Predictive capacity of the Integrated Care for Older People (ICOPE) screening tool for intrinsic capacity impairments: results from the INSPIRE-T cohort.

BACKGROUND: The Integrated Care for Older People (ICOPE) approach was developed by the World Health Organization (WHO) aiming to shift the traditional focus of care based on diseases to a function- and person-centered approach, focused on maintaining and monitoring intrinsic capacity (IC). This study aimed to investigate the ability of the ICOPE screening tool to identify older people with clinically meaningful impairments in IC domains. METHODS: This cross-sectional analysis included 603 older adults, participants (mean age 74.7 [SD 8.8] years, women 59.0%) of the INSPIRE Translational (INSPIRE-T) cohort. Responses at screening were compared to results of the subsequent in-depth assessment (i.e., Mini Mental State Examination, Mini Nutritional Assessment, Short Physical Performance Battery, Patient Health Questionnaire-9, and clinical investigation of vision problems) to determine its predictive capacity for impairments at the IC domains (i.e., cognition, psychological, sensory (vision), vitality, and locomotion). RESULTS: The ICOPE screening items provided very high sensitivity for identifying abnormality in vision (97.2%), and varied from 42.0% to 69.6% for the other domains. High specificity (>70%) was observed for all the IC domains, except for vision (2.7%). CONCLUSIONS: The ICOPE screening tool can be a useful instrument enabling the identification of older people with impairments in IC domains, but studies with different populations are needed. It should be considered as a low-cost and simple screening tool in clinical care.

Development and validation of an intrinsic capacity score in the UK Biobank study.

BACKGROUND: In 2015, the World Health Organization introduced the concept of intrinsic capacity (IC) to define the individual-level characteristics that enable an older person to be and do the things they value. This study developed an intrinsic capacity score for UK Biobank study participants and validated its use as a tool for health outcome prediction, understanding healthy aging trajectories, and genetic research. METHODS: Our analysis included data from 45,208 UK biobank participants who had a complete record of the ten variables included in the analysis. Factor adequacy was tested using Kaiser-Meyer-Olkin, Barthelt's, and the determinant of matrix tests, and the number of factors was determined by the parallel analysis method. Exploratory and confirmatory factor analyses were employed to determine the structure and dimensionality of indicators. Finally, the intrinsic capacity score was generated, and its construct and predictive validities as well as reliability were assessed. RESULTS: The factor analysis identified a multidimensional construct comprising one general factor (intrinsic capacity) and five specific factors (locomotor, vitality, cognitive, psychological, and sensory). The bifactor structure showed a better fit (comparative fit index = 0.995, Tucker Lewis index = 0.976, root mean square error of approximation = 0.025, root mean square residual = 0.009) than the conventional five-factor structure. The intrinsic capacity score generated using the bifactor confirmatory factor analysis has good construct validity, as demonstrated by an inverse association with age (lower intrinsic capacity in older age; (ß) =-0.035 (95%CI: -0.036, -0.034)), frailty (lower intrinsic capacity score in prefrail participants, ß = -0.104 (95%CI: (-0.114, -0.094)) and frail participants, ß = -0.227 (95%CI: -0.267, -0.186) than robust participants), and comorbidity (a lower intrinsic capacity score associated with increased Charlson's comorbidity index, ß =-0.019 (95%CI: -0.022, -0.015)). The intrinsic capacity score also predicted comorbidity (a one-unit increase in baseline intrinsic capacity score led to a lower Charlson's comorbidity index, ß = 0.147 (95%CI: -0.173, -0.121)) and mortality (a one-unit increase in baseline intrinsic capacity score led to 25 % lower risk of death, odds ratio = 0.75(95%CI: 0.663, 0.848)). CONCLUSION: The bifactor structure showed a better fit in all goodness of fit tests. The intrinsic capacity construct has strong structural, construct, and predictive validities and is a promising tool for monitoring aging trajectories.

A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions.

