Gerontology Nursing.

Gerontology Nursing.

Integrated care for older people Guidelines on community-level interventions to manage declines in intrinsic capacity

 

 

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Integrated care for older people Guidelines on community-level interventions to manage declines in intrinsic capacity

 

 

Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity

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iii Contents

Contents

Acknowledgements ………………………………………………………………………………………………………….. iv

Abbreviations …………………………………………………………………………………………………………………… v

Executive summary …………………………………………………………………………………………………………. vii

1 Introduction ……………………………………………………………………………………………………………. 1

1.1 Rationale for these guidelines ……………………………………………………………………………………….. 2

1.2 Scope ……………………………………………………………………………………………………………………….. 2

1.3 Target audience …………………………………………………………………………………………………………. 3

1.4 Guiding principles ………………………………………………………………………………………………………. 3

2 Guideline development process ……………………………………………………………………………….. 5

2.1 Guideline development group ………………………………………………………………………………………. 5

2.2 Declarations of interest and management of conflict ………………………………………………………… 5

2.3 Identifying, appraising and synthesizing available evidence ………………………………………………… 5

2.4 Consensus decision-making during the guideline development group meeting ……………………… 6

2.5 Document preparation and peer review …………………………………………………………………………. 6

3 Evidence and recommendations ………………………………………………………………………………. 7

3.1 Module I: Declining physical and mental capacities …………………………………………………………… 8

3.2 Module II: Geriatric syndromes ……………………………………………………………………………………..17

3.3 Module III: Caregiver support ……………………………………………………………………………………….21

4 Implementation considerations ………………………………………………………………………………. 25

5 Publication, dissemination and evaluation ……………………………………………………………… 29

5.1 Publication and dissemination ………………………………………………………………………………………29

5.2 Monitoring and evaluation …………………………………………………………………………………………..29

5.3 Future review and update…………………………………………………………………………………………… 30

References ………………………………………………………………………………………………………………………..31

Annex 1: Guideline development group (GDG) members ………………………………………………….. 34

Annex 2: Assessment of conflicts of interest …………………………………………………………………….. 35

Annex 3: Scoping questions …………………………………………………………………………………………….. 38

Annex 4: Evidence process ………………………………………………………………………………………………..41

Glossary ………………………………………………………………………………………………………………………….. 44

 

 

iv Integrated care for older people

Acknowledgements

These ICOPE guidelines were coordinated by the World Health Organization (WHO) Department of Ageing and Life Course. Islene Araujo de Carvalho, Jotheeswaran Amuthavalli Thiyagarajan, Yuka Sumi and John Beard oversaw the preparation of this document, with thanks to Susanna Volk for administrative support.

WHO acknowledges the technical contributions of the guideline development group (GDG). In alphabetical order: Emiliano Albanese (WHO Collaborating Centre, University of Geneva, Geneva, Switzerland); Olivier Bruyère (University of Liège, Liège, Belgium); Matteo Cesari (Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France); Alan Dangour (London School of Hygiene & Tropical Medicine, London, United Kingdom of Great Britain and Northern Ireland); Amit Dias (Goa Medical College, Goa, India); Astrid Fletcher (London School of Hygiene & Tropical Medicine, London, United Kingdom); Dorothy Forbes (University of Alberta, Edmonton, Canada); Anne Forster (University of Leeds, Leeds, United Kingdom); Mariella Guerra (Institute of Memory, Depression and Related Disorders, Lima, Peru); Jill Keeffe (WHO Collaborating Centre for Prevention of Blindness, Hyderabad, India); Ngaire Kerse (University of Auckland, Auckland, New Zealand); Qurat ul Ain Khan (Aga Khan University Hospital, Karachi, Pakistan); Chiung- ju Liu (Indiana University, Indianapolis, Indiana, United States of America); Gudlavalleti V.S. Murthy (Indian Institute of Public Health, Hyderabad, Madhapur, India); Serah Nyambura Ndegwa (University of Nairobi, Nairobi, Kenya); Joseph G. Ouslander (Florida Atlantic University, Boca Raton, United States); Jean-Yves Reginster (University of Liège, Liège, Belgium); Luis Miguel F. Gutiérrez Robledo (Institutos Nacionales de Salud de México, Mexico City, Mexico); John F. Schnelle (Vanderbilt University Medical Center, Nashville, United States); Kelly Tremblay (University of Washington, Seattle, United States); Jean Woo (The Chinese University of Hong Kong, Hong Kong, China). Special thanks go to the chair of the GDG, Martin Prince (King’s College London, London, United Kingdom).

The WHO Department of Ageing and Life Course would like to express its appreciation to the external review group: A.B. Dey (All India Institute of Medical Science, New Delhi, India); Minha Rajput-Ray (Global Centre for Nutrition and Health, Cambridge, United Kingdom); Sumantra Ray (Medical Research Council, Cambridge, United Kingdom); Richard Uwakwe (Nnamdi Azikiwe University, Awka, Nigeria).

