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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

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.

Rationale for recommendation 1

Moderate-quality evidence supports the use of

multimodal exercise training to improve the functional

outcomes in older adults with mobility impairment. The

GDG recognized a greater effect on critical functional

outcomes for multimodal exercise. The effects and

quality of evidence for stand-alone progressive

resistance training and t’ai chi were not considered

sufficient for incorporation into the recommendation.

Adverse events reported in a small proportion of trials

were reviewed. The most commonly reported events

were muscle soreness and joint pain. Very few trials

reported serious adverse events, such as fracture,

hospitalization or death. No clear relationship was

noted between severe events and exercise: similar

events were reported in the intervention and control

groups.

The GDG recognized the additional cost associated

with the scaling-up of supervised exercise training for

older people. The GDG felt that the programme cost

could be reduced through minimal training for family

members and the provision of self-help guides.

The GDG agreed that multimodal exercise was critical to

maintaining physical capacity in older people, and that it

would be acceptable to them, to family members and to

other stakeholders. Based on the moderate quality of

the evidence, the widespread acceptability of exercise

and the potential opportunities to shift health care tasks,

the GDG made a strong recommendation.

3.1.2 Malnutrition

Ageing 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. Ageing 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.

Considerations for recommendation 2

• Nutritional assessments should be specific to the older person and include nutritional history,

records of food intake or 24-hour dietary recall,

physical examination with particular attention to

signs of inadequate nutrition or

overconsumption, and specific laboratory tests if

applicable. There are several tools available to

assess nutritional status in older people (28, 29).

• Assessment of muscle mass and muscle strength must be included in the assessment of

nutritional status.

• Dietary counselling to ensure a healthy diet that provides adequate amounts of energy, protein

and micronutrients should be encouraged for all

older people, including those who are at risk of

or affected by undernutrition.

• It is important to consider specially formulated supplementary foods (in ready-to-eat or milled

form), which are modified in their energy density,

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

Recommendation 2

10 Integrated care for older people

protein, fat or micronutrient composition, to help

meet the nutritional requirements of older

people.

• Mealtime interventions (including family-style meals and social dining) are important

approaches for managing undernutrition in older

people. Consider family-style meals or social

dining for older people living alone or who are

socially isolated.

• Protein absorption decreases with age. Low protein intake is associated with loss of lean

body mass, and standard protein intake may not

be sufficient for older people.

• Refer older people with evidence of potentially serious underlying physical illness (gross

cachexia, rapid weight loss, obstruction or

difficulty swallowing, vomiting, chronic

diarrhoea, abdominal pain or swelling) for

medical review by a physician or specialist.

Supporting evidence for recommendation 2

Our search strategy identified three systematic reviews

to inform these recommendations (30–32). We conducted an independent search strategy in 2015 to

update the 2009 review (31) and identified 29 additional

trials.

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

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

The search strategy involved older people who were at

risk of or affected by undernutrition. All but two of the

trials were conducted in high-income countries. The

majority of the trials were in hospital settings or

long-term care facilities (nursing, retirement or

residential homes). The definition of undernutrition

varied in the trials. The majority applied an

anthropometric measure – typically body mass index

(BMI) – as a nutritional status indicator, and compared it

against WHO cut-off values (where underweight is

below 18.50 kg/m2). The assessed interventions were

aimed at improving the intake of protein and energy

using only the normal oral route. Protein was provided

together with non-protein energy sources such as

carbohydrate and fat, and with or without added

minerals and vitamins. The types of intervention

considered included supplements in the form of

commercial sip feeds; milk-based supplements;

fortification of normal food sources; addition of fluid

milk (low-fat or fat-free) to the usual daily consumption

of dairy products; commercial nourishing drink made up

with either milk or water; high-protein and high-calorie

feeding supplementary to the hospital diet; commercial

supplements or formulated meal-replacement

commercial drinks in addition to meals; and other

specially formulated nutrition products. Most

supplementation trials aimed to provide, per serving,

300–400 kcal, 12–20 g of protein, and additional

vitamins and minerals.

The evidence indicated that the consumption of oral

supplemental nutrition significantly reduced mortality

compared with people on placebo or usual care. In a

subgroup analysis, the pooled data from trials conducted

in community settings showed no effect on mortality,

whereas the treatment effect on mortality remained

significant in trials performed in hospital and long-term

care settings.

Weight gain, rated as a critical outcome, was reported in

70 trials. These data showed that the intervention

improved weight gain for older adults affected by

undernutrition. In the subgroup analysis, a significant

benefit was indicated in improving weight gain in these

older people in trials conducted both in the community

setting and in the hospital or long-term care setting.

Rationale for recommendation 2

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 GDG

reviewed the adverse effects associated with this

recommendation. Fifteen trials reported adverse effects

Box 2: Oral supplemental nutrition

Oral supplemental nutrition is the provision of additional high-quality protein, calories and adequate amounts of vitamins and minerals tailored to the individual’s needs assessed by a trained health care professional. The assessment allows for the best source and vehicle for these nutrients to be defined, whether through the use of supplements, nutrient-rich foods, or specialized commercial or non-commercial nutritional formulations.

11 Evidence and recommendations

in both treatment and control groups, but only four of

these (two hospital studies, one nursing home study and

one community study) provided a systematic evaluation

and comparison of adverse effects in the treatment and

control conditions. Common side-effects reported in the

studies were gastrointestinal symptoms, nausea and

diarrhoea. A higher number of adverse effects were

reported in studies conducted in hospital settings; this

may reflect the baseline severity of the undernutrition,

the intensity of supplementation, the presence of

comorbid acute illness or, possibly, increased monitoring

of adverse effects. Other trials reported a prevalence of

adverse effects in both the intervention and control

groups, and the majority of these studies reported no

between-group differences in adverse effects. The GDG

therefore concluded that the potential risks associated

with nutritional intervention were small.

Adherence to the nutritional interventions was discussed

in detail. The GDG suggested that oral supplemental

nutrition may be acceptable to many older people, and

would assist those at risk of, or affected by,

undernutrition to meet their nutritional requirements. In

conclusion, the GDG agreed that these

recommendations would be appreciated by older adults

and acceptable to key stakeholders.

The implementation of this recommendation may have

major resource implications, particularly in the training of

staff members. However, in many low- and middle-

income countries, community health workers deliver

nutritional interventions for children affected by

undernutrition and for pregnant mothers. Based on this

experience, the GDG concluded that training could be

undertaken for existing human resources to implement

these recommendations.

The GDG considered that if recourse to the provision of

supplemental nutrition or specific food products was

necessary to increase an individual’s dietary intake of

protein, energy or vitamins and minerals, this should

always be combined with dietary advice. Provision of

dietary advice will aid an older person’s understanding

of the need for oral supplemental nutrition and will

ensure that their dignity and human rights are respected.

Based on the evidence, the GDG made a strong

recommendation in favour of oral supplemental nutrition

for older people affected by undernutrition.

The GDG also considered the evidence for increasing

dietary intake and mealtime interventions. Although

there was enough evidence about their benefits to

support a recommendation, the GDG decided that,

due to the generic nature of these two interventions, it

was more appropriate not to issue a recommendation.

3.1.3 Visual impairment

Ageing is frequently associated with loss of vision that

limits physical performance and activities in daily life.

Over half of older adults with impaired vision

experience improvements through non-invasive

methods, mainly corrective lenses. Some 79% of

people over 60 years of age and 90% of people over

70 have cataract, representing the single-most

important cause of vision loss (1). These people go

back to full visual function with cataract surgery. Yet

many older people living in low-income countries have

never had even an eye examination, with little

opportunity for accessing eye-care services.

Community case finding and the immediate provision

of eye care or assisted referral for cataract surgery

could improve physical capacity and functional ability

in older people.

Considerations for recommendation 3

• At the primary health care level, visual screening can be performed using a Snellen chart to screen

for visual acuity.

• It is important to improve public awareness and generate demand for services through regular

community outreach activities.

• Promote case finding at the primary and community care settings, where health care

personnel such as community health workers can

be trained to screen for visual acuity.

• Establish comprehensive eye-care services, so that refraction services with the provision of

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

Recommendation 3

12 Integrated care for older people

suitable correction tools are available at the

primary health care level.

• Specifically, provide spectacles that are new, of high quality, accessible and affordable in

low-income settings.

• The most common causes of vision impairment in older people include presbyopia, cataract,

glaucoma, diabetic retinopathy and age-related

macular degeneration. Older people found to

have a visual impairment should therefore be

assessed for these medical conditions.

• Older people who have had diabetes for five years or more must be referred for an

assessment with an ophthalmologist.

Additionally, it is advisable that people who are

at risk of glaucoma (including people of African

descent and people with a positive family

history), who are at risk of diabetes, or who have

severe myopia undergo periodic assessment by

an ophthalmologist. The WHO publication,

Prevention of blindness from diabetes

mellitus (33) is available at http://www.who.

int/diabetes/publications/prevention_

diabetes2006.

• Refer to eye-care practitioners or occupational therapists who have expertise in environmental

modifications (working with colour and contrast

in the environment of the person with low vision)

and can teach activities of daily living and skills,

such as washing clothes.