Pedestrian injuries from falls are an understudied cause of morbidity. Here, we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 118,520 injurious pedestrian falls and 33,915 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty-two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 19% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.1 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was 3.9 for individuals 50 years and older and 6.1 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy, and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the USA.

A National Study on the Comparative Burden of Pedestrian Injuries from Falls Relative to Pedestrian Injuries from Motor Vehicle Collisions.

Pedestrian injuries from falls are an understudied cause of morbidity. Here we compare the burden of pedestrian injuries from falls occurring on streets and sidewalks with that from motor vehicle collisions. Data on injurious falls on streets and sidewalks, and pedestrian-motor vehicle collisions, to which Emergency Medical Services responded, along with pedestrian and incident characteristics, were identified in the 2019 National Emergency Medical Services Information System database. In total, 129,343 injurious falls and 33,910 pedestrians-motor vehicle collisions were identified, with 89% of the incidents occurring in urban areas. Thirty two percent of pedestrians struck by motor vehicles were coded as Emergent or Critical by Emergency Medical Services, while 20% of pedestrians injured by falls were similarly coded. However, the number of pedestrians whose acuity was coded as Emergent or Critical was 2.33 times as high for injurious falls as compared with pedestrians-motor vehicle collisions. This ratio was nearly double at 4.3 for individuals 50 years and older, and almost triple at 6.5 for those 65 years and older. In conclusion, there has been substantial and appropriate policy attention given to preventing pedestrian injuries from motor vehicles, but disproportionately little to pedestrian falls. However, the population burden of injurious pedestrian falls is significantly greater and justifies an increased focus on outdoor falls prevention, in addition to urban design, policy and built environment interventions to reduce injurious falls on streets and sidewalks, than currently exists across the U.S.

Association of intrinsic capacity with incidence and mortality of cardiovascular disease: Prospective study in UK Biobank.

BACKGROUND: The World Health Organization proposed the concept of intrinsic capacity (IC; the composite of all the physical and mental capacities of the individual) as central for healthy ageing. However, little research has investigated the interaction and joint associations of IC with cardiovascular disease (CVD) incidence and CVD mortality in middle- and older-aged adults. METHODS: Using data from 443 130 UK Biobank participants, we analysed seven biomarkers capturing the level of functioning of five domains of IC to calculate a total IC score (ranging from 0 [better IC] to +4 points [poor IC]). Associations between IC score and incidence of six long-term CVD conditions (hypertension, stroke/transient ischaemic attack stroke, peripheral vascular disease, atrial fibrillation/flutter, coronary artery disease and heart failure), and grouped mortality from these conditions were estimated using Cox proportional models, with a 1-year landmark analysis to triangulate the findings. RESULTS: Over 10.6 years of follow-up, CVD morbidity grouped (n = 384 380 participants for the final analytic sample) was associated with IC scores (0 to +4): mean hazard ratio (HR) [95% confidence interval, CI] 1.11 [1.08-1.14], 1.20 [1.16-1.24], 1.29 [1.23-1.36] and 1.56 [1.45-1.59] in men (C-index = 0.68), and 1.17 [1.13-1.20], 1.30 [1.26-1.36], 1.52 [1.45-1.59] and 1.78 [1.67-1.89] in women (C-index = 0.70). In regard to mortality, our results indicated that the higher IC score (+4 points) was associated with a significant increase in subsequent CVD mortality (mean HR [95% CI]: 2.10 [1.81-2.43] in men [C-index = 0.75] and 2.29 [1.85-2.84] in women [C-index = 0.78]). Results of all sensitivity analyses by full sample, sex and age categories were largely consistent independent of major confounding factors (P < 0.001). CONCLUSIONS: IC deficit score is a powerful predictor of functional trajectories and vulnerabilities of the individual in relation to CVD incidence and premature death. Monitoring an individual's IC score may provide an early-warning system to initiate preventive efforts.

Life-course inequalities in intrinsic capacity and healthy ageing, China.

