CM – Intrinsic Capacity and Its Association with Incident Dependence and Mortality in 10/66 Studies by the Dementia Research Group in Latin America, India, and China: A Population-Based Cohort Study

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Psychogeriatric Department, National Institute of Mental Health « Honorio Delgado Hideyo Noguchi », Lima, Peru,
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The World Health Organization (WHO) has realigned health and health care for the elderly to achieve the goal of healthy aging. The latest WHO guidelines on integrated care for the elderly (ICOPE) focus on maintaining intrinsic performance; The target audience with one or more dips in intrinsic capacity (DICs) is wide and can be challenging in environments with fewer resources. Our aim was to aid planning by assessing intrinsic capacity prevalence, characterizing the target audience, and validating the general approach by testing the hypotheses that DIC was consistently associated with a higher risk of incident dependency and death.

We conducted population-based cohort studies (Baseline, 2003–2007) in urban areas in Cuba, the Dominican Republic, Puerto Rico and Venezuela, and in rural and urban areas in Peru, Mexico, India and China. Eligible participants aged 65 and over who are ordinarily resident in each geographic area were identified by knocking on the door. All participants received questionnaires on sociodemographics, behavior and lifestyle, health and health care and costs, and physical exams, with incidence dependency and mortality assessed 3 to 5 years later (2008–2010). At the beginning of the study, 17,031 participants were surveyed at 12 locations in 8 countries. The average total age was 74.2 years, the mean values ​​by location 71.3–76.3 years; 62.4% were female, the range was 53.4% ​​-67.3%. Initially, only 30% retained full capacity across all domains. The percentage of storage decreased sharply with age, and declines across multiple domains were more common. Poverty, morbidity (especially dementia, depression and stroke) and disability were concentrated in the patients with DIC, although only 10% were frail and a further 9% were in need of care. The risk factors for high blood pressure and lifestyle for chronic diseases, as well as the use and costs of health care, were more evenly distributed among the population. A total of 15,901 participants were included in the mortality cohort (2,602 deaths / 53,911 person-years follow-up) and 12,939 participants in the dependency cohort (1,896 incidents / 38,320 person-years). One or more DICs strongly and independently predicted incident dependency (pooled adjusted subhazard ratio 1.91, 95% CI 1.69–2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1 , 49-1.85). The relative risks were higher for the frail, but also considerably increased for the much larger subgroups who were not yet frail. Mortality was mainly concentrated in the frail and dependent subgroups. The main limitations were the potential misclassification of DIC exposure and fluctuation bias.

In this study, we observed a high prevalence of DICs, especially in older age groups. Those affected had a significantly increased risk of dependency and death. The greatest need for care arose among people with DIC who are still frail. Our results support the strategy of optimizing intrinsic capacity for healthy aging. Implementation on a large scale requires community-based screening and assessment, as well as a step-by-step intervention approach with redefined roles for community health workers and efforts to involve, train and support them in these roles. ICOPE could usefully be integrated into community programs for the detection and treatment of chronic diseases such as high blood pressure and diabetes.

Citation: Prince MJ, Acosta D, Guerra M, Huang Y, Jacob KS, Jimenez-Velazquez IZ, et al. (2021) Intrinsic Capacity and Its Associations with Incident Dependence and Mortality in 10/66 Studies by the Dementia Research Group in Latin America, India, and China: A Population-Based Cohort Study. PLoS Med 18 (9):
e1003097.

https://doi.org/10.1371/journal.pmed.1003097

Copyright: © 2021 Prince et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which allows unrestricted use, distribution and reproduction in any medium, provided that the original author and source are acknowledged.

Data availability: The The data underlying this study are limited as participants did not consent to their information being published. The data on which the results presented in the study are based are available in the public data archive of the 10/66 Dementia Research Group for researchers who meet the criteria for access to confidential data. Information on the procedures for requesting access is available at https://www.alz.co.uk/1066/1066_public_archive_baseline.php or by contacting [email protected]

Funding: Funded by Wellcome Trust (MJP, JJLR -GR066133 – prevalence phase in Cuba; MJP, DA, MG, YH, JJLR, AS and ALS – GR080002- incidence phase in Peru, Mexico, Cuba, Dominican Republic, Venezuela and China and data analysis in all centers) – http: //www.wellcome.ac.uk/, World Health Organization (MJP, DA and YH – prevalence phase in the Dominican Republic and China) – www.who.int, US Alzheimer’s Association (MJP.), MG and ALS – IIRG – 04– 1286 – prevalence phase in Peru and Mexico) – http://www.alz.org/research/alzheimers_grants/, FONACIT / CDCH / UCV (AS – data collection in Venezuela) – http: //www.fonacit.gob.ve/, Puerto Rico Legislature (IJ-V – data collection in Puerto Rico), the European Research Council (MJP, DA, MG, YH, IJ-V, JJLR, AS and ALS – current dat Survey and further analysis of existing data – ERC-2013-ADG340755 LIFE2YEARS1066 and the National Institute of Health Research (MJP funded as Director, NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King’s College London [GHRU 16/136 / 54] with British assistance from the UK Government in support of global health research) – https://www.nihr.ac.uk/explore-nihr/funding-programmes/global- Gesundheit /. The donors played no role in the study design, data collection and analysis, the decision to publish or the preparation of the manuscript.