Supporting evidence for recommendation 3

Evidence was compiled from three systematic reviews: an

updated systematic review that identified five trials of

screening and referral, an updated systematic review that

identified two trials of screening plus provision of

immediate eye care, and an updated systematic review

that identified three trials of expedited cataract surgery.

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

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

No new trials have been identified in a WHO update of a

systematic review that was published in 2006 on

screening and referral, which found five trials (35). For

these guidelines, results from the three initial systematic

reviews therefore comprise the evidence base. In it,

pooled data from five trials of 3494 participants

indicated that there was no evidence to suggest that

visual screening alone could improve visual function in

older people. The authors concluded that the reasons for

the lack of benefit were high loss to follow-up,

contamination of the intervention, similar frequencies of

vision disorder detection and treatment in both groups,

the use of one screening question to identify people for

further testing, and a low uptake of recommended

interventions.

A review that identified two trials of visual screening

combined with immediate referral for correction of

refractive errors revealed evidence of beneficial effects. In

the first of the two trials, older people in the intervention

group received prescriptions and vouchers for free

eyeglasses (36), while participants in the second study

were immediately provided with corrective glasses (37).

The participants in the first trial were people 65 years of

age and over living in the community, whereas the second

trial recruited nursing home residents 55 years of age and

over. In both trials, visual functioning improved in the

immediate-treatment groups.

The systematic review that identified three trials

examining the effectiveness of expedited cataract surgery

found substantial improvements in vision for older people

who had undergone expedited surgery, compared with

outcomes for people in the routine surgery or waiting list

groups (38–40).

Rationale for recommendation 3

The GDG acknowledged the higher prevalence of

vision impairment in older people compared with

Box 3: Definitions of low vision

The following definitions of low vision are in use (34):

• Defined by WHO: visual acuity less than 6/18 in one eye and equal to or better than 3/60 in the better eye with best correction.

• In use by low-vision services or care: impairment of visual functioning for the person even after treatment and/or standard refractive correction, and a visual acuity of less than 6/18 to light perception, or a visual field less than 10 degrees from the point of fixation, but with ability or potential ability to use vision for planning and/or executing a task for which vision is essential.

13 Evidence and recommendations

younger, and the enormous individual and societal

burden associated with untreated vision conditions.

The group considered the limited supportive evidence

for the effects on self-reported visual improvement

following screening and referral (35). The GDG agreed

that the use of screening as a stand-alone intervention

was not warranted and that it should be combined

with immediate provision of indicated eye care to

improve the visual acuity of older people with visual

impairment. In addition, the large beneficial effects of

cataract surgery observed in three trials was noted by

the GDG in support of the provision of cataract

surgery, when indicated. None of the trials reviewed

reported any adverse consequences associated with

screening for vision plus timely provision of care. The

GDG recognized the high acceptability and feasibility

of this screening and care. The vision-care experts in

the GDG mentioned that in many countries, including

low- and middle-income ones, there were national

programmes for the management of blindness in

place, in which professionals trained in the early

identification of avoidable blindness performed vision

screening. This screening was focused largely on

children, however, while many older people

experienced difficulties accessing such screening and

timely provision of care. The GDG felt that screening

coupled with provision of indicated eye care might

increase equity in this field.

Given the minor variability in values and preferences,

the feasible and acceptable nature of the intervention,

and the potential for benefits to greatly outweigh

harms, especially in high-burden countries, the GDG

made a strong recommendation despite the low

quality of the evidence.

3.1.4 Hearing loss

Untreated hearing loss affects communication and can

contribute to social isolation and loss of autonomy,

with associated anxiety, depression and cognitive

impairment. Despite its considerable individual and

social implications, hearing loss is largely undetected

and undertreated in older people. Yet this common

limitation in intrinsic capacity can generally be

managed effectively. Simple interventions and

adaptations for hearing loss include fitting hearing

aids, environmental modifications, and behavioural

adaptations that include reducing background noise

and using simple communication techniques, such as

speaking clearly.

Considerations for recommendation 4

• Community awareness about hearing loss and the positive benefits of audiological rehabilitation in

older people, through community case finding and

outreach activities, should be promoted.

• Health care professionals should be encouraged to screen older adults for hearing loss by periodically

questioning them about their hearing. Audiological

examination, otoscopic examination and the

whispered voice test are also recommended.

• Hearing aids are the treatment of choice for older people with hearing loss, because they minimize the

reduction in hearing and improve daily functioning.

• Medications should be reviewed for potential ototoxicity.

• People with chronic otitis media or sudden hearing loss, or who fail any screening tests should be

referred to an otolaryngologist.

• Additional guidance can be found in the WHO Guidelines for hearing aids and services for developing

countries (41), available at http://www.who.int/pbd/

deafness/en/hearing_aid_guide_en.pdf.

Supporting evidence for recommendation 4

Evidence for this recommendation was obtained by

reviewing two randomized controlled trials. Both trials

demonstrated the benefit of screening and immediate

provision of hearing aids in older adults. The earlier of

the two found that immediate provision of hearing aids

was associated with statistically significant improvements

in the hearing-related quality-of-life score the Hearing

Handicap Inventory for the Elderly (HHIE), and in the

Quantified Denver Scale of Communication Function

(QDS) score (42). In the second trial both hearing aid

groups experienced greater improvements in hearing-

related outcomes compared with the no-treatment and

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

Recommendation 4

14 Integrated care for older people

assistive-listening device groups (43). The mean

improvement in HHIE scores in this trial was small for

control patients (2.2 points) and those who received an

assistive listening device (4.4 points), larger for patients

who received a conventional device (17.4 points), and

considerable for patients who received a programmable

device (31.1 points).

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

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

Rationale for recommendation 4

The GDG considered there was low-quality evidence

supporting the use of screening and provision of hearing

aids as a way to improve critical hearing-related outcomes

for older people. In addition to the evidence, however, the

GDG also considered issues such as the opportunity costs

and usefulness of potential interventions given the very

high prevalence of, and the enormous societal

implications associated with, undiagnosed and untreated

hearing loss; worldwide, one third of older people live

with some degree of hearing loss.

The GDG members thus agreed that the benefits of the

intervention outweighed the disadvantages and costs.

Screening and use of hearing aids does not seem to harm

individuals, high-quality hearing aids can now be fitted at

an affordable cost, and most older people do not object

to being assessed. Based on the acceptability, feasibility

and increasing affordability of hearing aids – coupled with

the potentially large beneficial effects afforded to older

people living in high-burden countries if they are able to

engage and communicate effectively within their

communities – the GDG decided to issue a strong

recommendation despite the low-quality evidence.

3.1.5 Cognitive impairment

Cognitive impairment is a strong predictor of functional

disability and the need for care among older people.

Mild cognitive impairment increases the risk of

developing dementia, and the available evidence

suggests that an average five-year postponement of the

age of onset would reduce the prevalence of dementia

by half (44). Cognitive stimulation therapy, such as

participation in a range of activities aimed at improving

cognitive and social functioning, is a critical strategy to

prevent and reverse declining cognitive capacity and,

consequently, to prevent functional disabilities and care

dependency in older age.

Considerations for recommendation 5

• Assessment for cognitive function can be performed using any locally validated tool.

• In the absence of standard assessment, the person, and also someone who knows them well, should

be asked about problems with memory,

orientation, speech and language, and any

difficulties in performing key roles and activities.

Memory, orientation and language should be

assessed.

• Cognitive stimulation could be delivered in short sessions. In high-income countries, it is usually

administered by psychotherapists. Some

characteristics of the intervention such as duration

or frequency could, however, be adapted for each

setting, and it could be administered by suitably

trained and supported non-specialists.

• It is important to encourage family members and caregivers to provide older people with regular

orientation information (day, date, time, weather,

names of people, and so on), to help them remain

orientated in time and place. They can use materials

such as newspapers, radio and television

programmes, family albums and household items to

promote communication, orientate the person to

current events, stimulate memories and enable

them to share and value their experiences.

• Impairment in cognitive function may be associated with memory deficits and difficulties managing

instrumental activities of daily living such as finances

and shopping, and with impaired social function.

Cases should be referred for medical assessment.

• More guidance on dementia can be found in the WHO mhGAP intervention guide (45), available at

http://www.who.int/mental_health/mhgap/mhGAP_

intervention_guide_02.

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

Recommendation 5

15 Evidence and recommendations

Supporting evidence for recommendation 5

Evidence on the effectiveness of cognitive stimulation

interventions for older adults with cognitive impairment

was extracted from one systematic review (44). In this

study, interventions were typically delivered in day-care

or long-term care settings, and involved participants

with dementia or mild cognitive impairment, or both.

The review analysed pooled data from 17 trials:

12 studies (810 participants) assessed cognitive

impairment using the Mini Mental State Examination

(MMSE) while the other five trials assessed cognitive

function using the Alzheimer’s Disease Assessment Scale

– Cognitive subscale (ADAS-Cog). Evidence from all of

these trials showed significant improvement in cognitive

function after the intervention. The overall quality of the

evidence was low. New randomized controlled trials are

needed to test the efficacy of different types of

cognitive-based interventions that exclusively target

older adults with cognitive impairment.

