Evidence
This page contains a snapshot of featured content which highlights evidence addressing key clinical questions including areas of uncertainty. Please see the main topic reference list for details of all sources underpinning this topic.
BMJ Best Practice evidence tables
Evidence tables provide easily navigated layers of evidence in the context of specific clinical questions, using GRADE and a BMJ Best Practice Effectiveness rating. Follow the links at the bottom of the table, which go to the related evidence score in the main topic text, providing additional context for the clinical question. Find out more about our evidence tables.
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: Older people 60 years of age and over (both male and female) with hearing loss
Intervention: Screening and provision of a hearing aid or assistive listening device
Comparison: Referral, no service, or delayed treatment
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Screening for hearing loss versus no screening | ||
Hearing aid use (follow-up: 1 year; assessed with self-report and direct observation) | Favours intervention | Low |
Screening and provision of hearing aids versus no hearing aid or assistive listening device | ||
Social function (follow-up: 3–4 months; assessed with Hearing Handicap Inventory; lower score = better performance) | Favours intervention | Very Low |
Depression (follow-up: 4 months; assessed with Geriatric Depression Rating Scale; lower score = better performance) | Favours intervention | Low |
Communication (follow-up: 4 months; assessed with Quantified Denver Scale; lower score = better performance) | Favours intervention | Low |
Recommendations as stated in the source guideline Screening followed by provision of hearing aids should be offered to older people for timely identification and management of hearing loss (quality of the evidence: low; strength of the recommendation: strong).
Note When making their recommendation, the guideline development group (GDG) also considered the acceptability, feasibility, and increasing affordability of hearing aids, in addition to the large number of people 60 years and over with hearing loss. They agreed that the benefits of the intervention outweighed the disadvantages and costs and therefore made a strong recommendation even though the quality of the evidence as assessed by GRADE was low. The GDG did not identify studies which covered harms of screening or provision of hearing aids for hearing loss in older people. They concluded that any harms are likely to be minimal due to the non-invasive nature of screening and since hearing aid use is not associated with significant harms.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes.
Population: Older people in primary healthcare/community setting or hospital/long-term care setting (60 years of age and over) at risk of undernutrition or who are undernourished.
Intervention: ONS ᵃ
Comparison: Placebo or usual care
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Primary healthcare or community setting | ||
Mortality (follow-up: 3–18 months) | No statistically significant difference | Moderate |
Mortality: subgroup at risk of undernutrition | No statistically significant difference | Moderate |
Mortality: subgroup with undernutrition | No statistically significant difference | Moderate |
Weight gain (follow-up: 3–18 months) | Favours intervention | Low |
Weight gain: subgroup at risk of undernutrition | No statistically significant difference | Low |
Weight gain: subgroup with undernutrition | Favours intervention | Moderate |
Hand-grip strength (follow-up: 3–18 months; assessed with handheld dynamometer; higher score = better performance) | No statistically significant difference | Moderate |
Hand grip: subgroup at risk of undernutrition | No statistically significant difference | Low |
Hand grip: subgroup with undernutrition | No statistically significant difference | Low |
Adverse effects | Results reported narratively ᵇ | GRADE not reported |
Hospital or long-term care setting | ||
Mortality (follow-up: 10 weeks–3 years) | Favours intervention | Moderate |
Mortality: subgroup at risk of undernutrition | No statistically significant difference | Moderate |
Mortality: subgroup with undernutrition | Favours intervention | Moderate |
Weight change (follow-up: 10 days–6 months) | Favours intervention | Low |
Weight gain: subgroup at risk of undernutrition | Favours intervention | Low |
Weight gain: subgroup with undernutrition | Favours intervention | Moderate |
Hand-grip strength (follow-up: 3–6 months; assessed with handheld dynamometer; higher score = better performance) | No statistically significant difference | Moderate |
Hand-grip strength: subgroup at risk of undernutrition | Favours intervention ᶜ | Moderate |
Hand-grip strength: subgroup with undernutrition | No statistically significant difference | Moderate |
Activities of daily living (ADLs) (follow-up: 4–6 months; assessed with Barthel Index [higher score = better performance]) | No statistically significant difference | Moderate |
ADLs: subgroup at risk of undernutrition | No statistically significant difference | Low |
ADLs: subgroup with undernutrition | No statistically significant difference | Low |
Adverse effects | Results reported narratively ᵇ | GRADE not reported |
Recommendations as stated in the source guideline ONS with dietary advice should be recommended for older people affected by undernutrition (quality of evidence: moderate; strength of recommendation: strong).