Abbreviations:
10/66 DRG,
10/66 Research Group Dementia; aHR,
adjusted hazard ratio; aOR,
adjusted odds ratio; aSHR,
adjusted subhazard ratio; CHW,
Healthcare workers; CSI-D,
Community screening tool for dementia; DIC,
Decrease in intrinsic capacity; HIC,
High income country; ICOPE,
Integrated elderly care; LMICs,
Low and middle income countries; LTFU,
Loss in tracking; WHO,
World Health Organization

In May 2018, the World Health Organization (WHO) announced a new set of priorities – 3 « triple billion » targets to ensure that 1 billion more people and 1 billion more people can benefit from universal health by 2023 Have better protection from health emergencies and 1 billion more people enjoy better health and wellbeing. Older people, whose number will rise to 1 billion by 2019, generally have poorer health and health-related quality of life than younger people, but do not have partial access to health services; they are particularly at risk in emergency situations and account for half or more of all deaths after natural disasters [1]. These disadvantages are most pronounced in low and middle income countries (LMICs). The needs of older people must therefore be given greater consideration. The WHO was also active on this front by providing the landmark World Report on Aging and Health 2015 [1], the Global Strategy and Action Plan on Aging and Health 2016-2020 [2] and 2017 the evidence-based guidelines for the Integrated Care of the Elderly (ICOPE) [3,4].

The WHO World Report defines health and health care for the elderly around the goal of healthy aging, which is achieved when functional abilities, the “health-related properties that it enable people to be and do what they appreciate to do ”, developed and maintained resume [1]. At the center of functional abilities are the physical, mental and cognitive intrinsic abilities of the individual that interact with their environment. The ICOPE guidelines support the core objective of the WHO Global Strategy of “aligning health systems to the needs of older populations”. Implementation will raise community awareness of the decline in intrinsic capacity (DICs) in older adults. Thirteen recommendations cover mobility loss, malnutrition, vision and hearing loss, cognitive impairment and depressive symptoms, with additional modules on geriatric syndromes (urinary incontinence and risk of falls) and support for family carers [3,4]. The WHO provides for a brief screening for intrinsic capacity. Significant decreases would prompt a more comprehensive needs assessment, but the prevalence and distribution of DICs in LMICs has yet to be determined. The focus is on providing assessment, health and social care to the elderly: in primary care, at home and in the community. This necessarily involves shifting and sharing tasks, especially in facilities with limited resources where specialized geriatric care services are underdeveloped. Given the scale of unmet needs, the optimal targeting of ICOPE intervention will be an important consideration if health gains are to be realized in a cost-effective manner.

Aside from the evidence base supporting each of the 13 ICOPE recommendations, the broad approach of the multidimensional assessment and management strongly supported, mainly by evidence from high income countries (HIC). The handicap cascade is neither inevitable, unidirectional nor irreversible. Longitudinal studies of frailty in older populations show a general tendency towards stability and modest net progression, with little return from frail to fully robust states; however, significant numbers of individuals improve, moving from pre-frail to robust and from frail to pre-frail states [5-10]. The results from studies on transitions into and out of addictive states are similar [11-14], with some evidence of less stability and more reversion in LMICs [12,13]. More favorable courses are associated with more education [10,11,15], a higher socio-economic status [15] and adherence to healthy behaviors and lifestyles, especially physical activity [14,16]. Certain chronically progressive diseases (diabetes, cancer, chronic obstructive pulmonary disease [COPD], osteoarthritis, dementia and cerebrovascular diseases) are associated with a poor prognosis [6,17] and can convey a large part of the educational effect [17]. The critical time window for possible interventions has not yet been clearly defined. A systematic review from 2008 identified 89 studies on multidimensional assessment and intervention at home, all of which were conducted in HICs [18]. Overall, while there was evidence of improved physical functioning, fewer falls, and fewer admissions to nursing homes and hospitals, these benefits were mainly limited to interventions in the general older adult population rather than those selected for their frailty. This may have contributed to the widespread belief that early intervention is better or even necessary to prevent frailty and disability from occurring. However, later studies in the Netherlands [19], Australia [20] and the US [21] also indicate potential for improvements in the health, functioning and quality of life of the frail and dependent elderly, with some evidence supporting the cost-effectiveness of multidimensional interventions [20,22].

To support the planning of ICOPE implementation activities, we performed a secondary analysis of the data obtained from the population-based baseline and incidence wave surveys of the 10/66 Dementia Research Group (10/66 DRG) in 12 catchment areas in 8 LMICs in Latin America, China, and India. Our goals were to (1) determine the prevalence of intrinsic capacity overall and in its various domains; to clarify the proportion of people likely to be identified with significant DIC and thus to be the target population for the ICOPE intervention; (2) characterize the target group in terms of disease burden (behavior and lifestyle risk factors, morbidity and disability) and use of health services and compare them with others; (3) Determine the extent to which DIC overlaps with frailty and dependency (need for care) and the concentration of stress indicators in each of these 3 groups with a hierarchical definition; and (4) Clarification of the prospective association of DIC with incident dependency and mortality.

This study is reported in accordance with the Guideline to Strengthen the Reporting of Observational Studies in Epidemiology (STROBE) (S1 Checklist).