Objective: To investigate the contribution of early-life factors on intrinsic capacity of Chinese adults older than 45 years. Methods: We used data on 21 783 participants from waves 1 (2011) and 2 (2013) of the China Health and Retirement Longitudinal Study (CHARLS), who also participated in the 2014 CHARLS Life History Survey to calculate a previously validated measure of intrinsic capacity. We considered 11 early-life factors and investigated their direct association with participants' intrinsic capacity later in life, as well as their indirect association through four current socioeconomic factors. We used multivariable linear regression and the decomposition of the concentration index to investigate the contribution of each determinant to intrinsic capacity inequalities. Findings: Participants with a favourable environment in early life (that is, parental education, childhood health and neighbourhood environment) had a significantly higher intrinsic capacity score in later life. For example, participants with a literate father recorded a 0.040 (95% confidence interval, CI: 0.020 to 0.051) higher intrinsic capacity score than those with an illiterate father. This inequality was greater for cognitive, sensory and psychological capacities than locomotion and vitality. Overall, early-life factors directly explained 13.92% (95% CI: 12.07 to 15.77) of intrinsic capacity inequalities, and a further 28.57% (95% CI: 28.19 to 28.95) of these inequalities through their influence on current socioeconomic inequalities. Conclusion: Unfavourable early-life factors appear to decrease late-life health status in China, particularly cognitive, sensory and psychological capacities, and these effects are exacerbated by cumulative socioeconomic inequalities over a person's life course.

Association of intrinsic capacity with respiratory disease mortality.

The World Health Organization (WHO) introduced a framework for healthy aging in 2015 that emphasizes functional ability instead of absence of disease. Healthy ageing is defined as "the process of building and maintaining the functional ability that enables well-being". This framework considers an individual's intrinsic capacity (IC), environment, and the interaction between them to determine functional ability. In this prospective cohort study, we investigated the link between mortality and various respiratory diseases in almost half a million adults who are part of the UK Biobank. We derived an IC score using measures from 4 of the 5 domains: two for psychological capacity, two for sensory capacity, two for vitality and one for locomotor capacity. The exposure variable in the study was the number of reported factors, which was summed and categorized into IC scores of zero, one, two, three, or at least four. The outcome was respiratory disease-related mortality, which was linked to national mortality records. The follow-up period started from participants' inclusion in the UK Biobank study (2006-2010) and ended on December 31, 2021, or the participant's death was censored. The average follow-up was 10.6 years (IQR 10.0; 11.3). During a median follow-up period of 10.6 years, 27,251 deaths were recorded. Out of these, 7.5% (2059) were primarily attributed to respiratory disease. The results showed that a higher IC score (+4 points) was associated with a significantly increased risk of respiratory disease mortality, with HRs of 3.34 [2.64 to 4.23] for men (C-index = 0.83) and 3.87 [2.86 to 5.23] for women (C-index = 0.84), independent of major confounding factors (P < 0.001). Our study provides evidence that lower levels of the WHO's IC construct are associated with increased risk of mortality and various adverse health outcomes. The IC construct, which is easily and inexpensively measured, holds great promise for transforming geriatric care worldwide, including in regions without established geriatric medicine.

WHO working definition of vitality capacity for healthy longevity monitoring.

Intrinsic capacity, a crucial concept in healthy ageing, is defined by WHO as "the composite of all the physical and mental capacities that an individual can draw on at any point in time". Vitality capacity is considered the underlying physiological determinant of intrinsic capacity. To advance the measurement and monitoring of vitality capacity, a working group of WHO staff members and twenty experts representing six WHO regions was convened to discuss and clarify the attributes of vitality capacity and to develop a clear working definition of the concept. Potential biomarkers to measure vitality capacity were identified, and the following consensual working definition was developed: vitality capacity is a physiological state (due to normal or accelerated biological ageing processes) resulting from the interaction between multiple physiological systems, reflected in (the level of) energy and metabolism, neuromuscular function, and immune and stress response functions of the body.

Implementation of the WHO integrated care for older people (ICOPE) programme in clinical practice: a prospective study.

