 2020; RCTs (n = 4), RCTS plus qualitative (n= 1), quasi-experimental (n = 3), quasi-experimental plus qualitative (n = 2).	Community health workers-led interventions might be effective for older adults with complex health needs.	9
Søgaard et al (2021)^Citation27	To evaluate the effects of patient engagement interventions for older patients with multimorbidity.	Setting unspecific; 8087 participants included. Mean age > 60 yr, range 60–84 years.	Two or more chronic diseases. Diabetes, hypotension, and heart disease were common conditions.	From inception to 2021; RCTs (n = 8), cohort (n= 3), quasi-experimental (n = 1).	Patient engagement intervention might be effective for older adults with multimorbidity.	10

Note: The included reviews were listed in chronological order.

Table 4 Summary for the Interventions, Outcomes, and Quality of Evidence of Included Reviews

Citations	Interventions	Outcomes	Quality of Evidence
Crowe et al (2016)^Citation22	Mixed interventions: chronic disease self-management programs (n = 3), home-based interventions (n = 2), community-based interventions (n = 4). Interventions on the environment: service level interventions (n = 3).	Functioning: self-rated health, exercise, IADL independence and FIM Total independence, ADL, mobility, disability, HRQoL, WHODAS-II, QoL, and work and social adjustment. Resource use: MD and/or ER visits, and hospital days, and hospital admission rate.	Health status: Low/moderate Functioning: Low Service utilization: Low
Kastner et al (2018)^Citation23	Mixed interventions: care coordination (n = 10), and information and health technology (n = 7).	Mortality/survival: mortality Physiological/clinical: depression, HbA1c, and SBP. Functioning: QoL and physical activities. Resource use: antidepressant use, mental health service use, and health care utilization.	Depression: Moderate HbA1c: Low/moderate Systolic blood pressure: Very Low Mortality: Moderate Mental health service: Moderate
Goehner et al (2019)^Citation24	Interventions on the body systems or functions: assistance with medication intake (n = 2). Mixed interventions: physical-cognitive activation (n = 5), and psychosocial-coordinative support (n = 5).	Physiological/clinical: anxiety, and colorectal symptoms. Functioning: QoL, physical functioning, and self-efficacy expectation. Resource use: use of service. Others: composite endpoints, knowledge, and behaviors, and support needs.	/
Parker et al (2020)^Citation25	Mixed interventions: support (n = 2), physical-cognitive activation (n = 4), psychosocial-domestic support (n = 1), and physical-cognitive activation plus social participation (n = 2).	Physiological/clinical: cognitive status, behavioral symptoms, and multimorbidity. Functioning: QoL, physical activities, mental health, and physical functioning.	/
Kennedy et al (2021)^Citation26	Interventions on the health-related behaviors: behavior change (n = 1). Interventions on the environment: workforce enhancement (n = 1). Mixed interventions: collaborative care (n = 1), health coaching (n = 2), psychosocial group exercise (n = 1), and peer support (n = 1).	Physiological/clinical: self-reported mood. Functioning: self-reported functioning, disability, physical performance, QoL, well-being, and physical activity. Adverse events: medication safety knowledge, attitudes, and behaviors. Others: self-care, and social support.	/
Søgaard et al (2021)^Citation27	Interventions on the health-related behaviors: psychosocial or behavioral approach (n = 9), and medication adherence intervention (n=1). Interventions on the activities and participation domains: physical activity plus a psychosocial or behavior change (n = 2), and trained home support workers in self-management skills (n = 2). Mixed interventions: health coaching interventions (n = 2), primary care collaborative care team model (n = 1), and peer support program (n = 1).	Physiological/clinical: BMI, SBP, HbA1c, LDL, and mood. Functioning: functioning, self-rated health, QoL, well-being, and Ill-being. Resource use: use of service. Others: patient activation communication, and self-care.	/

Notes: The included reviews were listed in chronological order.

Abbreviations: MD, Medical Doctor; ER, Emergency Room; ADL, Activities of Daily Living; IADL, Instrumental Activities of Daily Living; FIM, Functional Independence Measure; HRQoL, Health-related Quality of Life; WHODAS-II, World Health Organization Disability Assessment Schedule; QoL, Quality of Life; BMI, Body Mass Index; SBP, Systolic Blood Pressure; HbA1c, Hemoglobin A1c; LDL, Low-Density Lipoprotein.