The population-based 10/66 DRG studies on aging and dementia in LMICs comprised basic surveys of older people aged 65 and over who lived in geographically defined catchment areas in 8 countries, with a follow-up 3 to 5 years later. The study protocols [23] and the cohort profile (with detailed information on catchment area selection, sample size determination, cohort resource and follow-up) [24] are documented in open access publications. Current analyzes focus on urban and rural areas in Peru (urban Lima and rural Canete), Mexico (urban Mexico City and rural Morelos state), China (urban Xicheng and rural Daxing), and India (urban Chennai and rural Vellore) and urban locations in Cuba (Havana / Matanzas), Dominican Republic (Santo Domingo), Puerto Rico (Bayamon) and Venezuela (Caracas). The cohort was defined at baseline by systematically tapping all households in each catchment area to identify those eligible, all of whom were habitually resident and were 65 years of age or older on the specified census date. Population-based baseline surveys were carried out between 2003 and 2007 and incidence wave follow-up assessments between 2008 and 2010 [24]. For India, follow-up was only carried out at the urban location and included only one mortality sweep. The protocols for the single-phase surveys included a clinical interview; an interview on health, medical history, health care, and lifestyle; a cognitive assessment; a physical exam; and an informant interview. All participants were interviewed at home unless they wished an alternative arrangement. The study protocol and approval process were approved by the Research Ethics Committee of King’s College London and in each of the countries where the research was conducted: (1) Medical Ethics Committee of the Sixth Hospital, Beijing University (Institute of Mental Health, China); (2) Ethics Committee of the Memory Institute and Related Disorders (IMEDER) (Peru); (3) Finlay-Albarrán Medical Faculty of the Ethics Committee of the Medical University of Havana (Cuba); (4) Ethics Committee of the Hospital Universitario de Caracas (Venezuela); (5) Consejo Nacional de Bioética y Salud (Dominican Republic); (6) Ethics Committee of the Instituto Nacional de Neurología y Neurocirugía (Mexico); (7) Institutional Review Board of the Medical Sciences Campus of the University of Puerto Rico; (8) Research and Ethics Committee of Christian Medical College (Vellore, India); and (9) Voluntary Health Services Multi Specialty Hospital and Research Center Institutional Ethics Committee (Chennai, India). The informed consent was documented in writing in all cases. Literary participants signed their consent. Participants who were illiterate were read the information sheet in the presence of a well-read independent witness who signed a certificate stating that the process had been completed and that the participant had given his consent. In the case of participants unable to give their consent, the consent of the next of kin to participate was obtained. These procedures have been approved by the ethics committees.

Full details are in the published study protocol [23] and the full survey questionnaires are available online at https://www.alz.co.uk/1066/population_based_study_prevalence.php (Questionnaires baseline prevalence wave in English, Spanish and Tamil) and https://www.alz.co.uk/1066/population_based_study_incidence.php (incidence wave questionnaires in English and Spanish). Here we summarize the measures that are directly relevant to the analyzes presented in this paper.

The age was determined from participant and informant reports, documented age or an event calendar. The level of education was self-reported and coded as no education, with no completion of primary, primary, secondary or tertiary education. Food insecurity was defined as the reporting of famine in the last 1 month due to insufficient resources for the procurement of food.

Seven intrinsic capacities were evaluated at the beginning, linked to the concepts and, where possible, the operationalizations currently in the WHO- ICOPE Guide to Comprehensive Assessment are included. For each intrinsic capacity, we applied a threshold to determine whether the person has received capacity or experienced DIC. It is important to note that the decline is derived from a single rating and is not directly observed. Therefore, a long-term stable impairment could have been incorrectly classified as an age-related decline. The intrinsic capacities are as follows. (1) Neuromusculoskeletal Capacity: Walking speed was rated using a timed walking test (5 meters at normal speed, turning and returning to starting point); those who completed the test in less than 16 seconds were considered capable of capacity (with 3 seconds for the turn, this corresponds to a walking speed of> 0.8 m / s). (2) Vitality: The diet was considered sufficient if the elderly person did not report a weight loss of 4.5 kg in the last 3 months and their mean upper arm circumference was measured to be ≥ 22 cm; this limit is used in the Mini Nutritional Assessment (MNA) to identify the most severe degree of malnutrition [25]. (3) Sensory performance (visual impairment): Vision was considered sufficient if the elderly person did not report any “visual disturbances” that at least partially impaired their activities and if they were not identified as functionally blind by the interviewer. (4) Sensory Skills (Hearing Loss): Hearing was considered adequate if the elderly did not report « hearing problems or deafness » that at least partially affected their activities and if they were not identified as profoundly deaf by the interviewer. (5) Cognitive Capacity: Cognitive function was assessed using the Community Screening Instrument for Dementia (CSI-D) COGSCORE, which tests multiple domains of cognitive function and has robust cross-cultural measurement properties in the 10/66 DRG study websites; those who achieved a score of ≥ 29.5 were classified as cognitive skills, with scores below this threshold identifying “probable dementia” [26]. (6) Psychological performance: The psychological performance was considered to be given if the participants confirmed 3 or fewer of the 12 depression symptoms on the EURO-D depression scale; in previous analyzes, this limit value identified people with significant impairment of health-related quality of life [27], although a higher limit value is better suited for the identification of clinical cases [28]. (7) Continence: Incontinence (urinary, stool, or both) was only identified from the whistleblower report and capacity was maintained when none were reported. Continence is not currently a primary focus of ICOPE’s comprehensive assessment tool, although guidelines for the assessment and treatment of incontinence have been developed by the guideline development group.