• Further detail on the supporting evidence is in the Evidence profile: cognitive impairment, available at

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

Rationale for recommendation 5

Low-quality evidence supports the use of cognitive

stimulation interventions (of any form) to improve

cognitive function in older people with mild cognitive

impairment and dementia. The GDG recommends that

health care professionals provide these interventions to

people who are eligible. The GDG identified low-

quality evidence that the intervention improved

important health outcomes, and concluded that the

benefits outweighed the adverse effects. The

intervention is non-invasive and no trial reported any

harms associated with cognitive stimulation. Variability

in values and preferences was noted to be minor, and

the intervention was considered feasible and

acceptable. Resource requirements for delivery of

cognitive stimulation interventions would initially be

considerable, but the GDG argued that adaptation of

the intervention for specific settings, and investment in

training of non-specialists, would potentially discount

future costs. The strength of this recommendation is

conditional, due to the low quality of the evidence –

most trials involved older people who had dementia,

and the effects of cognitive stimulation interventions in

those with mild cognitive impairment without dementia

remains unclear.

3.1.6 Depressive symptoms

Depressive symptoms (or sub-threshold depression)

apply to older adults who have two or more

simultaneous symptoms of depression present for most

or all of the time, for at least two weeks in duration, but

who do not meet the criteria for a diagnosis of a major

depressive disorder. This is an important condition that

affects between 6% and 10% of older adults in primary

care settings, 30% in medical and long-term care

settings, and is associated with declining intrinsic

capacity (46).

Box 4: How to identify cognitive impairment • Assessment for cognitive function can be performed using any

locally validated tool.

• In the absence of standard assessment: (a) assess memory by asking the person to repeat three common words immediately, then again 3 to 5 minutes later, (b) assess orientation to time by asking the time of day, day of week, season, and year, and assess orientation to place by asking the person where they are being tested, or where the nearest market or store is to their home, and (c) test language skills by asking the person to name parts of the body and to explain the function of physical items (for example, “What do you do with a hammer?”).

• Confirm any cognitive deficit with a family member or someone else who knows the person well.

More detail is found in the WHO mhGAP intervention guide (45), available at http://www.who.int/mental_health/mhgap/ mhGAP_intervention_guide_02.

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

Recommendation 6

16 Integrated care for older people

Considerations for recommendation 6

• Older people can experience psychological difficulties consistent with the symptoms of depression but

without these necessarily meaning they have

moderate-to-severe depression. When assessing older

people, it is important to assess whether the person

has depressive symptoms, but also if these are

associated with social isolation, and whether the

person has difficulties in day-to-day functioning due

to depressive symptoms.

• Cognitive impairment and dementia may be associated with depressive symptoms and must be

assessed. People with dementia often present with

complaints of mood or behavioural problems, such as

apathy, loss of emotional control, or difficulties

carrying out usual work or domestic or social activities.

• The management and assessment of depressive symptoms is covered by the WHO mhGAP

intervention guide (45) (within the module for ‘Other

significant emotional or medically unexplained somatic

complaints; see Box 5).

• Older people who qualify for a diagnosis of depressive disorder should be advised and treated as

recommended in the mhGAP guidelines.

• Physical exercise should be considered as an adjunct to structured psychological treatments to improve

intrinsic capacity in older people (see the guidance in

section 3.1.1 on mobility loss).

Supporting evidence for recommendation 6

Evidence on the benefit of psychological intervention for

managing depressive symptoms in older adults was

extracted from two systematic reviews (47, 48). All the

trials reviewed were conducted in high-income countries

and administered by trained mental health care

professionals.

Pooled data from six trials (826 older adults) that used

cognitive behavioural therapy, problem-solving therapy

and life-review therapy indicated that these interventions

considerably reduced depressive symptoms in older

adults. The overall quality of the evidence was low.

Another review examined the effectiveness of behavioural

activation specifically in reducing depressive symptoms in

adults. However, only three of the included trials recruited

older adults. Evidence from these trials (102 older adults)

showed that behavioural activation significantly reduced

depressive symptoms in the intervention group. The

overall quality of the evidence was very low.

• Further detail on the supporting evidence is in the Evidence profile: depressive symptoms, available at

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

Rationale for recommendation 6

Very low-quality evidence supports the use of

psychological interventions (cognitive behavioural

therapy, problem-solving therapy, interpersonal

counselling, behavioural activation therapy and life-

review therapy) to reduce depressive symptoms in older

adults. No trials reported harms associated with these

interventions. In the absence of any specific harms, the

GDG concluded that these interventions were likely to

have limited potential for harm. The administration of

behavioural activation is a relatively unsophisticated

intervention that can be learned more quickly than

Box 5: Summary information for treatment of depression

Brief, structured, psychological treatment: • Interpersonal therapy and cognitive behavioural therapy

(CBT) (including behavioural activation), and problem- solving treatment should be considered as psychological treatment of depressive episode/disorder in non-specialized health care settings if there are sufficient human resources (supervised community health workers, for example). In moderate and moderate-to-severe depression, problem- solving treatment should be considered as adjunct treatment.

• A problem-solving approach should be considered in people with depressive symptoms (in the absence of a depressive episode disorder) who are in distress or have some degree of impaired functioning.

• Psychological treatment based on CBT principles should be considered in repeat adult help-seekers with medically unexplained somatic complaints who are in substantial distress and who do not meet the criteria for depressive episode/disorder.

More detail and further recommendations are in the WHO mhGAP intervention guide (45), available at http://www.who.int/mental_health/mhgap/mhGAP_ intervention_guide_02.

17 Evidence and recommendations

most other evidence-based psychological treatments.

The intervention has been studied mainly as a multiple-

session intervention performed by specialists, however,

which may not generalize to non-specialized health

care and carries considerable resource implications.

Nonetheless, the intervention could be modified into a

brief intervention as an adjunct treatment or as part of

a first step in a comprehensive care approach in

primary health care. Although the evidence specifically

for older people is scarce, WHO has comprehensive

tools and guidelines to manage depressive symptoms in

adults. Given that depression is associated with a

severe decline in functional ability among older people

– and that a recommendation in favour of the provision

of brief psychological interventions would be consistent

with the existing WHO mhGAP recommendation for

depression (45) – the GDG concluded that the benefits

outweighed the harms. In view of the very low quality

of evidence and the possible lack of generalizability to

all community settings, the GDG issued a conditional

recommendation for the treatment of depressive

symptoms in older adults.

3.2 Module II: Geriatric syndromes

3.2.1 Urinary incontinence

Urinary incontinence – involuntary leakage of

urine – affects about a third of older people

worldwide (49–51). Continence depends not only on

lower urinary tract function but also on intact mobility,

cognition and motivation. Urinary incontinence has

important medical repercussions and is associated with

decubitus ulcers, sepsis, renal failure, urinary tract

infections and increased mortality. Psychosocial

implications of incontinence include loss of self-esteem,

restriction of social and sexual activities, and

depression. Urinary incontinence is also a key

determinant of care dependency in older age.

Considerations for recommendations 7 and 8

• Urinary incontinence in older people is multifactorial and needs evaluation and treatment

that is not focused solely on the lower urinary tract.

Although an assessment of urinary incontinence can

be made by non-specialized health workers, full

evaluation is the responsibility of a medical

professional or clinician. The full assessment is

needed because of the multifactorial nature of

urinary incontinence in older people. The

examination should include cardiovascular,

abdominal and neurological systems as well as

assessment of mobility and cognition.

• An assessment of urinary incontinence includes the evaluation of fluid intake, medications, physical and

cognitive capacity (including mobility), and previous

urological surgeries.

• The single best question to ask when diagnosing urge incontinence is: “Do you have a strong and

sudden urge to void that makes you leak before

reaching the toilet?”

• A good question to ask when diagnosing stress incontinence is: “Is your incontinence caused by

coughing, sneezing, lifting, walking or running?”

• The person needs to be assessed for reversible causes of urinary incontinence, such as delirium,

infection, atrophic vaginitis, pharmaceutical causes

such as medication-induced urinary retention,

psychological disorder (depression), excessive urine

output (hyperglycaemia, for example), and stool

impaction.

• As a first-line treatment, provide advice on bladder training for a minimum of 6 weeks. Bladder training

involves advising the older person to follow a strict

schedule for bathroom visits. The schedule starts

with bathroom visits every 2 hours, but the time

between visits should be gradually increased to

improve bladder control.

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

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

Recommendations 7 and 8

18 Integrated care for older people

• Pelvic floor muscle training (PFMT) strengthens the muscles that support the urethra and augment its

closure. Often used for stress urinary incontinence,

PFMT may help with urge leakage as well. Similar to

other muscle-strengthening regimens, PFMT is

based on controlled repetitions of high-intensity

contractions, held for as long as possible. A starting

regimen could be 3 sets of 10 contractions (with

adequate relaxation between each) repeated

2–3 times per week.

• Key to the success of PFMT is correct identification of the target muscles and appropriate motivation to

continue the programme.

Supporting evidence for recommendations 7 and 8

Five systematic reviews were identified, of which two

systematic reviews served as the basis for the primary

findings on prompted voiding and PFMT

interventions (52, 53).

7: Prompted voiding

Four of the reviewed trials were conducted in the

United States of America, and most of the participants

in these had moderate-to-severe cognitive impairment.

