In 2017, The World Health Organization (WHO) released the Integrated Care for Older People (ICOPE) Guidelines, which focus on intrinsic capacity and functional ability, rather than the absence of disease. These guidelines provide evidence-based recommendations to help healthcare professionals improve the health and well-being of the aging population.
ANHI caught up recently with Mary Beth Arensberg, PhD, RDN, LD, FADA, Director of Abbott Nutrition Health Policy & Programs (Columbus, Ohio, USA) to talk about the latest guidelines and learn more about how to apply them.
THE LATEST ICOPE GUIDELINES WERE RELEASED IN 2017. WHY WERE THEY CREATED?
Populations around the world are rapidly aging. Aging presents both challenges and opportunities. It will increase demand for primary health care and long-term care, require a larger and better trained workforce and intensify the need for environments to be made more age-friendly. Yet, these investments can enable the many contributions of older people – whether it be within their family, to their local community (that is as volunteers or within the formal or informal workforce) or to society more broadly. Societies that adapt to this changing demographic and invest in Healthy Aging can help people live both longer and healthier lives and societies to reap the dividends.
WHAT DO THE GUIDELINES HOPE TO INFLUENCE?
Providing integrated care is key for older people. The WHO Guidelines on Integrated Care for Older People (ICOPE) provide evidence-based recommendations for health care professionals to prevent, slow or reverse declines in the physical and mental capacities of older people. These recommendations require countries to place the needs and preferences of older adults at the center and to coordinate care. The ICOPE Guidelines will allow countries to improve the health and well-being of their older populations. WHO has declared that the next 10 years—2020-2030 is the decade of Healthy Aging. The ICOPE guidelines are one of the strategies to help older adults age more healthfully.
THE GUIDELINES FOCUS ON INTRINSIC CAPACITY AND FUNCTIONAL ABILITY. HOW WOULD YOU DESCRIBE THESE POINTS OF FOCUS?
Intrinsic capacity is the potential each of has for a healthy life as we age—it is a measure of our physical and mental abilities and can be impacted by what we do to maintain our strengths (like good nutrition and exercise) as well as medical conditions and disease.
Functional ability is the interaction between our physical/mental abilities and where we live; for example for an older adult with very poor balance will likely have more limited functional ability if they live in home with stairs and multiple levels vs. a home where all living areas are on one floor.
THE GUIDELINES CLEARLY OUTLINE SIX RECOMMENDATIONS FOR MANAGING DECLINES IN INTRINSIC CAPACITY. CAN YOU WALK US THROUGH EACH OF THESE RECOMMENDATIONS? HOW WOULD A CLINICIAN APPLY EACH ONE, AND WHY?
- Improve musculoskeletal function, mobility & vitality
- Multimodal exercise, including progressive strength resistance training
- Oral supplemental nutrition with dietary advice
This recommendation is important because loss of muscle mass and strength, reduced flexibility, and problems with balance can all impair mobility. Nutritional status can also be affected negatively by physiological changes that can accompany aging, in turn with an impact on vitality and mobility. Clinicians can focus on including in their care plans and recommendations specific interventions that encourage physical exercise (like walking clubs) and improve nutrition (like using an oral nutrition supplement)
- Maintain sensory capacity
- Routine screening for visual impairment
- Screening followed by provision of hearing aids
Ageing is often associated with loss of hearing and/or vision that limits mobility, social participation and engagement, and can increase the risk of falls. Sensory problems could easily be addressed by simple and affordable strategies such as the provision of corrective glasses and hearing aids, cataract surgery and environmental adaptations (like placing frequently used items within an older adults’ field of vision)
- Prevent severe cognitive impairment and promote psychological well-being
- Cognitive stimulation
- Brief, structured psychological interventions
Cognitive impairment and psychological difficulties often occur together. They impact people’s abilities to manage daily life activities like their finances, shopping, and participate in social engagements. Cognitive stimulation therapy, which is a program of differently themed activities, and brief psychological interventions, can help prevent significant losses of mental capacity and prevent care dependency in older age.
- Manage age-associated conditions such as urinary incontinence
- Prompted voiding
- Pelvic floor muscle training
Urinary incontinence – involuntary leakage of urine – affects about 1/3 of older people worldwide. The psychosocial implications of incontinence include loss of self-esteem, restricted social and sexual activities, and depression. Pelvic floor muscle training strengthens the muscles supporting the urethra and augments its closure, and is effective in managing urge leakage.
- Prevent falls
- Medication review and withdrawal
- Multimodal exercise
- Action on hazards
- Multifactorial interventions
Falls are the leading cause of hospitalization and injury-related death in older people. Falls are due to a combination of environmental factors (loose rugs, clutter, poor lighting, etc) and individual factors (organ-system abnormalities that affect postural control, loss of muscle strength). Exercise, physical therapy, home-hazard assessments and adaptations, and withdrawal of psychotropic medications, where necessary, all reduce older people’s risk of falls.