A proposed physical frailty phenotype [29] includes 5 frailty indicators (fatigue, weight loss, poor grip , slow walking speed and low energy consumption). Individuals are frail if they meet 3 or more of the 5 criteria, pre-frail if they meet 1 or 2, and not frail if they do not meet any of the 5 criteria [29]. We rated 4 of the 5 indicators of frailty by omitting grip strength and using slightly different operationalizations than those originally suggested for fatigue, weight loss and energy expenditure [30]. Since grip strength was not measured, we considered participants frail if they met criteria for 2 or more of the 4 frailty indicators, and pre-frail if they met 1; the effect is the same as specifying a value of 1 for the grip strength. For most analyzes, we assign frail or dependent persons who are already dependent to the dependent subgroup, in line with the concept of frailty as susceptibility to disability and dependence.

The lifetime of smoking, the current physical activity, the Alcohol consumption and the food intake of fruit and vegetables were determined from the self-report. Unwanted behavior was defined as current smoking, self-declaration, being physically “not very” or “not at all” active, dangerous alcohol consumption (weekly consumption of ≥28 units of alcohol for men and ≥21 units for women) and less than 4 servings of fruit or Vegetables in the last 3 days. The waist circumference was measured in centimeters with a flexible tape measure; central obesity was defined according to the criteria for metabolic syndrome in the third report of the National Cholesterol Education Program – a waist circumference of more than 101.6 centimeters in men and more than 88.9 centimeters in women.

We assessed the physical , mental and cognitive morbidity through measurements of hypertension and diabetes and the main factors of disability and dependence [31,32]: stroke, dementia and depression. Dementia was diagnosed using the interculturally developed, calibrated and validated 10/66 DRG dementia diagnostic algorithm [26]. The ICD-10 depressive episode was diagnosed using a computer-aided algorithm that was applied to the structured clinical interview with GMS [33]. The stroke was self-reported, but confirmed by the interviewer as characteristic symptoms that lasted longer than 24 hours [34]. Hypertension was determined by measuring blood pressure using the criteria of the WHO / International Society of Hypertension (SBP ≥ 140 mm Hg and / or DBP ≥ 90 mm Hg) and self-reporting of previous diagnoses and treatments; those with high blood pressure were viewed as uncontrolled hypertension regardless of detection or treatment [35].

Disability was assessed using the WHODAS 2.0 scale, which is used by the WHO as a culturally appropriate assessment tool for use in cross-cultural comparative epidemiological and health research was developed [36,37]. The need for care (need for care) was assessed by interviewers after a series of open-ended exploratory questions posed to a key informant towards the end of the assessment, followed by a detailed assessment of care services and roles [32]. The classification as in need of care, partly in need of care or in need of care predominantly took place taking into account all information and observations collected in the course of the assessment. Further supporting information on the assessment procedures and the evidence for the construct validity of the dependency endpoint (S1 working paper) was provided. In order to identify likely cases of incident dependency in participants who died during the follow-up period, a predictive model for incident dependency was developed using variables from the informant part of the CSI-D informant interview, which was available to all participants. In the case of deceased participants, this was carried out as part of a verbal autopsy survey and referred to the time before death. The model used age, the total CSI-D informant score, and 5 items from the CSI-D informant interview: activity, feeding, using the toilet, dressing, and housework. The predictive model was developed from the survivors and then applied to those who died at follow-up to predict incidence dependency [38]. Details on health cost estimates are provided elsewhere [39]. Participants were asked about their contacts with primary health care professionals, doctors in public hospitals, other publicly provided professional health services, and private health services (private doctors, dentists, and traditional healers). For each service, the participants were asked how often they had used it in the last 3 months, how long the consultation lasted and what fees were charged for the service. Travel expenses were also collected. The length of stay and hospitalization expenses as well as the total cost of medication paid out of pocket for each of these services were also recorded. The expenses comprised the total annualized payments made by health care users. The total cost from a public perspective reflects the actual cost to the provider regardless of funding, including staff salaries, facilities and equipment, and overheads. The expenses and total costs were dichotomized in the 90th percentile of the distribution at each location to reflect catastrophic health expenditure or high total health costs.

Although dependency and mortality were identified as interesting results at the beginning of our research program, using general methods for longitudinal analysis Specified in advance and applied to previous publications (S1 Appendix) [38,40,41], our interest in DIC as an exposure stemmed from the publication of the WHO World Report on Aging and Health [1] and work on the ICOPE guidelines [3,4]. The data analysis plan was therefore written long after the survey and data collection was drafted.

We descriptively report the prevalence of the intrinsic capacity obtained for each of the 7 domains by location and, for the entire sample, the prevalence by 5-year age group of 65–69 years to 90 years and older. At the suggestion of experts, site-specific prevalences were also standardized directly according to age and gender; Details on the methods used are given in Appendix S2. We describe the socio-demographic and health characteristics (lifestyle risk factors, morbidity, disability and need for care) as well as the use and costs of health care for people with DIC that affect one or more domains, further stratified according to frailty status and need for care. The traits are compared with those of individuals with fully retained capacity (chi-square test and t-test) and across all 5 layers (full capacity, only DIC, DIC and pre-frail, DIC and frail, and DIC and dependent – chi -Square.) Compared tests and 1-way ANOVA tests for trend).

We modeled the effect of DIC exposures on the incidence of dependence (or « likely dependence » in the deceased) using a competitive regression Risks derived from the proportional subhazards model of Fine and Gray [27] (Stata stcrreg command), based on a cumulative incidence function that indicates the probability of failure (onset of dependency) before a certain point in time, the possibility of a recognizes competing event (dependency-free death) and reports adjusted subhazard ratios (aSHRs). Competing risk regression keeps those who experience competing events at risk so that they can be counted as having no chance. We modeled the effect of intrinsic capacity on mortality using Cox proportional hazards, built cumulative survival probability curves, and reported adjusted hazard ratios (aHRs). Proportional hazard assumptions were checked using methods based on Schönfeld residuals (Stata phtest command), and we adjusted interactions over time for covariates that violated these assumptions. The time to death was the time from the first interview to the exact date of death. The time to onset of dependence (which could not be precisely determined) was the midpoint between baseline and follow-up interview / death. All effect sizes are presented with robust 95% confidence intervals that were adjusted for household clustering.