The department would like to thank the ICOPE guidelines steering group: Said Arnaout (WHO Regional Office for the Eastern Mediterranean); Anjana Bhushan (WHO Regional Office for the Western Pacific); Alessandro Rhyl

Demaio (WHO Department of Nutrition for Health and Development); Shelly Chadha (WHO Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention); Tarun Dua (WHO Department of Mental Health and Substance Abuse); Manfred Huber (WHO Regional Office for Europe); Silvio Paolo Mariotti (WHO Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention); Maria Alarcos Moreno Cieza (WHO Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention); Alana Margaret Officer (WHO Department of Ageing and Life Course); Juan Pablo Peña-Rosas (WHO Department of Nutrition for Health and Development); Anne Margriet Pot (WHO Department of Ageing and Life Course); Ritu Sadana (WHO Department of Ageing and Life Course); Céline Yvette Seignon Kandissounon (WHO Regional Office for Africa); Maria Pura Solon (WHO Department of Nutrition for Health and Development); Mark Humphrey Van Ommeren (WHO Department of Mental Health and Substance Abuse); Enrique Vega Garcia (WHO Regional Office for the Americas); Temo Waqanivalu (WHO Prevention of Noncommunicable Diseases Management Team).

The WHO Department of Ageing and Life Course is grateful to the members of the WHO systematic review team: Alessandra Stella (Independent Consultant, Rome, Italy); Kralj Carolina (King’s College London, London, United Kingdom); Meredith Fendt-Newlin (King’s College London, London, United Kingdom).

King’s College London, London, United Kingdom, supported the development of the ICOPE guidelines by providing staff to work on the systematic reviews and assisting in the management of the GDG. King’s College London did not receive any external funding for engaging with WHO on the development of these guidelines. Finally, the peer-reviewers are due thanks for their thoughtful feedback of a preliminary version of these guidelines.

The WHO Department of Ageing and Life Course acknowledges the financial support of the Government of Japan for the development of the ICOPE guidelines.

Donors do not fund specific guidelines and do not participate in any decision related to the guideline development process, including for the composition of research questions, the memberships of the guideline groups, the conduct and interpretation of systematic reviews, or the formulation of the recommendations.

Editing, design and layout were provided by Green Ink, United Kingdom (greenink.co.uk).

 

 

v Abbreviations

Abbreviations

ADLs activities of daily living

AGREE Appraisal of Guidelines for Research and Evaluation

GDG guideline development group

GRADE Grading of Recommendations Assessment, Development and Evaluation

ICOPE integrated care for older people

mhGAP Mental Health Gap Action Programme

PFMT pelvic floor muscle training

PICO population, intervention, comparison, outcome

RCT randomized controlled trial

WHO World Health Organization

 

 

 

vii Executive summary

Over the past 50 years, socioeconomic development in

most regions has been accompanied by large reductions

in fertility and equally dramatic increases in life

expectancy. This phenomenon has led to rapid changes

in the demographics of populations around the world:

the proportion of older people in general populations

has increased substantially within a relatively short

period of time.

Numerous underlying physiological changes occur with

increasing age, and for older people the risks of

developing chronic disease and care dependency

increase. By the age of 60 years, the major burden of

disability and death arises from age-related losses in

hearing, seeing and moving, and conditions such as

dementia, heart disease, stroke, chronic respiratory

disorder, diabetes and musculoskeletal conditions such

as osteoarthritis and back pain.

The 2015 World Health Organization (WHO) World

report on ageing and health defines the goal of Healthy

Ageing as helping people in “developing and

maintaining the functional ability that enables well-

being”. Functional ability is defined in the report as the

“health-related attributes that enable people to be and

to do what they have reason to value”. Intrinsic capacity,

finally, is “the composite of all of the physical and

mental capacities that an individual can draw on”. The

WHO public health framework for Healthy Ageing

focuses on the goal of maintaining intrinsic capacity and

functional ability across the life course.

Health care professionals in clinical settings can detect

declines in physical and mental capacities (clinically

expressed as impairments) and deliver effective

interventions to prevent and delay progression. Yet early

markers of declines in intrinsic capacity, such as

decreased gait speed or muscle strength, are often not

identified, treated or monitored, which are crucial

actions if these declines are to be reversed or delayed.

The majority of health care professionals lack guidance

or training to recognize and manage impairments in

older age. There is a pressing need to develop

comprehensive community-based approaches and to

introduce interventions at the primary health care level

to prevent declines in capacity. These guidelines address

this need.

The recommendations provided here on integrated care

for older people (ICOPE) offer evidence-based guidance

to health care providers on the appropriate approaches

at the community level to detect and manage important

declines in physical and mental capacities, and to deliver

interventions in support of caregivers. These standards

can act as the basis for national guidelines and for the

inclusion of older people’s health care in primary care

programmes, using a person-centred and integrated

approach.