All except one of the trials recruited older adults with

urinary incontinence in nursing home settings. The

duration of the intervention ranged from 20 days to

32 weeks. The evidence showed that the prompted

voiding intervention significantly reduced the number

of incontinence episodes in 24 hours.

Data for self-initiated toileting outcomes were reported

in four trials, but only one provided sufficient data. All

of these trials showed a significant increase in

independent requests for the toilet as a result of the

prompted voiding intervention. The overall quality of

the evidence was low.

• Further detail on the supporting evidence for both prompted voiding and PFMT is in the Evidence

profile: urinary incontinence, available at http://

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

8: Pelvic floor muscle training (PFMT)

Evidence for PFMT was derived primarily from five

randomized controlled trials that investigated the benefit

of PFMT compared with placebo or control. Two of

these trials were conducted in Brazil, two in Japan, and

one in the United States. The mean age of the study

participants ranged from 60.2 years to 76.6 years. All of

the trials recruited older women living in the community.

Participants’ perceived cure of urinary incontinence was

reported in three trials. The data showed that PFMT

significantly increased the perceived cure rate and

significantly reduced urinary incontinence symptoms.

The overall quality of the evidence for PFMT was low.

The benefit of PFMT when combined with bladder

control strategies, with or without biofeedback, has

been examined. All of the trials reviewed recruited older

adults living in the community, and the majority of the

participants had mixed urinary incontinence. The

combined intervention was administered at home and in

clinical settings. The mean age of the study participants

ranged from 65.4 years to 74.7 years. All except one of

the trials recruited only older women. The pooled data

from five trials (709 participants) indicated that this

intervention significantly reduced the number of

incontinence episodes over 6–24 weeks of follow-up. The overall quality of the evidence was moderate.

Rationale for recommendations 7 and 8

Low-quality evidence supports the use of prompted

voiding to reduce episodes of urinary incontinence

among older people with cognitive impairment. Urinary

incontinence is common among those with cognitive

impairment and increases the need for formal and

informal care. No trial has reported adverse effects

associated with prompted voiding interventions. All of

the included trials were conducted in high-income

countries in long-term care settings and the GDG

recognized that these interventions may be difficult to

implement in community settings reliant on the help of

family caregivers. Based on the low-quality evidence and

the potential challenges to implementation in

community settings, the GDG made a conditional

recommendation.

Low-quality evidence supports PFMT when used on its

own to reduce incontinence in older women with urinary

incontinence. When combined with bladder control

strategies and self-monitoring, the quality of evidence

increases to moderate in support of using PFMT. Urinary

incontinence has a profound impact on the older

person’s quality of life and functional ability, and

increases the need for care. No trial has reported

adverse effects associated with this intervention, and the

GDG considered that the potential for harm from PFMT

19 Evidence and recommendations

was likely to be low given the non-invasive nature of the

intervention. The GDG indicated that the

recommendation was likely to be valued by older

women with urinary incontinence, and that the

intervention was highly acceptable to health care

providers. Based on the moderate quality of the

evidence for the combined approach, and the minimal

harms, the GDG made a strong recommendation for

provision of PFMT both alone and in combination with

other strategies.

3.2.2 Risk of falls

Declining physical capacity in older people often

manifests in falls and fall-related injuries. Around one

third of people over 65 years of age and living in the

community have a fall each year, many of whom are

experiencing recurrent falls (54, 55). Falls are the leading

cause of hospitalization and injury-related death. Fatal

fall rates rise considerably to sharply with five-year

increases above 60 years of age (56). Accidental falls are

due to a combination of extrinsic (environmental) and

intrinsic (organ system abnormalities affecting postural

control) factors. Extrinsic factors include environmental

hazards such as loose rugs, clutter, poor lighting and

improper foot wear such as ill-fitting, floppy slippers.

Intrinsic factors include abnormalities in any of the

organ systems that contribute to postural control such

as sensory, musculoskeletal and central nervous system.

Older people can decrease their fall risk with exercise,

physical therapy, home-hazard assessments and

adaptations, and withdrawal of psychotropic

medications.

Considerations for recommendations 9–12

• Older people who present for medical attention because of a fall, report recurrent falls in the past

year, or demonstrate abnormalities of gait and/or

balance should be offered a comprehensive risk

assessment.

• A comprehensive assessment may include the following items: history of falls; gait, balance,

mobility and muscle weakness; osteoporosis risk;

fear of falling, vision impairment, cognitive

impairment, neurological examination; urinary

incontinence; home hazards; cardiovascular

examination; and medication review.

• Multimodal exercise, including progressive resistance training and other exercise components (balance,

flexibility and aerobic training) must be included in

every care plan for older people at risk of falls (see

Recommendation 1 on mobility loss).

• Identification of older people with visual impairment and their referral for interventions should be

implemented in any approach to prevent falls. To

prevent falls for older people with cataract, for

example, immediate surgery should be

recommended.

• Medication review by a trained health care professional, especially to reduce psychotropic

medication, has been shown to reduce falls. Older

people should be encouraged to reduce their use of

sleeping aids, including over-the-counter medication

containing diphenhydramine or other sedating

antihistamine. Benzodiazepines and antidepressants

have also been associated with falls.

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

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

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

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

Recommendations 9–12

20 Integrated care for older people

Supporting evidence for recommendations 9–12

One systematic review of interventions designed to

reduce the incidence of falls in older people living in the

community was identified (55). The review included 159

randomized controlled trials with a total of 79 193

participants. Most trials compared a falls prevention

intervention with no intervention or one that was not

expected to reduce falls.

9: Medication review and withdrawal

Evidence is limited for the effectiveness of interventions

targeting medications (withdrawal of psychotropic

medications, for example, or educational programmes

for family physicians). Only one study showed that

withdrawal of psychotropic medication was effective in

reducing the rate of falls. Another study indicated that

educational programmes on medical review and

modification for general practitioners were effective in

reducing the numbers of falls. The quality of evidence

was low.

10: Multimodal exercise

Fifty-nine trials (13 264 participants) tested the effect of

exercise on falls in older people. Trials that combined

two or more categories of the following exercise

components were grouped as multicomponent exercise

interventions, delivered in groups or individually: gait,

balance and functional training; strength and resistance

training; flexibility; t’ai chi; general physical activity; and

endurance.

Sixteen trials (3622 participants) found evidence of

effects of multicomponent group exercise interventions

in preventing falls in older people. The quality of the

evidence was low.

Five trials (1563 participants) tested t’ai chi exercise

delivered as a group intervention. T’ai chi reduced the

rate of falls and the risk of falling. The benefit of t’ai chi

exercise on the rate of falls was greater for the subgroup

not selected for a higher risk of falling. Thus, t’ai chi

seems to be more effective in people who are not at a

high risk of falling. The overall quality of the evidence

was low.

Eight trials delivered individual exercise interventions at

the participant’s home. Home-based interventions

achieved a statistically significant reduction in the rate of

falls and the risk of falling. A trial that examined the role

of balance and strength training in daily activities

showed a statistically significant reduction in the rate of

falls. The overall quality of the evidence was moderate.

11: Home modifications

Six trials (4208 participants) investigated the

effectiveness of home safety interventions for reducing

the rate of falls and the risk of falling. The mean age of

the trial participants was over 75 years and the follow-

up period ranged from 3 to 18 months. Overall, home

safety assessment and modification interventions were

effective in reducing the rate of falls. Subgroup analysis

revealed that a home safety intervention delivered by an

occupational therapist was effective in reducing the rate

of falls in older adults who were at risk of falling

compared with delivery by a non-occupational therapist

(including nurses and trained research staff). The overall

quality was moderate.

12: Multifactorial interventions

Nineteen trials investigated the benefit of multifactorial

interventions (assessment and referral, or provision of

active interventions) in preventing falls in older people.

Multifactorial interventions that integrated assessment

with individualized intervention, usually involving a

multidisciplinary team, were effective in reducing the

rate of falls. All of the trials recruited older people living

in the community. Only one study was from a middle-

income country (Thailand); the other 18 trials were from

high-income countries, mainly Australia, Canada, China,

Denmark, Finland, the Netherlands, Taiwan, the United

Kingdom and the United States. The overall quality of

evidence was low.

Rationale for recommendations 9–12

9: Medication review and withdrawal

Low-quality evidence supports the effectiveness of

reviewing the use of psychotropic medication and of

medication withdrawal in reducing the incidence of falls

in older adults. The GDG was unclear about the harm

associated with these interventions, as no trials had

reported potential harm. Polypharmacy is acknowledged

as one of the main risk factors for falling. Medication

review should be part of any integrated care programme

addressing the risk of falls. A review of medications – in particular the withdrawal of any – requires consultation

with specialists (pharmacologists, geriatricians, mental

health care professionals). The GDG acknowledged that

21 Evidence and recommendations

the recommendation may be less feasible in low-

resource health care settings, where primary care

professionals have limited support from specialized

health care professionals. Given the low quality of the

evidence and the potential challenges of generalizing

implementation to settings where specialists are scarce,

the GDG issued a conditional recommendation.