Models included (1) the effect of DIC; (2) the effect of DIC when stratified as DIC only, DIC and Pre-Frail, DIC and Frail, and (mortality model only) DIC and dependent; and (3) the effect of DIC per number of affected intrinsic capacity domains before and after the control of frailty (and dependency in the mortality model). All models were adjusted for age, gender and education and estimated separately for each location, with the results combined with fixed effects using a meta-analysis. Higgins I2 estimates the proportion of inter-site variability in the estimates that is due to heterogeneity as opposed to sampling error; Up to 40% heterogeneity is conventionally viewed as negligible, while up to 60% reflect moderate heterogeneity [28].

Following the suggestions of the reviewers, we carried out further analyzes in order to add more detail to the attrition in the mortality and dependency cohorts and to investigate the potential for bias by assessing the association of baseline demographic and health covariates with Loss-to-Follow-up (LTFU) (S2 Appendix). ).

A total of 17,031 participants were surveyed at the start of the study at the 12 locations in 8 countries. Their properties have been reported in detail elsewhere [24]. The mean age varied between 71.3 and 76.3 years and was higher in urban areas than in rural areas and in more than less developed areas (Table 1). Most of the participants (62.4%) were female. The level of education varied widely between locations, with between 14.4% and 90.7% having completed elementary schooling, and was lowest in rural areas in India, Mexico and China, as well as in the Dominican Republic and in cities of Peru, Puerto Rico and Cuba highest. Food insecurity was most prevalent in urban (20.8%) and rural India (14.1%), rural Peru (13.5%), and the Dominican Republic (12.1%). Overall, 16.1% reported 3 or more physical impairments, 6.7% had a history of stroke, 5.5% met the criteria for an ICD-10 depressive episode in the previous month, and 9.3% for a 10 / 66 diagnosis of dementia. Physical impairment and strokes were reported less frequently in rural and less developed areas, and depression was rarely reported in China.

In the pooled dataset, capacity related to locomotion (neuromusculoskeletal capacity) (71.2%), eyesight (71 , 3%), cognition (73.5%), and mood (psychological capacity) (74.1%) most seldom retained, likely retained due to continence (96.5%). Only 29.6% retained full capacity across all domains (Table 2). This proportion fluctuated between 25% and 39% in most locations, with low outliers in rural India (11.0%) and the Dominican Republic (15.0%) and a high outlier in urban China (62.8%). The prevalence of the individual capacities varied greatly between the locations, mainly due to the Chinese locations; Maintaining mobility was exceptionally poor in rural China, cognition was well preserved in urban China, and malnutrition and depression were rare in either location. After direct standardization by age and gender, there were hardly any differences between standardized and raw prevalence, and differences in the demographic composition of the catchment area samples clearly did not explain the differences in the prevalence of intrinsic capacities (Tables 1.1 to 1.8 in Appendix S2). .

The proportion of maintenance capacity decreased significantly with age for all of the individual abilities examined, with the exception of psychological capacity (Fig. 1). In continence, hearing, and vision, DICs were more pronounced at ages 80 and over. The proportion who retain full employability decreased linearly with age from 38.9% for 65 to 69 year olds to 3.6% for over 90 year olds. Loss of capacity in several domains was also more common in older age groups (Fig. 2); A capacity loss in 4 or more domains was found in 11.3% of the 65 to 69 year olds and in 60.2% of the over 90 year olds.

In principle, anyone with DIC who could use one or more domains ( target group) benefit from the ICOPE intervention [4]. A total of 11,982 older people (70.4%) fulfilled this criterion, with the proportion fluctuating between 37.2% (urban China) and 88.0% (rural India) depending on the location, while other locations were close to the median of 72, 4% (25th, 75th percentile 74.4%. Of the patients with DIC, 4,541 (37.9%) were neither frail nor in need of care, another 4,193 (35.0%) were pre-frail, 1,743 (10.2%) were frail and 1,505 (8.8%) had an identified need for care. The characteristics of the target group are shown in Table 3, further broken down by frailty status and dependency (need for care). The target persons (with DIC) were on average 3 years older than those not selected , and mean age increased monotonically from DIC alone to pre-frailty, frailty and dependent groups. Women were overrepresented (65.7% in those with DIC versus 54.6% in those without DIC). Poverty and disadvantage were both DIC esp more pronounced; those in the DIC target group had nearly three times the prevalence of food insecurity (8.5% versus 2.9%), and most had no primary school diploma (50.9% versus 29.8%). Morbidity and disability also focused on the target group; this was very pronounced in depression (7.9% versus 0.1%), dementia (12.5% ​​versus 0.4%) and strokes (7.9% versus 3.4%) and these diseases continued to focus on those who were also frail or in need of care. Diabetes and health care utilization and costs were moderately associated with DIC. Apart from physical activity and diet, lifestyle risk factors for chronic diseases were not concentrated in those with DIC.