Note The guideline development group reported that most of the studies were in hospital and long-term care settings (n=43, compared with n=12 in primary/community care). However, they did not create separate recommendations based on where studies were undertaken, concluding that ONS was appropriate for this population regardless of setting. ᵃ Additional high-quality protein and calories tailored to the individual’s needs as assessed by a trained healthcare professional and delivered by the normal oral route. Studies used a wide range of ONS (e.g., milk- or juice-based, sweet and savoury) in different formats (liquid, powder, pudding, pre-thickened) alone and in combination. The majority of trials aimed to administer an additional 900–1200 kcal of calories and 12–20 g protein per day, with additional vitamins and minerals as required. In primary healthcare/community settings the duration of treatment was 3 months to 18 months; whilst in hospital and long-term care settings the duration of treatment was 10 days to 6 months. ᵇ Fifteen studies reported adverse events in both treatment and comparison groups. The guideline combined these across all settings (community, hospital, and long-term care) and it is unclear from the reporting how many studies from each setting were included. The guideline did comment on a higher number of adverse events overall in a hospital setting and discussed that this may be due to factors such as severity of undernutrition, intensity of supplementation, comorbid acute illness, or increased monitoring for adverse effects. Common side effects included gastrointestinal symptoms, nausea, and diarrhoea. The majority of studies reported no significant difference in adverse effects between intervention and control groups. ᶜ Lower confidence interval reported for this outcome SMD 0.18 (0 to 0.35); the guideline development group concluded that the intervention was favoured.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: (1) Older people aged 60 years and over ᵃ; (2) older people aged 60 years and over with refractive errors ᵇ
Intervention: (1) Vision screening and referral; (2) immediate provision of care ᵇ
Comparison: Usual care
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Vision screening and referral compared with standard care for older people | ||
Self-reported improvement in vision (follow-up: 20 months–4 years; assessed with direct question) | No statistically significant difference | Low |
Visual acuity less than 6/18 in either eye (follow-up: 3–5 years) | No statistically significant difference | Low |
Mean composite visual function score (follow-up: 3–5 years; assessed with National Eye Institute Visual Functioning Questionnaire – 25 item [NEI-VFQ-25]; higher score = better performance) | No statistically significant difference | Low |
Adverse effects | See note ᶜ | GRADE not reported |
Provision of immediate or delayed care (correction) for older people with uncorrected refractive error | ||
Improvement in vision-specific functioning (including near and distance vision; follow-up: 2–3 months; assessed with NEI-VFQ-25; higher score = better performance) | Favours intervention | Very Low |
Social functioning (follow-up: 3 months; assessed with NEI-VFQ; higher score = better performance) | No statistically significant difference | Very Low |
Depression (follow-up: 2–3 months; assessed with Geriatric Depression Scale; lower score = better performance) | Favours intervention | Low |
Adverse effects | See note ᶜ | GRADE not reported |
Recommendations as stated in the source guideline Older people should receive routine screening for visual impairment in the primary-care setting, and timely provision of comprehensive eye care ᵈ (quality of the evidence: low; strength of the recommendation: strong).
Note The guideline development group (GDG) emphasised that screening alone was not an adequate intervention and that it should be combined with the immediate provision of the indicated eye care. The GDG made a strong recommendation despite the low quality of the evidence due to the acceptable nature of the intervention, the potential for benefits to outweigh harms, and the minor variability in individual values and preferences. The GDG noted that all of the studies underpinning the recommendation were in high-income countries. ᵃ The Cochrane review, which informed the GDGs analysis on screening, included studies of people aged 65 years and over; most of the studies they identified evaluated people aged 70 years and over. ᵇ The guideline included additional evidence on expedited compared with routine cataract surgery for older people with cataract, which found increased improvement in visual acuity with expedited surgery. ᶜ None of the included studies reported any adverse effects due to screening or timely provision of care. ᵈ Defined as “refraction services with the provision of suitable correction tools available at the primary health care level”. The guideline also noted that for patients requiring cataract surgery, timely provision would mean expedited rather than routine surgery.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a Cochrane Clinical Answer that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes.