10: Multimodal exercise

Moderate-quality evidence supported the use of

multimodal physical exercise to prevent falls. This is in

line with the physiopathology and strong association of

falls with loss of muscle mass and strength as people

age. The GDG had made a prior strong recommendation

in the guideline meeting for using multimodal exercise to

reverse declining physical capacity, and based on that

review of evidence, found very low risks associated with

the intervention. The GDG concluded that the benefits

of this recommendation outweighed any associated

harms, provided that multimodal exercise (mainly

strength and balance) training was administered by

appropriately trained professionals. The GDG identified

that interventions to prevent falls would be highly valued

by older people and that provision of exercise was

acceptable to health care providers and feasible for

implementation in the community. The GDG recognized

that resource requirements were potentially large but

that task-shifting away from professionals, and

engagement of family members could reduce the overall

costs, provided that adequate training would be

available. Given the moderate quality of the evidence,

the large potential benefits and high acceptability and

feasibility, the GDG made a strong recommendation for

multimodal exercise to prevent falls – consistent with the

previous recommendation on physical exercises to

improve mobility.

11: Home modifications

Moderate-quality evidence supports the effectiveness of

providing a home-hazard assessment and environmental

modifications for older people at risk of falls. A

combination of advice with educational interventions to

increase confidence, risk awareness and home safety is

most effective. A lengthy debate ensued regarding who

should carry out the home-hazard assessments. The

GDG recognized that, in practice, this may be by any

trained professional rather than always a health care

professional. The majority of the trials involved

assessments by trained health care professionals,

including doctors, occupational therapists, nurses,

physiotherapists, social workers and trained assessors.

The GDG acknowledged the limited specialist human

resources (occupational therapists, for example) in

low-resource settings and the associated higher costs of

delivering adequate assessments via such professionals.

The GDG recognized that, with sufficient training,

non-specialist health care professionals could perform

home-hazard assessments for at-risk older adults. Given

the moderate quality of the evidence and the potential

for task-shifting, the GDG made a strong

recommendation.

12: Multifactorial interventions

Low-quality evidence supports multifactorial

interventions targeted at the risk factors of falls as a

way to reduce their incidence in older adults living in

the community. A definite recommendation from this

evidence is difficult for the specific components.

A sensible strategy may therefore be to refer older

people for interventions that target known risk factors.

The GDG recognized that multifactorial interventions

may have resource implications for health care and for

individuals. The existing evidence base is poor for

judging the cost-effectiveness of these interventions.

However, if at-risk older adults are identified and

undergo interventions, multifactorial intervention is likely

to be cost-effective when compared with no treatment.

On this basis, and considering the low quality of the

evidence, the GDG decided to issue a conditional

recommendation.

3.3 Module III: Caregiver support Worldwide, 349 million people are estimated to be care

dependent, of whom 5%, 18 million, are children

younger than 15 years, and 29%, 101 million, are

people 60 years of age and over (57). Care dependence

arises when functional ability has fallen to a point that

the individual is no longer able without assistance to

undertake the basic tasks needed for daily living.

Coexisting chronic diseases (multimorbidity) are

frequently associated with the need for health and

social care for older people (58). Such care in most

countries is provided by informal caregivers (for

example, the care receiver’s spouse, adult children or

other relatives or friends), and women are the primary

caregivers (59). Caregivers of people with severe

declines in intrinsic capacity are at higher risk of

22 Integrated care for older people

experiencing psychological distress and depression

themselves (60). In many low- and middle-income

countries, the formal system of long-term care is poorly

developed, with the result that the negative effects of

caregiving have a profound impact on the physical,

emotional and economic status of women and other

family caregivers.

Considerations for recommendation 13

• The focus of the support intervention should be the primary family caregivers. During the initial contact,

ask the older person to identify their primary

caregiver.

• Caregiver support should be provided by appropriately trained health care professionals who

are given support and supervision relevant to their

level of involvement.

• Psychological distress and psychosocial impact on carers should be identified.

• Family caregivers experiencing stress should be offered a needs assessment and access, whether in

primary or secondary care settings, to psychosocial

support.

• Family caregivers identified with caregiving strain should be assessed for depression. Refer to the WHO

mhGAP intervention guide for information on

assessment and management of depression (45).

• The focus of a caregiver support intervention should be based on the carer’s choice, and the emphasis

should be on optimizing their well-being.

• Acknowledgement should be given to caregivers that it can be extremely frustrating and stressful to care for

people with dementia. It is nonetheless important to

help ensure that carers continue to support care-

dependent older people, avoiding hostility or neglect.

• Carers can be encouraged to respect the dignity of older people through being involved in decisions

about the person’s life as far as possible.

• Training and support can be given to caregivers for specific skills, such as managing difficult behaviour.

• If possible, practical support should be considered. Where feasible, home-based respite care is one

example, whereby another family member or other

suitable person can supervise and care for the older

person. This may relieve the main caregiver who can

then rest or carry out other activities.

• If feasible, the carer’s psychological stress could be addressed with support and problem-solving

counselling.

• Exploration can be made as to whether the person qualifies for any social benefits or other social or

financial support. This may be from government or

nongovernmental sources.

Supporting evidence for recommendation 13

Evidence on caregiver support interventions was

extracted from three systematic reviews (61–63). One of

these included 78 trials with six different interventions,

including psycho-educational interventions, supportive

interventions, psychotherapy, respite care, training of the

care recipient, and multicomponent interventions (62).

The evidence from these trials indicated that caregiver

support interventions significantly improved several

critical and important outcomes (carer burden,

depression, well-being, ability/knowledge). In particular,

psychological education for carers of older people with

mental disorders showed significant effects in reducing

caregiver strain and improving ability and knowledge.

Supportive interventions (including professional- and

peer-led groups for support and discussion) have positive

effects on the care burden. The overall quality of

evidence was moderate.

Rationale for recommendation 13

Moderate-quality evidence supports the effectiveness of

psychological intervention, support and caregiving

training for reducing caregiver strain. The significant

beneficial effects of psychological interventions on the

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

Recommendation 13

23 Evidence and recommendations

critical outcomes of caregiver burden and depression

were considered sufficient to warrant a

recommendation in favour of the intervention. The

balance of harms and benefits was discussed by the

GDG. No trials had identified any harm for care-

dependent older people or their caregivers that was

directly related to caregiving support interventions. The

GDG concluded that limited potential for harm was

associated with these interventions. Such interventions

are frequently very resource intensive and may require

specialist delivery. The GDG acknowledged that the

implementation of these approaches may face

challenges in community settings. In those settings

where implementation would be possible, the GDG

agreed that the interventions would be highly valued by

caregivers and would be acceptable to health care

providers. In view of equity, with the health of

caregivers frequently being ignored in the delivery of

care for older people, and coupled with the moderate

quality of the evidence, the GDG made a strong

recommendation in favour of psychological

interventions for caregivers.

25 Implementation considerations

The recommendations in these guidelines need to

be implemented using an older person-centred and

integrated approach. The rationale and evidence base for

providing older person-centred and integrated care has

been detailed in the WHO World report on ageing and

health (1). WHO describes this type of health care needed

for ageing populations as integrated care for older people

(ICOPE).

In general, ICOPE can involve integration at the policy or

sector level (macro), at the organizational or professional

level (meso), and at the clinical or intervention level

(micro) (64, 65). The approach of WHO to populations of

older people spans all these levels, but as the entry point

emphasizes integration at the level of community care.

This approach is person-centred and grounded in the

perspective that older people are more than the vessels of

their disorders or health conditions – they are individuals with unique experiences, needs and preferences. ICOPE

also encompasses the context of individuals’ daily lives,

both in terms of the people close to them and those who

are in their lives as part of a community.

Important elements for designing ICOPE for people with

chronic and multiple conditions include community-based

interventions and (66):

• comprehensive assessment and care plans shared with all providers;

• common treatment/care goals;

• strong referral and monitoring;

• community engagement and caregiver support. These ICOPE guidelines are aligned with the wider WHO

framework on strengthening integrated people-centred

health services (20), which was adopted in 2016 by the

69th session of the World Health Assembly (67).

The five steps needed to deliver the ICOPE

recommendations in an integrated manner are outlined in

Fig. 2.

Comprehensive assessments and care plans Effective interventions start with a comprehensive

assessment of the intrinsic capacity of the older person,

and the associated conditions, impairments, behaviours

and risks that may influence future capacity, and of the

person’s environment. These assessments include not

only a traditional history-taking and, if appropriate, a

physical examination, but also a thorough analysis of

the person’s values, priorities and preferences

concerning the course of their health and its

management. Comprehensive assessments and care

plans should promote the identification of underlying

conditions associated with impairments such as

hypertension, diabetes and dementia, and establish

pathways for referral and treatment.

This assessment is essential to the development of a

care plan and to tailoring interventions that are

acceptable and appropriate for the older person.

Comprehensive assessments and care plans unite

different providers around one goal: to maintain

intrinsic capacity and functional ability. They can ensure

that the necessary follow-up occurs and that links are

made between health care and social care.

The ICOPE implementation guide to accompany the

present document is focused on this process for

developing an older person’s comprehensive

assessment and care plan.

Shared decision-making and goal- setting

Integration of care can be achieved only if services and

providers are working towards the single goal of

maintaining intrinsic capacity and functional ability. It is essential that the older person is involved with

decision-making and goal-setting from the outset, and

that goals are set in accordance with the person’s

needs and preferences.