A total of 12,939 participants who were not in need of care at the start of the study were included in the dependency cohort, of whom 9,053 (70.0%) ) were interviewed again and 1,684 (13.0%) died. The 2,202 participants (17.0%) who lost follow-up (that is, did not re-interview but did not die) were excluded from analysis. Of these, 726 had declined, 591 could not be traced, 578 were traced back but could not be contacted for a new interview (“uncontactable”) and 307 had no reason for the LTFU. Sufficient information was available from the oral autopsy interview to predict the need for care prior to the death of 1,328 of the 1,684 deceased (78.9%). 832 deceased were assigned the outcome of dependency-free death (competing risk) and 496 the onset of dependency before death. A further 1,400 incidents were identified among those surveyed again. Therefore, 1,896 incidents were identified in 38,320 person-years of follow-up, a rate of 49.5 per 1,000 person-years. We have provided further information on cohort exit, including a cohort flow chart (Fig. 2.1 in S2 Appendix) and site exit information (Table 2.4 in S2 appendix).

We also performed additional analyzes suggested by reviewers in order to Investigate potential for attrition bias (S2 Appendix). To sum up, in a pooled analysis comparing those who were re-interviewed, those who were no longer interviewed, and those who died, those who died older had poorer cognitive performance and were more likely to be male, to be less educated, to be frail, to have experienced a significant disability and to have more DICs at the start of the study (Table 2.5 in S2 Appendix). Those who got lost in the follow-up were more similar to those who were re-interviewed on all these aspects. Still, LTFU was arguably the greatest risk of bias, as dependency outcomes for most of the deceased were recorded from verbal autopsy interview data; 84.3% (2,202 / 2,613) of the cohort members who could not be included in the analysis were LTFU (Table 2.4 in Appendix S2). Accordingly, in a logistic regression analysis, we compared those who were interviewed again directly with those who were no longer followed up, looking at each other for potential determinants of LTFU (age, gender, education and number of domains affected by DIC – whatever are among the determinants of event dependency). The only consistent independent association across the sites was between older age and LTFU (pooled adjusted odds ratio [aOR] 1.07, 95% CI 1.02–1.12, per 5-year step in age) (Table 2.6 in Appendix S2). The number of DICs was positively associated with LTFU in Puerto Rico and reversed in rural Mexico, but with no overall effect across the locations (pooled aOR 0.98, 95% CI 0.94–1.03). There was also no evidence that frailty predicted LTFU when we replaced this exposure with the number of DICs in the model (pooled aOR 1.06, 95% CI 0.91–1.23).

Mutual control for all other domains of intrinsic capacity and further adaptation to age, gender and education, decrease in cognitive capacity (pooled aSHR 2.56, 95% CI 2.26–2.90) and continence (pooled aSHR 3.32, 95 % CI 2.48–4.44.)) Were strongly associated with a dependency on incidents (Table 4). A decrease in psychological performance (pooled aSHR 1.33, 95% CI 1.18 – 1.51), locomotor performance (pooled aSHR 1.42, 95% CI 1.26 – 1.60) and nutrition (pooled aSHR 1.21, 95% CI 1.04 – 1.41) were moderately associated. Neither sensory ability (sight and hearing) was associated with incident dependency.

DICs affecting one or more domains were associated with incident dependence (pooled aSHR 1.91, 95% CI 1.69–2 , 17) (Table 5). Although the increased risk was somewhat concentrated on the frail (compared to no DIC, pooled aSHR 2.90, 95% CI 2.44–3.45), it was still evident in the larger subgroups with DIC who did not were still frail pre-frail (compared to no DIC, pooled aSHR 1.72, 95% CI 1.50–2.17 and were considered pre-frail (compared to no DIC, pooled aSHR 1.89, 95% CI 1.64–2.19).

When comparing the gross and matched effects of frailty (versus no frailty) and the number of DICs (per affected domain), the number of DICs was the more independent predictor for the dependence on incidents. The influence of frailty was considerably weakened after controlling the number of DICs (from pooled aSHR 1.78 to aSHR 1.21), while the number of DICs was only moderately reduced when controlling the frailty (from pooled aSHR 1.35 per DIC to aSHR 1.32) (Table 6).

Total were 15,901 participants included in the mortality cohort, of whom 13,936 (87.5%) had their vital status at the follow-up examination; 2,602 deaths were recorded during the 53,911 person-year follow-up, resulting in a death rate of 48.2 per 1,000 person-years. We provide further information on cohort churn (Appendix S2), including churn by location (Table 2.1 in Appendix S2). At the request of reviewers, we also performed additional analyzes to investigate the potential for attrition bias. Overall, we found no evidence that relevant baseline covariates were associated with failure to assess vital status at follow-up for age (pooled aOR 1.02, 95% CI 0.97–1.07), gender ( pooled aOR 0.96, 95% CI 0.88.). -1.06), education (pooled aOR 1.01, 95% CI 0.96-1.07), number of DICs (pooled aOR 0.99, 95% CI 0.95-1.04), Frailty (pooled aOR 0.99, 95% CI 0.87–1.04) or dependency (pooled aOR 1.00, 95% CI 0.84–1.20) (Table 2.2 in Appendix S2). However, there was moderate to high site heterogeneity for the health covariates and evidence that DIC numbers and frailty may be inversely related to turnover in the Dominican Republic and positively related to turnover in Puerto Rico. Replicating an analysis previously reported for a different but overlapping set of covariates [40], we found that those who did not have vital status were less likely to have predicted mortality than those who had it in urban China was (0.181 vs.). 0.226, p = 0.002) and in the Dominican Republic (0.246 versus 0.271, p = 0.02), but similar between the two groups in other locations (Table 2.3 in Appendix S2).

