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 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.
Recommendations
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| 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) |