Implementation considerations4

26 Integrated care for older people

Fig. 2: Delivering ICOPE in an integrated way

Strong referral, monitoring and support Regular and sustained follow-up of older people, with

integration among different levels of care, is essential for

implementing the interventions recommended in these

guidelines. Such an approach promotes early detection

of complications or of changes in functional status, thus

preventing unnecessary emergencies and related

inefficiencies. It also provides for a forum for monitoring

progress against the care plan, as well as a means for

arranging additional support as needed. Follow-up and

support might be especially important following major

changes in the disease status, treatment plan or social

role/situation (a change in residence, for example, or the

death of a partner).

Community engagement and caregiver support

Caregiving can be demanding, and caregivers of people

with severely declining capacity are often isolated and at

high risk of experiencing psychological distress and

depression. In addition to these guidelines’

recommendations to support caregivers, caregivers also

need basic information about the older person’s health

conditions, and encouragement to develop a range of

practical skills, such as how to transfer a person from a

chair to a bed safely or how to help with bathing. The

older person and/or caregiver should be provided with

information about the community-based resources

Ensure a strong referral pathway and monitoring of the care plan

Engage communities and support caregivers

Assess older person’s needs and declining

physical and mental capacities

Implement the care plan using

principles of self-management

support

Define the goal of care and develop a

care plan with multicomponent

interventions

27 Implementation considerations

available to them. Opportunities to involve communities

and neighbourhoods more directly in supporting care

must be explored, particularly by encouraging local

volunteering and enabling older community members to

add contributions. The associations and groups that

draw together older people are one mechanism by

which such activities could happen.

The recommendations of these guidelines should be

adapted into a locally appropriate document that can

meet the needs of each country and its health services.

The headquarters of WHO will work closely with its

regional and country offices, as well as WHO

implementing partners, to ensure the communication

and country-specific adaptation of these guidelines,

through regional and national meetings.

As countries consider how to implement these

guidelines, an analysis should be made of the budgetary

and human resource requirements, and of other health

system implications, to identify which inputs and

systems are available and which areas require additional

investment. Extra input may be needed for the training

of health workers, the use of medical products and

technologies, or with regard to adaptations to health

information systems to collect data on intrinsic capacity

and functional ability.

An enabling environment should be created for

following these recommendations, including through

support to health care practitioners in the use of

evidence-based practices. In this process, the role of

local professional societies is important, and an all-

inclusive and participatory process should be

encouraged.

The inclusion of ageing and health into national policies

and plans should be considered. Creating and

strengthening linkages with other health and non-health

programmes towards achieving broader goals can

greatly enhance sustainability and effectiveness.

To further support country implementation, WHO is

producing a series of subsidiary tools to address the

clinical and service-delivery aspects of implementing the

recommendations of these ICOPE guidelines.

29 Publication, dissemination and evaluation

5.1 Publication and dissemination These guidelines are to be disseminated as a print

publication and electronically at a dedicated section of

the WHO website (http://www.who.int/ageing/health-

systems/icope). The information here is organized in line

with the priorities of the WHO Global strategy and

action plan on ageing and health (6). All of the evidence

profiles are available online, giving detailed information

about the available evidence, the GRADE (Grading of

Recommendations Assessment, Development and

Evaluation) quality analyses, the narrative descriptions of

the evidence that was not included in the GRADE

tables, and the considerations of values, preferences

and feasibility.

A series of subsidiary products deriving from these

ICOPE guidelines support the implementation of

module I (declining physical and mental capacities),

module II (geriatric syndromes) and module III (caregiver

support). These products include:

• The ICOPE implementation guide for integrated clinical care for older people, with:

� steps on how to set person-centred care goals, develop an integrated care plan, and provide

self-management support; and

� a set of colour-coded algorithms to lead the practitioner 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).

The guidelines and products are developed in English to

be translated into other WHO official languages for wider

dissemination in collaboration with WHO regional offices.

Dissemination will be supported by the publication of

selected systematic reviews and evidence in peer-

reviewed journals, and presentations and workshops at

key conferences and events.

These ICOPE guidelines and products are key tools to

support the implementation of the Global strategy and

action plan on ageing and health; activities for

disseminating them were included in the strategy’s

action plan approved by the World Health Assembly in

2016 (19). Actions include the piloting and evaluation of

these guidelines in 20 countries by 2020.

5.2 Monitoring and evaluation Implementation of these 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. 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

programmes 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 (6). The

global survey will provide information at a country level

Publication, dissemination and evaluation 5

30 Integrated care for older people

on health status, health needs, and how well needs are

being met. This information will form the basis for

international comparisons and a baseline against which

to measure the impact of the programme.

The WHO Department of Ageing and Life Course will

work closely with the Health Data Collaborative1 to

ensure harmonization of standards and tools and

alignment with the WHO 2015 global reference list of

100 core health indicators (68).

5.3 Future review and update The WHO Department of Ageing and Life Course will

regularly monitor new evidence in priority areas, with

the assistance of WHO collaborating centres. The

department will also collect regular feedback from

country implementation teams on ICOPE products.

These ICOPE guidelines will be updated after a four-year

period, applying a similarly rigorous methodology. WHO

welcomes suggestions for any additional issues that

should be considered for inclusion in future guidelines.

Please email these to Dr Islene Araujo de Carvalho:

araujodecarvalho@who.int.

1 Further information is availabe at http://www.healthdatacollaborative.org

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34 Integrated care for older people

Emiliano Albanese, World Health Organization (WHO) Collaborating Centre, University of Geneva, Geneva,

Switzerland.

Olivier Bruyère, Department of Public Health, Epidemiology and Health Economics, 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, Department of Preventive and Social Medicine, Goa Medical College Bambolim, Goa, India.

Astrid Fletcher, Department of Epidemiology and Population Health, London School of Hygiene & Tropical

Medicine, London, United Kingdom.

Dorothy Forbes, Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, Edmonton,

Alberta, Canada.

Anne Forster, Stroke Rehabilitation, Academic Unit of Elderly Care and Rehabilitation, University of Leeds,

Leeds, United Kingdom.

Mariella Guerra, Institute of Memory, Depression and Related Disorders, Lima, Peru.

Jill Keeffe, L.V. Prasad Eye Institute, WHO Collaborating Centre for Prevention of Blindness, Hyderabad, India.

Ngaire Kerse, School of Population Health Faculty of Medical and Health Sciences, University of Auckland,

Auckland, New Zealand.

Qurat ul Ain Khan, Department of Psychiatry, Aga Khan University Hospital, Karachi, Pakistan.

Chiung-ju Liu, Department of Occupational Therapy, School of Health and Rehabilitation Sciences, 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, Department of Integrated Medical Sciences, Charles E. Schmidt College of

Medicine, Florida Atlantic University, Boca Raton, Florida,

United States.

Martin Prince (GDG chair), Institute of Psychiatry, Psychology and Neuroscience, King’s College London,

United Kingdom.

Jean-Yves Reginster, Department of Public Health, Epidemiology and Health Economics, University of Liège,

Liège, Belgium.

Luis Miguel F. Gutiérrez Robledo, Instituto Nacional de Geriatría, Institutos Nacionales de Salud de México,

Mexico City, Mexico.

John F Schnelle, Center for Quality Aging Geriatric Research, Education and Clinical Center, Vanderbilt

University Medical Center, Nashville, Tennessee, United

States.

Kelly Tremblay, University of Washington, Seattle, Washington, United States.

Jean Woo, Department of Medicine and Therapeutics, and Institute of Aging, The Chinese University of Hong

Kong, Hong Kong, China.

Annex 1: Guideline development group (GDG) members

35 Annex 2

Individuals involved in the assessment of conflicts of

interest:

– John Beard, Director, Department of Ageing and Life Course, WHO headquarters

– Islene Araujo De Carvalho, Senior Policy and Strategy Adviser, Department of Ageing and Life

Course, WHO headquarters

– Nandi Siegfried, Independent Consultant, Guideline Methodologist

– Jotheeswaran Amuthavalli Thiyagarajan, Technical Officer, Department of Ageing and Life Course,

WHO headquarters

– Martin Prince (guideline development group [GDG] chair), Professor of Epidemiological Psychiatry,

Health Services and Population Research Institute

of Psychiatry, King’s College London, London,

United Kingdom of Great Britain and Northern

Ireland.

The minutes presented below summarize the

discussions with the ICOPE GDG chair and the director

of the Department of Ageing and Life Course on the

management of declarations of interest for GDG

members and external resource people for the GDG

meeting held at WHO headquarters in Geneva. The

follow-up and suggested actions agreed on to

manage the conflicts of interest declared are

summarized below:

I. WHO is under scrutiny on the management of

known and perceived conflicts of interest. The

revised declaration-of-interest policy for experts2

and the framework of engagement with non-state

actors3 are followed.

II. Conflicts of interest are a subjective matter and it

is very important that not only the known but also

the perceived conflicts of interest are declared and

managed appropriately, particularly for guideline

development at WHO.

III. The declarations are shared only with the WHO

steering group for guideline development and only

summaries of the declarations are available to

meeting participants.

IV. Specific cases in which potential conflicts of

interest have been declared will be discussed and

the agreements and follow up actions summarized

below.

V. Participants of the GDG meetings participate in

their individual capacities and not as institutional

representatives.