Supplementary to the present guidance is an ICOPE

implementation guide, which addresses how to set

person-centred care goals, develop an integrated care

plan, and provide self-management support. This will

also include guidance to lead the practitioner through

the process of assessing, classifying and managing

declining physical and mental capacities in older age in

an integrated way.

The present guidelines and the supplementary

implementation guide are both organized into three

modules.

• Module I: Declines in intrinsic capacity, including mobility loss, malnutrition, visual impairment and

hearing loss, cognitive impairment, and depressive

symptoms

• Module II: Geriatric syndromes associated with care dependency, including urinary incontinence and

risk of falls

• Module III: Caregiver support: interventions to support caregiving and prevent caregiver strain.

The physical and mental impairments were selected

because they represent, consistent with the WHO

Executive summary

 

 

viii Integrated care for older people

framework on Healthy Ageing, clinically important

declines in physical and mental capacities, and are

strong predictors of mortality and care dependency in

older age. The recommendations need to be

implemented using an older person-centred and

integrated approach. The rationale and evidence base

for doing this has been described previously in the

WHO World report on ageing and health.

The ICOPE implementation guide will outline the

important elements that should be taken into account

at the clinical level when designing integrated care for

older people, and the steps required to deliver the

present community-level recommendations in an

integrated manner.

These ICOPE guidelines and associated products are

key tools in support of the implementation of the

WHO Global strategy and action plan on ageing and

health approved by the World Health Assembly in

2016. WHO will partner with ministries of health,

nongovernmental organizations, professional

associations and academic institutions to disseminate

these guidelines, and support their adaptation and

implementation by Member States.

Guideline development methods The process followed in the development of these

guidelines is outlined in the WHO handbook for

guideline development and has involved:

(i) establishment of the steering group, guideline

development group (GDG), external review group and

systematic review team; (ii) declarations of interest by

GDG members and peer reviewers; (iii) identification,

appraisal and synthesis of available evidence;

(iv) formulation of the recommendations with inputs

from a wide range of stakeholders; and (v) preparation

of documents and plans for dissemination.

The GDG is an international group of experts (Annex 1)

representing the six WHO regions. The scope of the

guidelines and questions (Annex 3) were defined in

consensus with the GDG members. A total of nine

PICO (population, intervention, comparison group,

outcomes) questions were formulated by the GDG and

the steering group with inputs from external reviewers.

A series of searches for systematic reviews and

randomized controlled trials was conducted across the

Cochrane Library, Embase, Ovid MEDLINE and

PsycINFO databases applying a search strategy

involving the United States Library of Medicine’s MeSH

terms where appropriate (Annex 4). For each

preselected critical question, evidence profiles

following the Grading of Recommendations

Assessment, Development and Evaluation (GRADE)

approach were prepared from existing systematic

reviews or systematic reviews updated with newer

trials.

The recommendations were formulated by the GDG

during a meeting at WHO headquarters in Geneva,

Switzerland, 24–26 November 2015. The GRADE

methodology continued to be followed, to prepare

evidence profiles related to preselected topics, based

on up-to-date systematic reviews. The GDG members

discussed the evidence, clarified points and interpreted

the findings to develop recommendations. The GDG

considered the relevance of the recommendations for

older people, considering the balance of benefit and

harm for each intervention, the values and preferences

of older people, and the costs and resource use as well

as other relevant practical issues of concern for

providers in low- and middle-income countries.

The recommendations now formed in these

guidelines are interrelated, and aim to produce

synergistic effects on the intrinsic capacities and

functional abilities of individuals. Although

recommendations were made on the separate

interventions, it was recognized that these would be

best implemented in the context of a comprehensive

needs assessment and an integrated care plan.

The key recommendations for the secondary

prevention of declines in physical and mental

capacities are classified by the strength of

recommendation. When making a strong

recommendation, the GDG was confident that any

desirable effects outweighed any undesirable effects.

For conditional recommendations, the GDG concluded

that the desirable effects of adherence probably

outweighed any harm. The GDG members reached a

unanimous agreement on the majority of the

recommendations and ratings. Voting was required on

the recommendations about cognitive training and

respite care and the GDG decided that, because the

evidence was unavailable, the group would not

formulate any recommendations on these two

interventions.