Cumulative survival progressively worsened between the subgroups from those without DIC to those who only had DIC, had DIC and were also pre-frail, frail and dependent (Fig. 3). Detailed site-specific and meta-analytically pooled results from the modeling of mortality predictors are contained in the S1 table. In summary, it can be said that post-control mortality by age, gender and education was strongly influenced by DIC (any DIC versus no DIC), with negligible heterogeneity between the locations (pooled aHR 1.66, 95% CI 1.49–1 , 85; I2 = 0.95% CI 0-60). The mortality risk in the frail (versus no DIC, pooled aHR 2.20, 95% CI 1.89–2.56; I2 = 0, 95% CI 0–60) and dependent (versus without DIC, pooled aHR 3 , 92, 95% CI 3.43.) Significantly increased -4.49; I2 = 33, 95% CI 0–67) subgroups, with only about half surviving up to 6 years (Fig. 3). However, there was also a slight increase in mortality among those with DIC who were neither pre-frail nor frail (compared to no DIC, pooled aHR 1.27, 95% CI 1.12–1.45; I2 = 39 , 95% CI 0-70) and in those who were pre-frail (compared to no DIC, pooled aHR 1.42, 95% CI 1.24-1.63; I2 = 1.95% – KI 0-61). Although the mortality risk increased monotonically with each additional DIC (per affected domain, pooled aHR 1.32, 95% CI 1.28–1.36; I2 = 44, 95% CI 0–72), this effect was observed after control clearly weakened by frailty and dependency (pooled aHR 1.16, 95% CI 1.12–1.20; I2 = 58, 95% CI 17–78). The proportional hazards test indicated some deviations from the proportional hazard assumptions at some locations. These all related to control covariates (age or age and gender) and not to the DIC variables. Interactions over time were introduced for the covariates for the locations where this was a problem, and the impact on the pooled estimates was negligible.

In this retrospective analysis of data previously obtained from a prospective population-based cohort study , we showed that typically two-thirds to three-quarters of those over 65 experience a decline affecting one or more domains of intrinsic capacity. DICs were more common in older age groups, as were DICs that affected multiple domains. While DIC was strongly associated with disability, only about a fifth of those affected were frail or dependent. There was a high concentration of cases of dementia, stroke, and clinically relevant depression in those with DIC, especially those who were already frail or in need of care. Hypertension, diabetes, and behavioral risk factors for chronic illness were less strongly associated with intrinsic capacity, with a significant prevalence in those who had not previously experienced DIC. DIC (both any decline and the number of domains affected) strongly and independently predicted incident dependency and death. The increased risk of dependency was concentrated on the frail, but was also significantly higher in the much larger subgroups who still became frail. Mortality was particularly high in the frail and dependent groups.

The theoretical conceptualization of intrinsic capacity as a core component of healthy aging is a recent development [1]. We believe our research will be among the first to report the epidemiology of the intrinsic performance of older populations in LMICs, using ratings and indicators that may be applicable to demographic and health surveys and routine care. Our findings of important independent associations between DICs and incident dependency agree with those of a causal modeling analysis using data from the English Longitudinal Study of Aging; In this study, intrinsic capacity was directly related to loss of daily living activities and mediated some of the effects of age, gender, wealth, education, and multimorbidity on this outcome. [42] The main strengths of our study are the large population-based samples with high proportions of responders in most locations and modest lack of data. The different countries and environments on 3 continents allowed us to study and explore variations in the context of a common study protocol, with a detailed assessment of physical, mental and cognitive disorders, health care utilization, disability, frailty and care needs.

There are several limitations. WHO has yet to determine the criteria it will recommend for screening for intrinsic capacity. Both the approach and the thresholds chosen are likely to have a significant impact on the proportions that are positive. We would acknowledge some shortcomings in the measures available to us from our survey, which was not designed for that purpose. Reliance on informant reports of incontinence may have selectively identified more severe cases, hence possibly the low prevalence and strong association with both predominant and incident dependence in our study. Brief self-assessment measures such as the International Consultation on Incontinence Questionnaire (ICIQ) could provide information about the etiology and effects as well as a more realistic feeling for the population prevalence [43]. Seeing and hearing could be assessed better by objective function tests than by the self-assessment available to us and the judgment of the interviewer. As previously reported, our frailty indicators have been operationalized in a slightly different way [30] than those originally proposed [29] and the resulting measurement errors may have impaired their ability to predict the onset of care needs. Our outcome measure of care dependency was not formally validated before it was introduced into the baseline wave of our surveys. Although criterion validation is not feasible, we have gathered evidence at the sites where we have worked that supports construct validity (concurrent and predictive) (S1 working paper). Another limitation is the lack of information on the interrater reliability of the assessment process. Finally, we are unable to rule out the possibility that selective attrition may have biased estimates of the associations with incident dependency (in which 17% of the cohort was lost to follow-up) and mortality (in which the result could not be established for 12%) could. of the cohort). While the fluctuation in relevant socio-demographic and health exposures, including DIC, appeared to be random, there was evidence that it may not be the case in some locations where local factors interacting with health exposures may have a role in the Determination of turnover.