Population: Older adults (mean age 82 years) living in the community with frailty
Intervention: Mobility training (includes gait, balance and functional exercises, strength or resistance training, endurance training or a combination)
Comparison: Usual care (includes general health education, social visits, cognitive therapy, very gentle exercise not expected to impact on mobility, nutritional supplements)
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Mobility ᵃ | Favours intervention | High |
Subgroup analysis: Mobility - 4-6 months post-intervention | Favours intervention | Moderate |
Function ᵃ | Favours intervention | Moderate |
Subgroup analysis: Function – 4-6 months post-intervention | No statistically significant difference | Low |
Adverse events – follow‐up: 36‐52 weeks ᵇ | Occurs more commonly with usual care compared with mobility training (favours intervention) | Very Low |
Admission to a nursing care facility – follow‐up: 52 weeks | No statistically significant difference | Low |
Number of fallers – follow‐up: 52 weeks | No statistically significant difference | Low |
Mortality rates – follow‐up: 3‐52 weeks | No statistically significant difference | Moderate |
Note ᵃ Study length was 3 to 12 months in 11 studies, and one study was 6 weeks. The duration of the intervention varied from 6 weeks to 9 months, with 4 out of 12 studies reporting on outcomes at 4-6 months post intervention. ᵇ Most adverse events were non‐serious and musculoskeletal in nature.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is very low or low where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes. However, this is uncertain and new evidence could change this in the future.
Population: Older people aged 60 years and over with depressive symptoms with or without diagnostic status (depressive episode or disorder)
Intervention: Psychological interventions (behavioural activation, cognitive behavioural therapy [CBT], psychoeducational therapy, interpersonal therapy, problem-solving therapy, stepped-care protocol therapy, or life-review therapy)
Comparison: Usual care or waiting list
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Behavioural activation treatment versus usual care | ||
Depression symptoms (follow-up: 6–10 weeks; assessed with self-reported and structured clinical interview) | Favours intervention | Very low |
Psychological interventions (CBT, problem-solving therapy, interpersonal counselling, or life-review therapy) versus usual care | ||
Depression symptoms (follow-up: 3–6 months; assessed with the Geriatric Depression Scale (GDS), Center for Epidemiological Studies Depression Scale [CES-D], or self-reported depression symptom) | Favours intervention | Low |
Incidence of depressive disorder (follow-up: 2 months; assessed with diagnostic instruments) | Favours intervention | Low |
Incidence of depressive disorder (follow-up: 6 months; assessed with diagnostic instruments) | No statistically significant difference | Very Low |
Incidence of depressive disorder (follow-up: 12 months; assessed with diagnostic instruments) | No statistically significant difference | Very Low |
Adverse effects | See note ᵃ | GRADE not reported |
Recommendations as stated in the source guideline Older adults who are experiencing depressive symptoms can be offered brief, structured psychological interventions in accordance with World Health Organization Mental Health Gap Action Programme (WHO mhGAP) intervention guidelines, delivered by healthcare professionals with a good understanding of mental health care for older adults (quality of the evidence: very low; strength of the recommendation: conditional).
Note The guideline development group (GDG) made a conditional recommendation due to the low to very low quality of the evidence and potential lack of generalisability to all community settings. ᵃ None of the included studies reported any adverse events associated with psychological interventions. The GDG concluded that overall there was little potential for harm, especially if a targeted and stepped-care approach is used.
This evidence table is related to the following section/s:
This table is a summary of the analysis reported in a guideline (underpinned by a systematic review) that focuses on the above important clinical question.
Confidence in the evidence is moderate or low to moderate where GRADE has been performed and the intervention may be more effective/beneficial than the comparison for key outcomes.