 

 

ix Executive summary

Recommendations Module I: Declining physical and mental capacities

Mobility loss Recommendation 1: 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)

Malnutrition Recommendation 2: Oral supplemental nutrition with dietary advice should be recommended for older people affected by undernutrition. (Quality of the evidence: moderate; Strength of the recommendation: strong)

Visual impairment

Recommendation 3: Older people should receive routine screening for visual impairment in the primary care setting, and timely provision of comprehensive eye care. (Quality of the evidence: low; Strength of the recommendation: strong)

Hearing loss Recommendation 4: 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)

Cognitive impairment

Recommendation 5: Cognitive stimulation can be offered to older people with cognitive impairment, with or without a formal diagnosis of dementia. (Quality of the evidence: low; Strength of the recommendation: conditional)

Depressive symptoms

Recommendation 6: Older adults who are experiencing depressive symptoms can be offered brief, structured psychological interventions, in accordance with WHO mhGAP intervention guidelines, delivered by health care professionals with a good understanding of mental health care for older adults. (Quality of the evidence: very low; Strength of the recommendation: conditional)

Module II: Geriatric syndromes

Urinary incontinence

Recommendation 7: Prompted voiding for the management of urinary incontinence can be offered for older people with cognitive impairment. (Quality of the evidence: very low; Strength of the recommendation: conditional)

Recommendation 8: Pelvic floor muscle training (PFMT), alone or combined with bladder control strategies and self-monitoring, should be recommended for older women with urinary incontinence (urge, stress or mixed). (Quality of the evidence: moderate; Strength of the recommendation: strong)

Risk of falls Recommendation 9: Medication review and withdrawal (of unnecessary or harmful medication) can be recommended for older people at risk of falls. (Quality of the evidence: low; Strength of the recommendation: conditional)

Recommendation 10: Multimodal exercise (balance, strength, flexibility and functional training) should be recommended for older people at risk of falls. (Quality of the evidence: moderate; Strength of the recommendation: strong)

Recommendation 11: Following a specialist’s assessment, home modifications to remove environmental hazards that could cause falls should be recommended for older people at risk of falls. (Quality of the evidence: moderate; Strength of the recommendation: strong)

Recommendation 12: Multifactorial interventions integrating assessment with individually tailored interventions can be recommended to reduce the risk and incidence of falls among older people. (Quality of the evidence: low; Strength of the recommendation: conditional)

Module III: Caregiver support

Recommendation 13: Psychological intervention, training and support should be offered to family members and other informal caregivers of care-dependent older people, particularly but not exclusively when the need for care is complex and extensive and/or there is significant caregiver strain. (Quality of the evidence: moderate; Strength of the recommendation: strong)

 

 

 

1 Introduction

In most regions over the past 50 years, socioeconomic

development has been accompanied by large drops in

fertility and equally dramatic rises in life expectancy. This

phenomenon has led to rapidly ageing populations

around the world. The fastest rate of change is occurring

in low- and middle-income countries. Even in sub-

Saharan Africa, which has the world’s youngest

population structure, the number of people over 60

years of age is expected to increase over threefold, from

46 million in 2015 to 147 million in 2050 (1).

With increasing age, numerous underlying physiological

changes occur, and the risks for older people developing

chronic disease and care dependency increase. The major

population burdens of disability and death in people over

60 arise from age-related losses in hearing, seeing and

moving, and conditions such as dementia, heart disease,

stroke, chronic respiratory disorder, diabetes and

osteoarthritis. These are not problems just for higher-

income countries; in fact, the burden associated with

these conditions affecting older people is generally far

higher in low- and middle-income countries (2).

Population ageing will dramatically increase the

proportion and number of people needing long-term

care in countries at all levels of development. This will

occur at the same time as the proportion of younger

people who might be available to provide care will fall,

and the societal role of women, who have until now

been the main care providers, is changing. Therefore, an

approach to prevent and reverse functional decline and

care dependency in older age is critical to improving

public health responses to population ageing. Such an

approach is needed urgently.

The 2015 World Health Organization (WHO) World

report on ageing and health defines the goal of Healthy

Ageing as helping people to develop and maintain the

functional ability that enables well-being (1). Functional

ability is defined in the report as the “health-related

attributes that enable people to be and to do what they

have reason to value”. Intrinsic capacity is “the

composite of all of the physical and mental capacities

that an individual can draw on”. A summary of these

definitions is given in the box below.

The WHO public health framework for Healthy Ageing

focuses on the goal of maintaining function across the

life course (Fig. 1). Intervening at an early stage is

essential because the process of becoming frail or care

dependent can be delayed, slowed or even partly

reversed by interventions targeted early in the process of

functional decline (3–5). Health care professionals in

clinical settings can detect declining physical and mental

capacities (clinically expressed as impairments) and

deliver effective interventions to prevent and slow or

halt the progression of these impairments.

In 2016, following the release of the WHO World report

on ageing and health (1), the Global strategy and action

plan on ageing and health was adopted by the World

Health Assembly (6). Both reflect a new conceptual

model for Healthy Ageing that is built around the

concept of the intrinsic capacities and functional abilities

of older people, rather than the absence of disease. The

rationale and evidence base for providing older person-

centred and integrated care have been described in the

World report on ageing and health and a publication in

The Lancet (7). The present community-level ICOPE

Intrinsic capacity and functional ability

WHO defines intrinsic capacity (IC) as the combination of the individual’s physical and mental, including psychological, capacities; and functional ability (FA) as the combination and interaction of IC with the environment a person inhabits.