Table 5 Summary of Quality Appraisal of Included Reviews

Citations	Quality Appraisal Methods	Quality Appraisal Results
Crowe et al (2016)^Citation22	Effective Practice and Organization of Care Methods, Grading of Recommendations, Assessment, Development and Evaluation (GRADE)	Two studies had a low risk of bias; Four studies had an unclear risk of bias; Six studies had a high risk of bias.
Kastner et al (2018)^Citation23	Cochrane Risk of Bias tool, Mixed Methods Appraisal Tool, and GRADEPro.	Most had a low risk of bias for random-sequence generation, blinding of outcome assessors, incomplete or selective reporting of outcomes, and other biases. There was an unclear risk of bias for allocation sequence and blinding of patients or personnel in half of the studies. Two studies were found to have a high risk of bias for blinding of participants and personnel.
Goehner et al (2019)^Citation24	Cochrane Risk of Bias Tool for randomized trials and the Acrobat-NRSI for non-randomized trials	Selection bias (LRB: 3, URB: 4, HRB: 2), performance bias (LRB: 2, URB: 0, HRB: 5), detection bias (LRB: 3, URB: 1, HRB: 3), attrition bias, (LRB: 2, URB: 2, HRB: 2), reporting bias (LRB: 2, URB: 6, HRB: 0), and other bias (LRB: 2, URB: 5, HRB: 1).
Parker et al (2020)^Citation25	Joanna Briggs Institute’s critical appraisal tools	Quality score for RCT: (11/13: 2, 7/13: 2, 8/13:3, 9/13:2, 10/13) Quality score for quasi-experimental: (7/9, 3/9) Quality score for case series: (1)
Kennedy et al (2021)^Citation26	The Revised Cochrane Risk-of-Bias; the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool	ROB (L: 1, M: 1, H: 1), EPHPP (W:2, M: 2)
Søgaard et al (2021)^Citation27	GRADE, ROBINS-l, Cochrane Collaboration’s tool	Risk of bias (LRB: 3, MRB: 9, HRB: 0), imprecision (HRB: 6, MRB: 3, VL:1, U: 2), inconsistency (L: 0, M: 1, H: 9, U: 2), indirectness (L: 1, Very L: 2, M: 2, H: 7), publication bias (M: 2, U: 1, H: 9)

Note: The included reviews were listed in chronological order.

Abbreviations: LRB, Low risk of bias; MRB, Moderate risk of bias; HRB, High risk of bias; URB, Unclear risk of bias; L, Low; M, Moderate; H, High; U, Unclear; W, Weak; VL, Very Low.

Table 6 Methodological Quality Assessment by JBI Critical Appraisal Checklist

Publication	1	2	3	4	5	6	7	8	9	10	11
Crowe et al (2016)^Citation22	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	Y
Kastner et al (2018)^Citation23	N	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Goehner et al (2019)^Citation24	N	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Parker et al (2020)^Citation25	N	Y	Y	Y	Y	N	Y	Y	Y	Y	Y
Kennedy et al (2021)^Citation26	N	Y	Y	Y	Y	Y	Y	U	Y	Y	Y
Søgaard et al (2021)^Citation27	N	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y

Note: The included reviews were listed in chronological order.

Abbreviations: Y, Yes; N, No; U, Unclear.

Crowe M, Jordan J, Burrell B, et al. Clinical effectiveness of transdiagnostic health management interventions for older people with multimorbidity: a quantitative systematic review. J Adv Nurs. 2016;72(10):2315–2329. doi:10.1111/jan.13011

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Kastner M, Cardoso R, Lai Y, et al. Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis. CMAJ. 2018;190(34):E1004–E1012. doi:10.1503/cmaj.171391

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Goehner A, Kricheldorff C, Bitzer EM. Trained volunteers to support chronically ill, multimorbid elderly between hospital and domesticity - a systematic review of one-on-one-intervention types, effects, and underlying training concepts. BMC Geriatr. 2019;19(1):126. doi:10.1186/s12877-019-1130-2

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Parker KJ, Hickman LD, Phillips JL, Ferguson C. Interventions to optimise transitional care coordination for older people living with dementia and concomitant multimorbidity and their caregivers: a systematic review. Contemp Nurse. 2020;56(5–6):505–533. doi:10.1080/10376178.2020.1812416

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Kennedy MA, Hatchell KE, DiMilia PR, et al. Community health worker interventions for older adults with complex health needs: a systematic review. J Am Geriatr Soc. 2021;69(6):1670–1682. doi:10.1111/jgs.17078

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Søgaard MB, Andresen K, Kristiansen M. Systematic review of patient-engagement interventions: potentials for enhancing person-centred care for older patients with multimorbidity. BMJ open. 2021;11(12):e048558. doi:10.1136/bmjopen-2020-048558

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