Initially, we identified those with DIC and further divided these individuals into 4 groups reflecting the common concept of the « disability cascade » by which individuals become frail as DIC accumulates and progresses Experience limitations in the core activities of daily living and require care. The results of our analysis largely support the WHO’s strategy of focusing on optimizing intrinsic capacity in the pursuit of healthy aging. If the ultimate public health goal is to reduce future disabilities and addictions, most incidents will occur in those with DIC who are still frail, and a simple count of the affected domains of intrinsic capacity is a better predictor than Fragility of the onset of long-term care across the spectrum. Our research confirms the importance of cognitive and mental health in maintaining functional independence, and the inclusion of cognitive and psychological capacity in the intrinsic capacity framework ensures that in addition to physical frailty, the brain and mind are also considered. Nonetheless, the goal of optimizing intrinsic capacity extends the potential scope of the intervention from a fifth of the elderly population who are already frail or dependent (the focus of most programs so far) to up to three quarters of the total elderly population. This raises important questions about an appropriate alignment from the point of view of feasibility and economic viability.

A comprehensive approach to healthy aging should be promotion (optimization of health behavior and structural conditions in society), prevention (which underlies coping risk factors and conditions), treatment (to improve health), rehabilitation (to improve functioning and reduce the effects of disability), and relief (to improve quality of life). The importance of each of these activities varies across the disability cascade, with promotion and prevention dominating for those who do not yet have DIC, treatment and rehabilitation for those with early isolated relapses, and rehabilitation and relief for those who are frail and dependent on some of which are nearing the end of their lives [1]. Much will blur across these lines. As our data shows, advertising and prevention are consistently relevant, but not well covered in ICOPE; Integration into the WHO Major Noncommunicable Disease Treatment (PEN) package will be important as cardiovascular risk is high and the detection and control of high blood pressure and diabetes is not optimal [35,44,45].

Community Healthcare Workers (CHWs) play an essential role in expanding general health care to older adults in facilities with limited resources. There was interest in expanding this cadre’s responsibilities from maternal and child health, hygiene, and infection control to noncommunicable disease prevention and control. There is early evidence of feasibility and effectiveness in reducing cardiovascular risk, detecting hypertension and diabetes [46,47], and supporting the treatment of hypertension [48,49]. Coordinating integrated care for the elderly in the community would be a logical next step, benefiting from the unique reach and knowledge of CHWs for elderly people and their families [50]. The assessment of intrinsic capacity in older adults does not require any specialist knowledge and can be carried out by CHWs in resource-poor settings with a structured instrument after brief training [50]. Contact may be required for early identification of DICs; In the current analysis, although people with DIC are slightly more likely to use health services, this is mainly limited to those who are also frail or dependent. Public outreach will also help attract frail or dependent individuals with DICs who may otherwise have difficulty accessing services. In a previous report by the same cohort, we highlighted inequality in access related to poverty and lack of health insurance [51]. Nevertheless, the challenges in providing integrated care on a large scale would be considerable. A full-fledged system could include universal screening followed by a more detailed assessment for two-thirds or more of the elderly population who could benefit from one or more ICOPE interventions. Optimal reevaluation intervals for screen negative and screen positive groups would need to be established. This would require significant redirection of limited health resources and the cost-effectiveness of the investment is uncertain. Screening would not be justified if the resources and systems were not in place to provide the recommended interventions.

The evidence used in support of most ICOPE recommendations is indirect [3]. The interventions were mostly evaluated in HICs with experienced senior nurses, physiotherapists or occupational therapists or nutritionists, often with professional support and full access to further referral channels. In LMICs with few skilled workers, shifting tasks to trained and assisted non-specialized health workers will be a key feature of any accessible health care system for the elderly. This does not have to imply a weakening of the effect; in the previously cited systematic review, effect sizes were larger for earlier studies (prior to 1993) before generalizing systematic approaches to increasing treatment and care coverage in HICs for the elderly [18]. Task shifting has proven to be an effective innovation in the health system in expanding access to many different aspects of health care in resource poor settings [52].

Training is required to ensure the rigor and accuracy of screening assessments Where possible, a longer-term decline is distinguished from acute and / or self-limiting illnesses. While many of the ICOPE interventions can be performed by CHWs at home, there must be clear and well-functioning referral channels for further clinical evaluation and treatment of acute and severe cases (« red flags »), as well as for the provision of optometry and cataract surgery and hearing aid service. For each of the recommendations, a pilot intervention development is required to confirm the feasibility and optimize the implementation modalities in different contexts. ICOPE is a complex intervention that includes a package of interventions flexibly delivered in an individualized and person-centered care plan that involves different cadres and different levels of the health system and older people and their carers through direct physical interventions as well as behavioral and environmental changes speak to. Health systems research should focus on the planning, funding, resourcing and organizational change management that may be required to implement the ICOPE program on a large scale. Implementation science is needed to understand the nature of the potential benefit, the underlying mechanisms, and how best to achieve them. Ultimately, randomized controlled trials with clusters that provide evidence of cost-effectiveness are most likely to contribute to funding decisions. Most importantly, no opportunity should be missed to evaluate pilot projects and learn by doing.

If the WHO’s three billion goals are to be achieved fairly, the gaps in health access and outcomes must be filled people who have elderly people, especially those with disabilities, those living in poverty and those living in socially disadvantaged backgrounds, receive special attention. Resource areas. The implementation and expansion of the ICOPE program provides a conceptually simple, bottom-up, public health approach to ensuring that the benefits of universal health coverage and the enjoyment of better health and wellbeing are fairly shared and inclusive. Effective implementation requires political will, prioritization, investment, and strengthening and restructuring of the health system. Research is crucial in guiding and evaluating early implementation attempts and providing the evidence governments and policymakers need to prioritize action and attract investment.

The in this publication The views expressed are those of the authors and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.

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