Introduction1

 

 

2 Integrated care for older people

Fig. 1: A public health framework for Healthy Ageing: opportunities for public-health action across the life course

Intrinsic capacity and functional ability do not remain constant but decline with age as a result of underlying diseases

and the ageing process.

guidelines were rewritten to align with this new WHO

concept of Healthy Ageing. The implementation guide to

accompany them aims to provide further evidence-based

guidance to health care providers on appropriate

approaches to detect and manage important reductions

in physical and mental capacities, and to deliver

interventions to support caregivers.

1.1 Rationale for these guidelines Declining intrinsic capacity is very frequently

characterized by common problems in older age such as

difficulties with hearing, seeing, remembering, moving,

or performing daily or social activities. Yet these

problems are often overlooked by health care

professionals. Early markers of decline in intrinsic

capacity, such as decreased gait speed or reduced

muscle strength, are often not identified, treated or

monitored, which is crucial to do if they are to be

reversed or delayed. The majority of health care

professionals lack guidance or training to recognize and

manage impairments in older age.

Based on the belief that there is no treatment available

for their problems, older people may disengage from

services, not adhere to treatment and/or not attend

primary health care clinics. There is a pressing need to

develop comprehensive community-based approaches

and to introduce interventions to prevent declining

capacity and provide support to informal caregivers.

These guidelines address this need.

Approaching older people through the lens of

intrinsic capacity and the environment in which they live

helps to ensure that health services are orientated

towards the outcomes that are most relevant to their

daily lives. This approach can also help to avoid

unnecessary treatments, polypharmacy and side-

effects (1).

1.2 Scope These guidelines cover evidence-based interventions to

manage common declines in capacity in older age,

covering mobility, nutrition or vitality, vision, hearing,

cognition and mood, as well as the important geriatric

syndromes of urinary incontinence and risk of falls.

These conditions were selected because they express

reductions in physical and mental capacities, as outlined

in the WHO framework on Healthy Ageing (7), and are

strong independent predictors of mortality and care

dependency in older age (8).

Declining physical and/or mental capacity can be

identified by the presence of one or more of the

following indicators:

High and stable capacity Declining capacity Significant loss of capacity

Functional ability

Intrinsic capacity

 

 

3 Introduction

Mobility loss: After reaching a peak in early

adulthood, muscle mass tends to decline with

increasing age, and this can be associated with

declining strength and musculoskeletal function (9).

One way of measuring muscle function is to measure

hand grip strength, which is a strong predictor of

mortality (10, 11).

Malnutrition: Malnutrition represents a major

problem that affects 22% of older adults (12). It often

manifests as reduced muscle and bone mass, and it

increases the risk of frailty. Malnutrition has also been

associated with diminished cognitive function,

diminished ability to care for oneself, and a higher risk

of becoming care dependent.

Visual impairment and hearing loss: Ageing is

frequently associated with decrements in both vision

and hearing. Worldwide, more than 180 million people

over 65 years of age have hearing loss that interferes

with understanding normal conversational speech.

Severe visual impairment is highly prevalent in people

over 70 years of age, and a leading cause of blindness

in high-income and upper-middle-income

countries (13, 14).

Cognitive impairment: Worldwide, 46.8 million older

people are living with dementia. This number is

expected to double every 20 years, reaching

74.7 million in 2030 (15). Many cognitive functions

begin to decline at a relatively young age, with

different functions decreasing at different rates. In mild

cognitive impairment, the cognitive deficit is less severe

than in dementia, and normal daily function and

independence are generally maintained. This chronic

condition is a precursor to dementia in up to a third of

cases (16).

Depressive symptoms: Episodes of affective disorders

might be expected to be more prevalent in older age

due to the increased risk of adverse life events.

Compared with younger adults, older people more

often have substantial depressive symptomatology

without meeting the diagnostic criteria for a depressive

disorder. This condition is often referred to as

subthreshold depression, and affects nearly 1 in 10

older adults (17). Subthreshold depression also has a

major impact on the quality of life of older people, and

is a major risk factor for a depressive disorder (18).

The relationship of these indicators to care dependency,

disability and other important adverse health outcomes

has been proposed in numerous different conceptual

definitions, and longitudinal studies have shown strong

predictive validity for these indicators in relation to the

onset of care dependency and mortality (8). A clear

understanding of the nature of declining physical and

mental capacities, and of the relationships to ageing and

chronic diseases, is paramount to informing and

prioritizing interventions and strategies.