BACKGROUND: The INSPIRE integrated care for older people (ICOPE)-CARE programme is a public health programme implementing the ICOPE health-care pathway in clinical practice. The primary objective of this study was to describe the large-scale implementation and feasibility of the INSPIRE ICOPE-CARE guidelines in clinical practice. The secondary aims were to describe the characteristics of patients who were identified as positive for abnormalities in intrinsic capacity (ie, locomotion, cognition, psychology, vitality, hearing, and vision) during step 1, and to describe the prevalence of these positive screenings. METHODS: In this prospective study, we evaluated a real-life population of users of primary care services in the Occitania region (France). Participants who were aged 60 years and older and lived in a community were eligible for inclusion in our study. Individuals aged ≥60 years were screened (step 1) by health-care providers or through self-assessments using digital tools (the ICOPE MONITOR app and the ICOPEBOT conversational robot). Our implementation strategy involved raising awareness among health-care professionals about the WHO ICOPE programme, training professionals in the ICOPE-CARE guidelines, and developing a digital infrastructure (ie, digital tools, a database, and a remote ICOPE monitoring platform). The feasibility of implementing the INSPIRE ICOPE-CARE guidelines was determined by the anticipated inclusion of ≥10 000 participants, and having a follow-up rate of over 50%. FINDINGS: Between Jan 1, 2020, and November 18, 2021, 10 903 older people (mean age 76·0, SD 10·5 years; 6627 [60·8%] of whom were women) had a baseline step 1 screening done, and 5185 (70·4%) of 7367 eligible participants had a 6-month follow-up of step 1 screening. 10 285 (94·3%) participants had a positive intrinsic capacity result during screening at baseline. 958 (9·3%) participants were evaluated with step 2 (in-depth assessments). Positive intrinsic capacity was confirmed in 865 (90·3%) participants. Most recommendations in step 3 (care plan) were related to locomotion, vitality, and cognition. INTERPRETATION: The high number of participants included in our study, as well as the high rates of follow-up, provides evidence to suggest that the large-scale implementation of ICOPE in clinical practice is feasible. The very high prevalence of positive screening for impaired intrinsic capacity during step 1, as well as the high rates of confirmed deficits in intrinsic capacity during step 2, suggest that the INSPIRE ICOPE-CARE programme is able to target individuals who are at increased risk for functional loss and disability. FUNDING: Occitania Regional Health Agency, Region Occitanie and Pyrénées-Méditerranée, European Regional Development Fund, and The Interreg Program V-A Spain-France-Andorra.

Intrinsic Capacity: Validation of a New WHO Concept for Healthy Aging in a Longitudinal Chinese Study.

BACKGROUND: The World Health Organization has proposed a model of healthy aging built around the concept of functional ability, comprising an individual's intrinsic capacity, the physical and social environment they occupy, and interactions between the two. However, these constructs have been poorly defined. We examined the structure of intrinsic capacity in a representative sample of the Chinese population aged 60 years and older and assessed its value in predicting declining performance in instrumental activities of daily living (IADLs) and activities of daily living (ADLs) using similar methods to a construct validation previously undertaken in an English cohort. METHODS: Deidentified data were accessed on 7 643 participants of the China Health and Retirement Longitudinal Study 2011 and 2013 waves. Incrementally related structural equation modeling was applied, including exploratory and confirmatory factor analysis, and path analysis. Multiple linear regression tested construct validity, and simple and serial mediation models assessed predictive validity. RESULTS: Factor loadings for the models showed a clear structure for intrinsic capacity: 1 general factor with 5 subfactors-locomotor, cognitive, psychological and sensory capacities, and vitality (reflecting underlying physiologic changes). Intrinsic capacity predicted declining performance in both IADLs (standardized coefficient (SE) -0.324 (0.02), p < .001) and ADLs (-0.227 (0.03), p < .001), after accounting for age, sex, education, wealth, and number of chronic diseases. Each characteristic was associated with intrinsic capacity, providing strong construct validity. CONCLUSIONS: Assessment of intrinsic capacity provides valuable information on an individual's subsequent functioning beyond that afforded by age, other personal factors, and multimorbidity.