- Support caregivers
- Psychological intervention, training and support
Caregivers of people with severe declines in intrinsic capacity are at a higher risk of experiencing psychological distress and depression themselves. Caregiving stress or burden has a profound impact on the physical, emotional and economic status of women (how are often family caregivers) and family and friends who may be unpaid caregivers. A needs assessment and access to psychosocial support and training should be offered to caregivers experiencing stress.
HOW ARE THE RECOMMENDATIONS INTERCONNECTED?
Declines in intrinsic capacity rarely occur in isolation--they impact each other. For example, poor hearing increases cognitive decline, poor nutrition impacts mobility, poor vision impacts depressive symptoms. Intrinsic capacity and functional ability do not remain constant but decline with age as a result of underlying diseases and the aging process, so the recommendations need to inter-connected as well.
THE GUIDELINES SUGGEST IMPLEMENTING THE RECOMMENDATIONS THROUGH AN OLDER PERSON-CENTERED AND INTEGRATED APPROACH, AND SUGGEST FOLLOWING THESE FIVE KEY STEPS:
- Assess older person’s needs and declining physical and mental capacities
- Define the goal of care and develop a care plan with multicomponent interventions
- Implement the care plan using principles of self-management support
- Ensure a strong referral pathway and monitoring of the care plan
- Engage communities and support caregivers
WHAT ARE SOME PRACTICAL METHODS FOR FOLLOWING EACH STEP?
The process starts with a comprehensive assessment of the 6 intrinsic capacity domains. Through a conversation with the older adult and their caregiver(s), the HCP can determine the older adult’s needs and challenges. During the conversation, the HCP can also determine the older adult’s goals and need for support. Next the HCP can develop a multi-component care plan, with a strong self-management (family support and community care component). This plan would also include a follow-up conversation with the older adult (and family). With their agreement, referrals can then be made, as well as plans for future review and plans for follow-up.
THE GUIDELINES SUGGEST THAT THESE TWO FACTORS PLAY A CRITICAL ROLE IN IMPROVING PATIENT OUTCOMES
- Strong referral, monitoring & support
- Community engagement and caregiver support
HOW AND WHY ARE THESES FACTORS SO IMPORTANT?
Community engagement and caregiver support are critical. For example, as the Baby Boom generation ages in the US, 10,000 people turn 65 daily. For the first time in our history, there are more than 50 million seniors. A third of those older than 65 live alone, and half of the “oldest old”—those aged 85 + are on their own at this late life stage. The aging population coupled with the high cost of senior living and in-home care, is driving the growing demand for family caregivers—a trend that is expected to continue through the next several decades and beyond. A 2015 survey conducted by the National Alliance for Caregiving and AARP identified about 34.2 million Americans provide unpaid care to an adult aged 50+ in the last 12 months. Paths for help and support and community engagement are needed to augment caregiver support.
In addition to promoting integrated person-centered care, the recommendations should be implemented with a view to supporting aging 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.
IF A PATIENT IS MALNOURISHED, DOES THAT DIAGNOSIS INFLUENCE HOW A CLINICIAN WOULD APPLY THE GUIDELINES? HOW?
Aging is accompanied by physiological changes that can have a negative impact on nutritional status and, consequently, intrinsic capacity. Sensory impairments (a decreased sense of taste and smell, for example), poor oral health, isolation, loneliness and depression – individually or in combination – all increase the risk of malnutrition in older age. Aging is associated with changes in body composition; after the age of 60 years, there is a progressive decrease in body weight that results mainly from a decrease in fat-free mass and lean mass, and an increase in fat mass. Stable body weight overall masks such age-related changes in body composition. Older people who do not consume enough protein are at increased risk of developing sarcopenia, osteoporosis and impaired immune response. To address malnutrition, the guidelines recommend oral supplemental nutrition. These products provide additional high-quality protein, calories and adequate amounts of vitamins and minerals to meet the individual’s nutrition needs.
THE GUIDELINES OFFER A SUPPLEMENTAL PIECE, CALLED “EVIDENCE PROFILE: MALNUTRITION.” THE PROFILE INTRODUCTION STATES THAT, DESPITE THE HIGH PREVALENCE OF UNDERNUTRITION REPORTED IN POPULATION STUDIES, NUTRITIONAL TRIALS TARGETING COMMUNITY-DWELLING OLDER ADULTS ARE LIMITED. WHY IS THIS? WHAT WOULD AN INCREASE IN TRIALS AND REPORTING MEAN FOR THE GLOBAL COMMUNITY?
Nutrition studies addressing malnutrition have typically been focused in hospitals vs. in community-dwelling populations, because the infrastructure and support for community-based research is often lacking. In addition, since funding for community-based research is limited, for community-based nutrition research to increase, it would likely need to be linked to other community-based research platforms to leverage limited resources.