1.3 Target audience Health care providers working in communities and in

primary and secondary health care settings are the

primary audience for these ICOPE guidelines on

community-level interventions. Equally, these guidelines

are also aimed at professionals responsible for

developing training curricula in medicine, nursing and

public health.

Other targeted audiences for this document include

health care managers – such as programme managers

organizing health care services at national, regional and

district levels – entities funding and implementing public

health programmes, and nongovernmental organizations

and charities active in the care of older people in the

community setting.

1.4 Guiding principles The following principles have informed the development

of these guidelines and should guide the implementation

of the recommendations.

• The guidelines contribute to the achievement of key global goals in the WHO Global strategy and plan of

action on ageing and health (6, 19), which outlines

the role of health systems in promoting Healthy

Ageing by optimizing the trajectories of intrinsic

capacity.

• These guidelines are also a tool for the implementation of the WHO framework on

integrated people-centred health services (20). This

framework calls for shifting the way health services

are managed and delivered, and proposes key

approaches to be adopted to ensure quality

integrated care for people, including older people: a

strong case-management system in which individual

needs are assessed; the development of a

comprehensive care plan; and services driven towards

the goal of maintaining intrinsic capacity and

functional ability.

 

 

4 Integrated care for older people

• In addition to promoting integrated person-centred care, the recommendations should be implemented

with a view to supporting ageing in place; health

services should therefore provide care where people

live. The interventions are designed to be

implemented through models of care that prioritize

primary care and community-based care. This

includes a focus on home-based interventions,

community engagement and a fully integrated

referral system.

These guidelines provide evidence-informed

interventions that non-specialized health workers can

implement in primary health care and community

settings. One of the key principles to underpin the

development of these guidelines is the recognition of

the critical role that community health workers play in

increasing access to quality essential health services, in

the context of national primary health care and universal

health coverage. WHO guidance is available for country

programme managers and global partners, placing

emphasis on those key elements that strengthen the

capacity of community health workers. This covers, for

example, health system and programme considerations,

and the roles and core competencies of community

health workers (21).

 

 

5 Guideline development process

The WHO handbook for guideline development (22)

outlines the process used in the development of these

guidelines, following the steps below.

2.1 Guideline development group A WHO guideline steering group, led by the Department

of Ageing and Life Course, was established with

representatives from relevant WHO departments and

programmes with an interest in the provision of scientific

advice regarding older people. The guideline steering

group provided overall supervision of the guideline

development process. Two additional groups were

formed: a guideline development group (GDG) and an

external review group.

The GDG included a panel of academics and clinicians

with multidisciplinary expertise on the conditions

covered by the guidelines, plus geriatricians/specialist

doctors in the care of older people. Consideration was

given to the balance of gender and of geographically

diverse representation (see Annex 1).

Potential members of the GDG were selected on the

basis of their contribution to the area, as well as on the

need for regional and area-of-expertise diversity. As a

respected researcher in the field, the chair was selected

for his extensive experience of guideline development

methodology, and his participation in other guideline

development groups. Each potential GDG member was

asked to complete the WHO declaration-of-interest

form. The personal statements were reviewed by the

steering group.

2.2 Declarations of interest and management of conflicts of interest

All GDG members, peer reviewers and systematic review

team members were requested to complete the

declaration-of-interest form prior to the evidence-review

process for guideline development. Invitations to

participate in the GDG meeting were sent only after the

declarations of interest had been reviewed and

approved. These were reviewed by the responsible

technical officer at WHO – in this case the director of

the Department of Ageing and Life Course – and, when

necessary, legal counsel. The group composition was

finalized after this process. Annex 2 gives a summary of

relevant declarations of interest.

The declarations were once more assessed for potential

conflicts before the meeting in Geneva. The members

who were involved in conducting either primary research

or systematic reviews that would relate to the

recommendations did not participate in the formulation

of any recommendations themselves. The majority of the

members had no major conflicts of interest. Minor

conflicts of interest, of which there were two cases,

were managed individually by restricting participation at

relevant stages of the GDG meeting. All decisions were

documented (see Annex 2).

2.3 Identifying, appraising and synthesizing available evidence

The scope of the guidelines and questions (Annex 3)

were defined. A total of nine PICO (population,

intervention, comparison group, outcomes)

questions (23) were formulated by the GDG and

steering group. Outcomes were rated by GDG

members and external experts according to the

importance of each outcome from the perspectives of

older people and service providers, as not important

(rated 1–3), important (4–6), or critical (7–9). Outcomes

rated as critical were selected for inclusion into the

PICO analysis. The GDG engaged in regular

communications by email and discussions by

teleconference.