VI. The WHO Secretariat and external resource people

do participate in deliberations leading to decision-

making (voting). They do not participate in any of

the closed sessions.

A. Members and contributors with no relevant interests declared on the declaration-of-interest form and no relevant interests found in the CV/ résumé:

– Martin Prince, GDG chair, Professor of Epidemiological Psychiatry, Health Services and

Population Research Institute of Psychiatry, King’s

College London, London, United Kingdom

– Emiliano Albanese, Head, Division of Public Mental Health, and Aging, Institute of Global Health,

Geneva, Switzerland

– Olivier Bruyère, Department of Public Health, Epidemiology and Health Economics, University of

Liège, Liège, Belgium

– Kralj Carolina, King’s College London, London, United Kingdom

Annex 2: Assessment of conflicts of interest

2 Available at http://www.who.int/occupational_health/ declaration_of_interest.pdf

3 Available at http://www.who.int/about/collaborations/ non-state-actors

36 Integrated care for older people

– A.B. Dey, Professor and Head of Department, Department of Geriatric Medicine, All India Institute

of Medical Science, New Delhi, India

– Amit Dias, Department of Preventive and Social Medicine, Goa Medical College Bambolim, Goa,

India

– Meredith Fendt-Newlin, Social Care Workforce Research Unit, King’s College London, London,

United Kingdom

– Astrid Fletcher, Faculty of Epidemiology and Population Health, London School of Hygiene &

Tropical Medicine, London, United Kingdom

– Dorothy Forbes, Faculty of Nursing, University of Alberta, Edmonton Clinic Health Academy, Alberta,

Canada

– Anne Foster, Professor of Stroke Rehabilitation, Faculty of Medicine and Health, Leeds Institute of

Health Sciences, University of Leeds, Leeds, United

Kingdom

– Mariella Guerra, Institute of Memory, Depression and Related Disorders, Lima, Peru

– Jill Keeffe, L.V. Prasad Eye Institute, WHO Collaborating Centre for Prevention of Blindness,

Hyderabad, India

– Qurat Khan, Assistant Professor, Department of Psychiatry, Aga Khan University Hospital, Karachi,

Pakistan

– Gudlavalleti V.S. Murthy, Indian Institute of Public Health, Hyderabad, Madhapur, India

– Joseph G. Ouslander, Chair, Department of Integrated Medical Science, and Senior Associated

Dean of Geriatric Programs, Charles E. Schmidt

College of Medicine, Florida Atlantic University,

Boca Raton, Florida, United States of America

– Minha Rajput-Ray, Medical Director, Need for Nutrition Education/Innovation Programme, Global

Centre for Nutrition and Health, Cambridge, United

Kingdom

– Sumantra Ray, Lead Clinician (National Diet and Nutrition Survey), Medical Research Council (Human

Nutrition Research), Cambridge, United Kingdom

– Luis Miguel F. Gutiérrez Robledo, Director-General, Instituto Nacional de Geriatría Institutos Nacionales

de Salud de México, Mexico City, Mexico

– John F. Schnelle, Professor of Medicine, Director, Center for Quality Aging Geriatric Research,

Education and Clinical Center, Vanderbilt Center for

Quality Aging, Nashville, Tennessee, United States

– Alessandra Stella, Independent consultant, Rome, Italy

– Richard Uwakwe, Faculty of Medicine Nnamdi Aikiwe University Nnewi Campus, Awka, Nigeria

– Abebaw Fekadu Wassie, Associate Professor, Addis Ababa University, College of Health Science,

Department of Psychiatry, Addis Ababa, Ethiopia

– Jean Woo, Department of Medicine and Therapeutics, and Institute of Aging, The Chinese University of Hong

Kong, Hong Kong, China

B. Guideline development group members who have declared an interest on the declaration-of- interest form or for whom a potentially relevant interest has been noted from the CV/résumé:

1. Olivier Bruyère, Department of Public Health,

Epidemiology and Health Economics, University of

Liège, Liège, Belgium

Professor Bruyère did not declare any interests on the

declaration-of-interest form. It is noted from his CV

that he is a member of the Scientific Advisory Board of

the European Society for Clinical and Economic Aspects

of Osteoporosis, Osteoarthritis and Musculoskeletal

Diseases (ESCEO).

ESCEO is a not-for-profit organization, dedicated to a

close interaction between clinical scientists dealing with

bone, joint and muscle disorders, the pharmaceutical

industry developing new compounds in this field,

regulators responsible for the registration of such

medications, and health policy-makers, to integrate the

management of osteoporosis and osteoarthritis within

the comprehensive perspective of health resources

utilization.

The objective of ESCEO is to provide practitioners with

the latest clinical and economic information, allowing

them to organize their daily practice, using an

evidence-based-medicine perspective, with a cost-

conscious perception. Financial details can be found in

the organization’s annual report.44 Available at http://www.esceo.org/reports

37 Annex 2

Action: It was felt that this interest was insignificant or

minimal and unlikely to affect, or be reasonably

perceived to affect, Professor Bruyère’s judgement in

the development of the present guidelines. No further

action was necessary.

2. Alan Dangour, London School of Hygiene & Tropical

Medicine, London, United Kingdom

Dr Dangour declared in the declaration-of-interest

form that he had received from the United Kingdom

Department of Health a competitive grant (£660 000)

to conduct research on nutrition in older people. He

also provided expert opinion to the same department

for a judicial review on nutrition in older people.

Action – Participation with verbal disclosure: It was

felt that this interest was relatively minor and Dr

Dangour should continue his involvement in the GDG.

At the start of the meeting, he was requested to

verbally disclose the research involvement to all

meeting participants.

3. Jean-Yves Reginster, Department of Public Health

Sciences, University of Liège, Liège, Belgium

Professor Reginster declared that he was president of

the European Society for Clinical and Economic

Aspects of Osteoporosis, Osteoarthritis and

Musculoskeletal Diseases (ESCEO). ESCEO is a not-for-

profit organization, dedicated to a close interaction

between clinical scientists dealing with bone, joint and

muscle disorders, pharmaceutical industry developing

new compounds in this field, regulators responsible

for the registration of such medications and health

policy-makers, to integrate the management of

osteoporosis and osteoarthritis within the

comprehensive perspective of health resources

utilization. The objective of ESCEO is to provide

practitioners with the latest clinical and economic

information, allowing them to organize their daily

practice, using an evidence-based-medicine

perspective, with a cost-conscious perception.

Financial details can be found in the organization’s

annual report.5

Action – Partial exclusion: It was decided that

Professor Reginster could continue as a member of

the GDG and participate in the deliberations of the

evidence to inform all of the guidelines. He will be

excluded from participating in the decision-making

(voting) process relating to drafting the final

recommendation on nutritional supplements for lean

muscle mass and muscle strength. At the start of the

meeting, Professor Reginster was asked to disclose

verbally his position in ESCEO, his intellectual interests

and the interests of his organization in the guidelines

related to nutritional interventions targeting muscle

strength and lean muscle mass.

4. Matteo Cesari, Gérontopôle, Centre Hospitalier

Universitaire de Toulouse, Toulouse, France

Professor Cesari declared that he was a speaker for Nestlé. Nestlé is a leading company that manufactures

nutritional supplements for older people, targeting

their unique nutritional needs. A small number of the

trials included in the reviews had been funded by

Nestlé or tested the benefit of Nestlé nutritional

supplements for older people.

Action – Partial exclusion: It was decided that

Professor Cesari could continue as a member of the

GDG and participate in the deliberations of the

evidence to inform all guidelines. He was excluded

from participating in the decision-making (voting)

process relating to the drafting of the final

recommendation on oral nutritional supplementation

for older people with undernutrition.

C. External resource people with no relevant interests declared on the declaration-of-interest form or for whom such interests declared are insignificant or minimal

1. Nandi Siegfried, Consultant, Guideline Methodologist,

Independent Consultant

Dr Siegfried did not declare any interests on the

declaration-of-interest form. It was noted from her

CV/résumé that she has provided technical support,

expert input, and facilitation to WHO clinical

guidelines development processes in the fields of HIV/

AIDS and nutrition.

Action: Dr Siegfried was a technical resource and did

not therefore participate in any of the closed sessions

(voting on or drafting of final recommendations).

5 Available at http://www.esceo.org/reports

38 Integrated care for older people

1. Mobility loss

Does physical exercise training (progressive resistance training or multimodal exercise) produce any benefit or harm for older people with limitations in activities of daily living (ADLs)?

Population

• Non-institutionalized older people with limitations in ADLs

Intervention

• Progressive resistance training • Physical exercise (balance training or

multicomponent)

• Physical rehabilitation (tailored to older person’s need)

Comparison

• No intervention • Control (low physical activity or any social or other

intervention)

• Usual care activities

Outcomes

• Main function measure (higher score = better function)

• Physical function domain of Short Form Health Survey (SF-36/SF-12)

• ADLs measure • Activity level measure • Main lower limb strength measure • Main measure of aerobic function • Six-minute walk test (metres) • Balance measures (higher = better balance) • Gait speed (metres/second) • Timed walk (seconds) • Timed “up-and-go” (seconds) • Time taken to stand from seated in a chair • Stair climbing (seconds) • Chair stand within time limit (number of times) • Vitality (SF-36/Vitality plus scale, higher = more

vitality)

• Pain (higher score = less pain, bodily pain on SF-36) • Pain (lower score = less pain) • Mortality • Adverse effect

2. Undernutrition Does oral nutritional supplement, dietary advice or mealtime enhancement produce any benefit for older people at risk of undernutrition or who are affected by undernutrition?