THE MALNUTRITION EVIDENCE PROFILE POSED THIS SCOPING QUESTION: “DOES ORAL NUTRITION SUPPLEMENT, DIETARY ADVICE OR MEALTIME ENHANCEMENT PRODUCE ANY BENEFIT FOR OLDER PEOPLE AT RISK OF UNDERNUTRITION OR WHO ARE AFFECTED BY UNDERNUTRITION?” WHAT, ULTIMATELY, WAS THE ANSWER?
Moderate-quality evidence showed that administration of oral supplemental nutrition plus dietary advice could prevent mortality and improve weight gain in older people affected by undernutrition. The WHO workgroup developing the ICOPE guidelines reviewed the adverse effects associated with this recommendation. Based on the evidence, the WHO workgroup made a strong recommendation in favor of oral supplemental nutrition for older people affected by undernutrition.
WHAT OBSTACLES MIGHT CLINICIANS FACE AS THEY STRIVE TO APPLY THE GUIDELINES? WHAT ARE SOME PRACTICAL IDEAS TO HELP OVERCOME THOSE OBSTACLES?
Any new policies, practices, and processes can face obstacles in implementation. In addition to developing the guidelines, WHO has developed a series of support products, including:
- The ICOPE implementation guide for integrated clinical care for older people, with steps on how to set person-centered care goals, develop an integrated care plan, and provide self-management support
- A set of color-coded algorithms to lead the clinician through an integrated process of assessing, classifying and managing declining physical and mental capacities in older age
- A country toolkit comprising guidance for implementing and evaluating integrated health and social care services for older people in communities
- ICOPE mobile phone technology for health workers and older people (the WHO mAgeing initiative).
HOW IS DATA CHANGING PROGRESS IN THIS REALM?
Implementation of the ICOPE recommendations will be monitored at the community and health-facility levels. Data will be collected through surveys or updated lists of service availability. Special studies can be considered where routine monitoring is not feasible or appropriate. A monitoring and evaluation framework, including a list of core indicators, is to be developed and included in the ICOPE country toolkit. Indicators will measure the performance of service delivery (the health system inputs, and the processes and outputs of service delivery), as well as the feasibility and acceptability of the recommendations.
DID ANYTHING ABOUT THE GUIDELINES SURPRISE YOU?
I was particularly interested to see WHO’s development of mHealth for Ageing, or mAgeing. They have a handbook providing guidance for national programs and organizations responsible for the care of older persons to develop, implement, monitor, and evaluate an mAgeing programs. The text messaging communication provided uses evidence-based behavior change techniques to help older persons prevent and manage early declines in intrinsic capacity and functional ability.
WHAT COUNTRIES ARE MAKING THE STRONGEST PROGRESS TOWARD THESE GOALS? WHY DO YOU THINK THAT IS?
At this point, there have been limited published results. An international working group of experts, including representatives of the WHO regions and countries, will develop the framework and oversee monitoring and evaluation activities. Broader stakeholder engagement in policy design, implementation, and monitoring and evaluation will help to ensure that the national adaptation of these guidelines results in programs that are legitimate, acceptable, effective, equitable, and address community needs. Intermediate health systems outcomes and the impacts of the interventions will be measured by the WHO global survey on Healthy Ageing, which was also included in the WHO Global strategy and action plan on ageing and health approved by the World Health Assembly.
WHAT MAKES YOU FEEL HOPEFUL AFTER READING THE LATEST ICOPE GUIDELINES?
Services need to be orientated around the needs of older people rather than the needs of the services themselves. Services should respond to a diversity of older people that ranges from those with high and stable levels of intrinsic capacity through those with declining capacity, to people whose capacity has deteriorated to the point of needing the care and support of others. Delivering ICOPE can support a transformation in the way health systems are designed and operate.
ARE THERE ANY ADDITIONAL KEY POINTS YOU’D LIKE TO MAKE?
The ICOPE guidelines will assist health care professionals in clinical settings to detect declines in physical and mental capacities and to deliver effective interventions to prevent and delay progression. National guidance will also benefit from drawing on these ICOPE guidelines. The ICOPE guidelines can inform the inclusion of Healthy Ageing interventions in the basic benefits packages for older adults.
WANT TO LEARN MORE?
- Enroll in our free continuing education course (1.0 CE/CPEU), “Applying Specific WHO ICOPE Guidelines to Promote Active Aging,” featuring Chiung-Ju Liu, PhD, OTR, FGsa; Kyle Timmerman, PhD, FACSM; Abby Sauer, MPH, RD; and Colin Milner, CEO, International Council on Active Aging
- Visit our collection of ICOPE resources under our new IMPORTANT INITIATIVES tab on anhi.org