When formulating the scoping questions and conducting

the reviews, the focus was on evidence that applied

specifically to older people who were frail or care-

dependent or had priority conditions, and on

Guideline development process 2

 

 

6 Integrated care for older people

interventions that could be used by non-specialist health

workers in community settings or primary health care. The

steps that were taken for evidence retrieval, assessment

and synthesis are summarized in Annex 4. Further detail

on the review methods and available evidence is

summarized in the evidence profiles supporting these

guidelines. The evidence profiles used the Grading of

Recommendations Assessment, Development and

Evaluation (GRADE) methodology (24) followed by the

WHO guidelines handbook, and the profiles are available

at the WHO web pages for ICOPE (http://www.who.int/

ageing/health-systems/icope). The search strategy and

methods of quality assessment and appraisal are included

in each profile. This GRADE methodology for evidence-

based medicine was also used to formulate the

recommendations on the interventions, by providing a

rating of the overall quality of evidence arising from each

systematic review. All of the recommendations were

based on direct evidence and analysis of quantitative

data.

2.4 Consensus decision-making during the guideline development group meeting

The GDG met at the WHO headquarters in Geneva,

Switzerland, 24–26 November 2015. The evidence

reviews had been sent out in advance and were

presented in a summarized version during the meeting.

The GDG members discussed the evidence, clarified any

points and interpreted the findings, to develop

recommendations based on the draft prepared by the

WHO Secretariat. The GDG then proceeded with

deliberations and considered the relevance of the

recommendations for older people based on:

• the balance of benefit and harm of each intervention;

• values and preferences of older people;

• costs and resource use;

• acceptability of the intervention to health care providers in low- and middle-income countries;

• feasibility of implementation;

• impact on equity and human rights. To evaluate the values and preferences of older people

and the acceptability of proposed interventions to health

workers, no formal surveys were carried out; the

discussion and assessment of these domains instead

relied on the combined expertise and observations of

the GDG members. Similarly, no formal cost-

effectiveness studies were undertaken; again the GDG

members informed the assessments of resource

constraints based on their knowledge and experience.

Taking into account all of the above considerations, it

was agreed that if a recommendation would be of

general benefit, it would be rated as strong. If,

however, there were caveats about its benefits in

different contexts, and/or the quality of evidence was

less robust, the recommendation would be rated as

conditional. In the event of a disagreement, the chair

and the methodologist would ascertain whether the

dispute was related to the interpretation of the data or

to the way that the recommendation was formulated. If

a consensus agreement was not reached, the GDG

members agreed to a simple majority vote (51%/49%),

in which voting for this decision was by raised hands.

GDG members reserved the right to have any

objections recorded. Excluded from voting were any

WHO staff members present at the meeting and any

technical experts involved in the collection and review

of the evidence.

The GDG reached a consensus agreement on the

13 recommendations and ratings given in this

document. At the voting stage for recommendations

on cognitive training and respite care, these further

two were not supported due to insufficient evidence.

2.5 Document preparation and peer review In addition to the GDG members, four peer reviewers

provided expert input from specialized fields –

psychiatry, nutrition, physical therapy and geriatrics. A

preliminary version of these guidelines and the evidence

profiles prepared by WHO staff and the GDG were

circulated to the peer reviewers and the WHO steering

group. All inputs and remarks from reviewers were

discussed and agreed with the GDG by email.

Additionally, peer reviewers were asked to rate the

quality of the guidelines using a slightly modified version

of the tool, Appraisal of Guidelines for Research and

Evaluation (AGREE II). The original AGREE II tool lists 23

key items in the following domains: scope and purpose,

stakeholder involvement, rigour of development, clarity

of presentation, applicability, and editorial

independence (25). The reviewers’ total AGREE II scores

ranged from 22 to 154, and the average was 122.2.

 

 

7 Evidence and recommendations

Box 1: WHO guidelines and resources related to ICOPE

Mental Health Gap Action Programme (mhGAP) – mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0 (2016): http://www.who.int/mental_health/mhgap/mhGAP_ intervention_guide_02

Package of essential noncommunicable (PEN) disease interventions for primary health care in low-resource settings (2010): http:// www.who.int/nmh/publications/essential_ncd_interventions_ lr_settings.pdf

Guidelines for hearing aids and services for developing countries (2004): http://www.who.int/pbd/deafness/en/ hearing_aid_guide_en.pdf

Global recommendations on physical activity for health (2010): http://www.who.int/dietphysicalactivity/factsheet_ recommendations

Evidence and recommendations 3 Most of the conditions selected for these integrated

care for older people (ICOPE) guidelines share the same

underlying factors and determinants. It may be

possible to prevent or delay the onset of losses in

intrinsic capacity through a unified approach to

modifying a set of predisposing factors. For example,

highly intensive strength training is the key

intervention necessary to prevent and reverse mobility

impairments, but it also indirectly protects the brain

against depression and cognitive impairment, and

prevents falls. Nutrition enhances the effects of

exercise and has a direct impact on increasing muscle

mass and strength.

It is therefore necessary to implement these guidelines

using an older person-centred and integrated

approach. The recommendations are specific to the

community setting, but many are also applicable to

health care facilities.