Population: Non-institutionalised older people with limitations in ADLs
Intervention: Progressive resistance exercise or multimodal exercise (combining two or more types of exercise: progressive resistance exercise or strength, balance, stretching, and endurance or aerobic exercise) ᵃ
Comparison: No exercise or attention-control or usual care or waiting list
| Outcome | Effectiveness (BMJ rating)? | Confidence in evidence (GRADE)? |
|---|---|---|
Progressive resistance training versus control | ||
Balance (follow-up: 8–24 weeks; assessed with single-leg stand, functional reach, Berg balance scale, FICSIT balance test; higher score = better performance) | No statistically significant difference | Moderate |
Gait speed (follow-up: 8–24 weeks; assessed with timed walk; higher score = better performance) | No statistically significant difference | Low |
Chair stand (follow-up: 6–12 months; assessed with five chair stands; lower score = better performance) | Favours intervention | Very Low |
Timed up and go (follow-up: 8–24 weeks; assessed with timed up and go; lower score = better performance) | No statistically significant difference | Moderate |
Overall physical functioning (follow-up: 10–12 weeks; assessed with Short Physical Performance Test, SF36-physical functioning; higher score = better performance) | No statistically significant difference | Moderate |
ADLs (follow-up: 10–16 weeks; assessed with Groningen Activity Restriction Scale, Barthel Index, Continuous Scale Physical Functional Performance; higher score = better performance) | No statistically significant difference | High |
Muscle strength of the lower extremity (follow-up: 8–24 weeks; higher score = better performance) | Favours intervention | Low |
Multimodal exercise training versus control | ||
Balance (follow-up: 12–18 months; assessed with Berg balance scale, functional reach, modified Romberg test, single-leg stand, Tinetti balance score; higher score = better performance) | Favours intervention | Moderate |
Gait speed (follow-up: 12–18 months; assessed with timed walk; higher score = better performance) | No statistically significant difference | Moderate |
Chair stand (follow-up: 5 weeks to 18 months; assessed with five chair stands, number of chair stand repetitions; lower score = better performance) | Favours intervention | Moderate |
Timed up and go (follow-up: 12 weeks to 16 months; assessed with timed up and go and modified timed up and go; lower score = better performance) | No statistically significant difference | Very Low |
Overall physical functioning (follow-up: 12 weeks to 18 months; assessed with eight-item physical performance test, modified physical performance test, SF36-physical functioning, Short Physical Performance Battery, Balance Outcome Measure for Elder Rehabilitation, Organization Quality of Life Instrument-physical domain; higher score = better performance) | Favours intervention | Low |
ADLs (follow-up: 12 weeks to 18 months; assessed with Barthel Index, functional status questionnaire, NHANES independence measure, The Older Americans Resources, and Services ADL scale; higher score = better performance) | Favours intervention | Moderate |
Muscle strength of the lower extremity (follow-up: 12–18 months; assessed with muscle strength of knee extension, hip adductor, or quadriceps; higher score = better performance) | Favours intervention | Moderate |
T’ai chi compared with control | ||
Balance (follow-up: 8 weeks to 12 months; assessed with single-leg stand, Berg balance scale; higher score = better performance) | Favours intervention | Low |
Gait speed (follow-up: 8–48 weeks; assessed with timed walk; higher score = better performance) | No statistically significant difference | Low |
Chair stand (follow-up: 48 weeks; assessed with time to rise from the chair, three times; lower score = better performance) | No statistically significant difference | Low |
ADLs (follow-up: 12 months; assessed with Groningen Activity Restriction Scale; lower score = better performance) | No statistically significant difference | Low |
Recommendations as stated in the source guideline Multimodal exercise, including progressive strength resistance training and other exercise components (balance, flexibility, and aerobic training), should be recommended for older people with declining physical capacity, measured by gait speed, grip strength, and other physical performance measures (quality of the evidence: moderate; strength of the recommendation: strong).
Note The guideline development group (GDG) did not include stand-alone progressive resistance training and t’ai chi in the recommendation due to the lack of evidence for treatment effectiveness and the low quality of the evidence. The GDG noted that adverse events were reported in a small number of studies and the most common were muscle soreness and joint pain. Few studies reported serious adverse events such as fracture, hospitalisation, or death, and whether there was a causal relationship was unclear. The majority of the included trials were conducted in high-income countries. There may be limitations in generalising these findings since the average age of older people recruited in the evaluated studies may be over that of target populations in low- and middle-income countries. ᵃ Duration of multimodal exercise intervention ranged from 2.7 to 12 months. The frequency of training was most commonly three days per week.
This evidence table is related to the following section/s:
Cochrane Clinical Answers
Cochrane Clinical Answers (CCAs) provide a readable, digestible, clinically focused entry point to rigorous research from Cochrane systematic reviews. They are designed to be actionable and to inform decision making at the point of care and have been added to relevant sections of the main Best Practice text.
- What are the benefits and harms of mobility training for older community‐dwelling people with frailty?
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