Reviews in Clinical Gerontology 2010 20; 128–153 First published online 7 April 2010 C  Cambridge University Press 2010 doi:10.1017/S0959259810000079 Maintaining independence in older people AD Beswick, 1 R Gooberman-Hill, 1 A Smith, 1 V Wylde 1 and S Ebrahim 2 1 Department of Clinical Science at North Bristol, University of Bristol, UK and 2 Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK Summary Appropriate social and medical interventions may help maintain independence in older people. Determinants of functional decline, disability and reduced independence are recognized and specific interventions target the treatment of clinical conditions, multiple health problems and geriatric conditions, prevention of falls and fractures, and maintenance of physical and cognitive function and social engagement. Preventive strategies to identify and treat diverse unmet needs of older people have been researched ex- tensively. We reviewed systematically recent randomized controlled trials evaluating these ‘complex’ interventions and incorporated the findings of 21 studies into an established meta-analysis that included 108,838 people in 110 trials. There was an overall benefit of complex interventions in helping older people to live at home, explained by reduced nursing home admissions rather than death rates. Hospital admissions and falls were also reduced in intervention groups. Benefits were largely restricted to earlier studies, perhaps reflecting general improvements in health and social care for older people. The wealth of high-quality trial evidence endorses the value of preventive strategies to help maintain independence in older people. Keywords: geriatric assessment, randomized controlled trials (as topic), systematic review, aged, independence, complex intervention. Introduction In its most general sense, independence in older age denotes self-reliance or autonomy. 1 Promotion of ‘successful ageing’ often includes the idea that in- dependence is essential to good physical, emotional and cognitive health. In addition to improved life expectancy, life satisfaction and psychological health, the main constituents of healthy ageing relate to independence including personal growth, Address for correspondence: Andrew Beswick, Ortho- paedic Surgery, Department of Clinical Science at North Bristol, University of Bristol, Bristol BS2 8HW. Email: andy.beswick@bristol.ac.uk physical functioning, psychological perceptions and social participation. 2 The value placed on independence in older age is rooted in the ideology that individuals should have responsibility for their own wellbeing. However, this does not preclude appropriate intervention (social and medical) to facilitate or enhance that wellbeing. Indeed, many older people require encouragement to assert their rights to health care and social benefits. Successful ageing – in terms of autonomy and wellbeing – can occur in people who are very dependent on others for daily living. Ageing takes place most successfully in the context of strong social engagement, 3 and social interdependence has been identified as a desirable element of successful ageing. 4 Causes of reduced independence The onset of disability in activities of daily living performed by older people in their daily lives is one of the greatest threats to the ability of older adults to live independently. 5 The determinants of func- tional decline, disability and reduced independence have been studied extensively. In a systematic re- view of 78 longitudinal studies published between 1985 and 1997, Stuck et al. assessed the strength of risk factors for functional decline on the basis of the number of studies and the effect size. 6 The highest strength of evidence was for risk factors relating to co-morbidities, physical and psychosocial health, environmental conditions, social circumstances, and nutrition and lifestyle. 6 Updating this review to 2001, Spiers et al. emphasized the link between depression and cognitive impairment, and subsequent functional decline. 7 Ayis et al. studied the predictors of rapid global deterioration in mobility over one year in people aged 65 years and older in a UK Office of National Statistics Omnibus survey. 8 The incidence of this ‘catastrophic decline’ was one in twenty people per year. Predictors of decline were older age, previous