The rationale and evidence base for the ICOPE

approach has been described previously in the WHO

World report on ageing and health (1).

Providers must ensure the following.

1. The assessment of individual impairments/declines

in capacity is used to inform the development of a

comprehensive care plan, and all domains are

assessed together.

2. Interventions to improve nutrition and encourage

physical exercise are included in most of the care

plans, and all the interventions needed are delivered

in conjunction with each other.

3. The presence of any impairment/decline in capacity

always triggers an urgent referral for medical

assessment of the associated disease (examples

being hypertension, diabetes, chronic obstructive

pulmonary disease, and dementia). WHO has

developed clinical guidelines to address most of the

relevant chronic diseases, and every health care

provider should have access to these (Box 1).

The ICOPE guidelines are organized into three modules.

• Module I: Declining physical capacities, including mobility loss, malnutrition, and visual impairment

and hearing loss, as well as declines in mental

capacities, such as cognitive impairment and

depressive symptoms.

• Module II: Geriatric syndromes associated with care-dependency in older age, including urinary

incontinence and risk of falls.

• Module III: Caregiver support.

 

 

8 Integrated care for older people

3.1 Module I: Declining physical and mental capacities

3.1.1 Mobility loss

Mobility is an important element of an older person’s

physical capacity. The loss of muscle mass and muscle

strength, decreased flexibility and problems with

balance can all impair mobility. Mobility impairment is

found in 39% of people over 65 years of age, which is

more than three times higher than among the

working population (26). Mobility loss can be

detected and its progression stopped or slowed if

appropriate exercise interventions are instigated early

in the process (27).

Considerations for recommendation 1

• The effects of exercise can be enhanced by combining it with increased protein intake and

other nutritional interventions.

• Consult a physical therapist or specialist, if available, before recommending exercise for older

people.

• Refer for investigations into, and treatment of, associated underlying diseases, such as arterial

and pulmonary disease, frailty and sarcopenia.

• Consider tailored, simple and less structured exercise programmes for older adults with

limitations in cognitive function. For older people

with severely reduced capacity, advise chair- and

bed-based exercise training as a starting point.

• Environmental characteristics associated with older people gaining more physical activity include

providing safe spaces for walking, ensuring easy

access to local facilities, goods and services,

seeing people of a similar age exercising in the

same neighbourhood, and regular participation in

exercise with friends and family.

• The effects of multimodal exercise interventions are enhanced when prescribed in association with

self-management support. Self-management

support also improves adherence.

• Multimodal interventions are a combination of different modes of exercise (aerobic, resistance,

flexibility, balance), with an emphasis on

important muscle groups and performed in a

functional manner. Older adults should be offered

guidance on the physical activity recommended

for their age and health conditions. WHO provides

recommendations that consider different starting

points and levels of capacity for physical activity to

maintain health (see http://www.who.int/

dietphysicalactivity/factsheet_

recommendations) (27).

Supporting evidence for recommendation 1

A systematic search identified 130 reviews, 11 of which

served as the basis for the primary findings summarized

below.

• Further detail on the supporting evidence is in the Evidence profile: mobility loss, available at http://

www.who.int/ageing/health-systems/icope.

Seven reviews from high-income countries used a

multimodal exercise programme of progressive muscle

strengthening or generic strength training, balance

retraining exercise, aerobic training and flexibility

training. Pooled data from the trials included in these

reviews indicated that this intervention significantly

improved critical outcomes, including muscle strength

of the lower extremity (10 trials, 1259 participants),

balance (16 trials, 1313 participants), gait speed (15

trials, 1543 participants), chair stand test score (9 trials,

827 participants), overall physical function (9 trials, 976

participants) and activities of daily living (7 trials, 551

cases). The overall quality of evidence was rated as

moderate as the results were consistently beneficial for

all critical outcomes and the GDG considered that

several of the critical outcomes would individually

suffice to support a recommendation for the

intervention.

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 low gait speed, grip strength and other physical performance measures.

Quality of the evidence: moderate Strength of the recommendation: strong

Recommendation 1

 

 

9 Evidence and recommendations

Eleven trials, reported in four reviews, investigated the

benefit of progressive resistance training in older

people with mobility impairment. Evidence suggests

that progressive resistance training improves muscle

strength of the lower extremity (8 trials, 655

participants) and chair stand test scores (2 trials, 38

participants). The overall methodological quality rating

was moderate for the muscle strength outcome and

low for the chair stand test. Progressive resistance

training had no effect on other critical outcomes

(balance, gait speed, Timed Up and Go score, overall

physical function and activities of daily living). In

addition, three trials of t’ai chi training showed a

significant benefit in terms of improving balance (348

cases), but no effect on the gait speed, chair stand

score, activities of daily living or the number of falls.

The overall methodological quality rating was low for

the balance outcome.