The structure and predictive value of intrinsic capacity in a longitudinal study of ageing.

OBJECTIVES: To assess the validity of the WHO concept of intrinsic capacity in a longitudinal study of ageing; to identify whether this overall measure disaggregated into biologically plausible and clinically useful subdomains; and to assess whether total capacity predicted subsequent care dependence. DESIGN: Structural equation modelling of biomarkers and self-reported measures in the English Longitudinal Study of Ageing including exploratory factor analysis, exploratory bi-factor analysis and confirmatory factor analysis. Longitudinal mediation and moderation analysis of incident care dependence. SETTINGS: Community, United Kingdom. PARTICIPANTS: 2560 eligible participants aged over 60 years. MAIN OUTCOME MEASURES: Activities of daily living (ADL) and instrumental activities of daily living (IADL). RESULTS: One general factor (intrinsic capacity) and five subfactors emerged: locomotor, cognitive; psychological; sensory; and 'vitality'. This structure is consistent with biological theory and the model had a good fit for the data (χ2=71.2 (df=39)). The summary score of intrinsic capacity and specific subfactors showed good construct validity. In a causal path model examining incident loss of ADL and IADL, intrinsic capacity had a direct relationship with the outcome-root mean square error of approximation (RMSEA)=0.02 (90% CI 0.001 to 0.05) and RMSEA=0.008 (90% CI0.001 to 0.03) respectively-and was a strong mediator for the effect of age, sex, wealth and education. Multimorbidity had an independent direct relationship with incident loss of ADLs but not IADLs, and also operated through intrinsic capacity. More of the indirect effect of personal characteristics on incident loss of ADLs and IADLs was mediated by intrinsic capacity than multimorbidity. CONCLUSIONS: The WHO construct of intrinsic capacity appears to provide valuable predictive information on an individual's subsequent functioning, even after accounting for the number of multimorbidities. The proposed general factor and subdomain structure may contribute to a transformative paradigm for future research and clinical practice.

Redesigning care for older people to preserve physical and mental capacity: WHO guidelines on community-level interventions in integrated care.

Islene Araujo de Carvalho and coauthors discuss the WHO guidelines on integrated care for older people.

Longitudinal associations between lifestyle, socio-economic position and physical functioning in women at different life stages.

Women's physical functioning declines with age and the rate of decline increases with age, but substantial disparities exist in trajectories over time. To inform development of interventions to optimise physical functioning across the adult life span, the aim is to explore which lifestyle and socio-economic position (SEP) factors contribute to disparities in physical functioning across the adult life span in women. Younger (born 1973-1978, n = 14,247), middle-aged (born 1946-1951, n = 13,715) and older (born 1921-1926, n = 12,432) participants from the Australian Longitudinal Study on Women's Health completed six questionnaires between 1996 and 2012 at approximate 3-year intervals. Physical functioning was measured with a 10-item subscale of the Short-Form Health Survey (score 1-100). Relationships between age and physical functioning were modelled using spline regression, stratified by baseline categories of physical activity, alcohol intake, smoking status, level of education, managing on income and index of neighbourhood socio-economic disadvantage for area. Multivariable models excluding one of the six factors were compared with models including all six factors to examine the relative importance of each factor. Women with unhealthy lifestyles (inactive, smokers or risky alcohol intake) and lower SEP had lower levels of physical functioning and more rapid declines across the adult life span. The variables with the greatest relative contribution to the models for physical functioning differed by age cohort: i.e. education and physical activity in younger women, managing on income and physical activity in middle-aged women and physical activity in older women. For optimal physical functioning, socio-economic factors seemed particularly important in younger and middle-aged women, while physical activity seemed important at all ages.

Rethinking Human Enhancement as Collective Welfarism.

Human enhancement technologies are opening tremendous opportunities but also challenges to the core of what it means to be human. We argue that the goal of human enhancement should be to enhance quality of life and well-being not only of individuals but also of the communities they inhabit.

The Sustainable Development Agenda Needs to Include Long-term Care.

The rapid ageing of populations around the world and the associated shift in the burden of disease from infectious to chronic conditions are creating complex challenges for national governments. Addressing the needs of these older populations in a sustainable and equitable way, will be a fundamental pillar of socioeconomic development in the 21st Century. The World Health Organization (WHO) Global strategy and action plan on ageing and health, which was adopted by all the Organization's 194 Member states in 2016, provides a clear framework for global action. One critical priority is to establish sustainable and equitable long-term care systems in every country. WHO defines long-term care as "the activities undertaken by others to ensure that people with, or at risk of, a significant ongoing loss of intrinsic capacity can maintain a level of functional ability consistent with their basic rights, fundamental freedoms and human dignity". These activities include both social care and health care, as well as contributions from other sectors, such as education or transport. And these activities need to be effectively coordinated if they are to efficiently, equitably and sustainably meet the needs of older people. This requires the stewardship of governments to ensure that: care is accessible and affordable; the rights of older people to lives of meaning and dignity are upheld regardless of their physical or mental capacity; services are oriented around the individual's specific needs; caregivers are supported; the workforce (both paid and unpaid) are treated fairly; and older people's intrinsic capacity is maintained for as long as possible. WHO has proposed three inter-related strategies to establish and sustain long-term care systems. System infrastructure needs to be developed and continually improved. The capacity of the workforce needs to be strengthened and families and communities must be supported. And the care and support provided needs to be more person-centred and integrated, underpinned by minimum standards and accreditation for care providers. This paper outlines some of the critical issues confronting governments in countries at all levels of development if this ambitious vision is to be achieved.

Longitudinal Patterns of Physical Activity Among Older Adults: A Latent Transition Analysis.

Most epidemiologic studies of physical activity measure either total energy expenditure or engagement in a single type of activity, such as walking. These approaches may gloss over important nuances in activity patterns. We performed a latent transition analysis to identify patterns of activity, as well as neighborhood and individual determinants of changes in those activity patterns, over 2 years in a cohort of 2,023 older adult residents of New York, New York, surveyed between 2011 and 2013. We identified 7 latent classes: 1) mostly inactive, 2) walking, 3) exercise, 4) household activities and walking, 5) household activities and exercise, 6) gardening and household activities, and 7) gardening, household activities, and exercise. The majority of subjects retained the same activity patterns between waves (54% unchanged between waves 1 and 2, 66% unchanged between waves 2 and 3). Most latent class transitions were between classes distinguished only by 1 form of activity, and only neighborhood unemployment was consistently associated with changing between activity latent classes. Future latent transition analyses of physical activity would benefit from larger cohorts and longer follow-up periods to assess predictors of and long-term impacts of changes in activity patterns.

Evidence for the Domains Supporting the Construct of Intrinsic Capacity.

Healthy ageing can be defined as "the process of developing and maintaining the functional ability that enables wellbeing in older age". Functional ability (i.e., the health-related attributes that enable people to be and to do what they have reason to value) is determined by intrinsic capacity (i.e., the composite of all the physical and mental capacities of an individual), the environment (i.e., all the factors in the extrinsic world that form the context of an individual's life), and the interactions between the two. This innovative model recently proposed by the World Health Organization has the potential to substantially modify the way in which clinical practice is currently conducted, shifting from disease-centered toward function-centered paradigms. By overcoming the multiple limitations affecting the construct of disease, this novel framework may allow the worldwide dissemination of a more proactive and function-based approach toward achieving optimal health status. In order to facilitate the translation of the current theoretical model into practice, it is important to identify the inner nature of its constituting constructs. In this article, we consider intrinsic capacity. Using the International Classification of Functioning, Disability and Health (ICF) framework as background and taking into account available evidence, five domains (i.e., locomotion, vitality, cognition, psychological, sensory) are identified as pivotal for capturing the individual's intrinsic capacity (and therefore also reserves) and, through this, pave the way for its objective measurement.