Population

• Older people, 60 years of age and over (both male and female) at risk of undernutrition

• Older people, 60 years of age and over (both male and female) affected by undernutrition

Intervention

• Oral nutrition supplement (macro- and/or micronutrients)

• Dietary advice • Mealtime strategy to improve food intake

Comparison

• Placebo • Usual care • Control group (waiting to receive intervention)

Outcomes

• Critical: mortality, weight change • Important: hand grip strength, ADLs

Setting

• Primary health care/community

3. Vision impairment For older people with vision impairment, does case finding, provision of care or referral produce any benefit and/or harm compared with controls?

Annex 3: Scoping questions

39 Annex 3

Population

• Older people 60 years of age and over (both male and female) with refractive errors or cataract

Intervention

• Case-finding and referral for refractive error or cataract

• Case-finding and immediate provision of care for refractive error

Comparison

• Usual care

Outcomes

• Critical: visual acuity, vision-related quality of life, self-reported improvement

• Important: social function, depression

Setting

• Primary health care/community

4. Hearing loss Does case-finding and provision of hearing aids or assistive listening devices produce any benefit or harm for older people 60 years of age and over with hearing loss?

Population

• Older people 60 years of age and over (both male and female) with hearing loss

Intervention

• Screening and provision of hearing aid or assistive listening device

• Educational intervention to improve uptake or use of hearing aid

Comparison

• Referral or no service or delayed treatment

Outcomes

• Critical: improvement in communication, social function, hearing function

• Important: depression, quality of life, use of verbal communication strategy, self-reported hearing

handicap scale

5. Cognitive impairment Does cognitive stimulation, cognitive training or rehabilitation produce any benefit for older people with cognitive impairment or early stage of dementia?

Population

• Older people 60 years of age and over (both male and female) with cognitive impairment or mild

cognitive impairment

• Older people 60 years of age and over (both male and female) with early stage of Alzheimer’s disease

and vascular dementia

Intervention

• Cognitive stimulation • Cognitive training • Cognitive rehabilitation

Comparison

• No treatment/usual care/standard treatment • Waiting list control • Active control condition

Outcomes

• Critical: cognitive functions assessment by Mini Mental State Examination (MMSE) and Alzheimer’s

Disease Assessment Scale – Cognitive subscale

(ADAS-Cog), immediate and delayed memory recall

6. Depressive symptoms Does psychological intervention (behavioural activation, cognitive behavioural therapy, psychoeducational therapy, interpersonal therapy, problem-solving therapy, stepped-care protocol therapy, or life-review therapy) produce any benefit or harm for older people with depressive symptoms?

Population

• Older people 60 years of age and over (both male and female) with depressive symptoms with or

without diagnostic status (depressive episode or

disorder)

Interventions

• Behavioural activation, cognitive behavioural therapy, psychoeducational therapy, interpersonal therapy,

problem-solving therapy, stepped-care protocol

therapy, or life-review therapy

Comparison

• Usual care or waiting list

Outcomes

• Critical: depressive symptoms, incidence of clinically significant depression (depressive episode or major

depressive episode)

40 Integrated care for older people

7. Urinary incontinence Do non-pharmacological interventions (prompted voiding, timed voiding, toilet training, habit retraining, pelvic floor muscle training) produce any benefit and/or harm for older people with urinary incontinence?

Population

• Older people with urgency or stress or mixed urinary incontinence

Intervention

• Prompted voiding • Timed voiding • Bladder training • Habit retraining • Pelvic floor muscle training

Comparison

• No intervention/usual care

Outcomes

• Critical: proportion of mean change in frequency of urinary incontinence, change in mean

proportion of hourly checks that are wet, number

of patients with reductions in incidence of daytime

incontinence, number of patients with reductions

in incidence of night-time incontinence,

incontinent episodes in 24 hours, mean urinary

incontinence incidence per 24 hours, urinary

incontinence symptoms

• Important: perceived cure, self-initiated toileting, median percentage of checks wet, number of

incontinent episodes, urinary incontinence urgency,

urinary incontinence frequency, nocturia, quality of

life

8. Risk of falls Do interventions to prevent falls produce any benefit or harm for older people (60 years of age and over) at risk of falls?

Population

• Older people 60 years of age and older (both male and female) at risk of falls

Intervention

• Multicomponent exercise programme/strength training

• Falls risk assessment by the physiotherapist to develop individualized falls and injury prevention

• Individually tailored exercises • Medication review • Withdrawal of psychotropic medication • Multifactorial interventions with comprehensive

geriatric assessment

• Environmental modification for home safety • Assistive technology (walking aid, hearing aid,

personal alarm system)

• Footwear assessment • Insertion of a pacemaker (carotid sinus

hypersensitivity)

Comparison

• Usual care or standard care • Placebo or no active intervention • Waiting list control • Active control intervention

Outcome

• Critical: rate of falls

Setting

• Primary health care/community

9. Caregiver support Does respite care or psychosocial support produce any benefit or harm for family caregivers of care-dependent older people?

Population

• Family caregivers (both male and female) of care- dependent people of 60 years of age and over

Intervention

• Respite care • Psychosocial support • Technology-based interventions

Comparison

• Usual or standard care • Waiting list control • Active control intervention

Outcomes

• Critical: caregiver burden, caregiver depression, care recipients’ symptoms

• Important: well-being, ability/knowledge, quality of life, anger, anxiety

41 Annex 4

STEP ONE

Search For the evidence synthesis, we performed a

comprehensive search for published systematic

reviews and randomized controlled trials (RCTs) using

the Cochrane Library, Embase, Ovid MEDLINE and

PsycINFO databases.6 A search strategy was developed

for each of the scoping questions (Annex 3). Details of

the search strategies can be found in the GRADE

(Grading of Recommendations Assessment,

Development and Evaluation) tables7 and evidence

profiles appended to these guidelines, which are

available at http://www.who.int/ageing/health-

systems/icope.

STEP TWO

Screening Identified references were exported to reference

manager software and duplicates were identified and

deleted. References were screened first by title and

abstract and then by full text to identify systematic

reviews and RCTs. Details of the search process and

the number of records retrieved and assessed for

eligibility are presented in a PRISMA (Preferred

Reporting Items for Systematic Reviews and Meta-

Analyses) flow diagram for each PICO (population,

intervention, comparison, outcome) question in the

relevant GRADE evidence profile documents.

STEP THREE

Eligibility Systematic reviews that reported the methodological

quality assessment of included RCTs were eligible for

inclusion. Of the 32 included systematic reviews, 20

were published between 2011 and 2015 and were

updated with newer RCTs identified in consultation

with guideline development group (GDG) members.

The remaining 12 systematic reviews were published

before 2011, and were updated with new RCTs

identified from the search strategies during screening.

STEP FOUR

Quality assessment of included studies The AMSTAR appraisal tool was used on each

included systematic review to provide an indication of

review conduct quality (see Fig. 3). No review was

excluded based on the cut-off points in the AMSTAR

tool as there is no score recommended for separating

high- from low-quality reviews.

STEP FIVE

Meta-analysis Where new trials were identified and included

comparable interventions and outcomes, meta-

analysis was conducted either as an update to the

analyses contained in a previous review, or as a de

novo meta-analysis. Review Manager 5 (RevMan 5)

software was used to calculate mean differences and

standardized mean differences between intervention

and control groups. Relative risks or odds ratios were

presented for categorical outcomes.

STEP SIX

GRADE assessment The meta-analysed results were exported to the

GRADE profiler software for evidence grading work.8

The evidence was graded as very low, low, moderate,

or high, based on the limitations of the included

Annex 4: Evidence process

6 See: — Cochrane Library (http://www.cochranelibrary.com/cochrane-database-of-systematic-reviews) — Embase (http://www.elsevier.com/solutions/embase-biomedical-research) — Ovid MEDLINE (http://ovid.com/site/catalog/databases/901.jsp) — PsycINFO (http://www.apa.org/pubs/databases/psycinfo/index.aspx) 7 Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J et al. GRADE guidelines: 1. Introduction – GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011;64(4):383–94. doi:10.1016/j.jclinepi.2010.04.026. 8 GRADE’s software for summary of findings tables, health technology assessment and guidelines [website]. Hamilton (ON): McMaster University and Evidence Prime; 2015 (http://gradepro.org, accessed 11 September 2017).

42 Integrated care for older people

studies, specifically in terms of inconsistency,

indirectness, imprecision and publication bias. Except

for one Cochrane review, none of the included

systematic reviews performed GRADE assessments.

Therefore, for each meta-analysis, we conducted an

independent assessment of the quality of results using

GRADE profiler software.

STEP SEVEN

Reporting The final outcome of the systematic reviews, meta-

analysis and the evidence-grading exercise was

summarized in a 2×2 table of all results and

interventions, which was then discussed with the GDG.

43 Annex 4

Hearing loss

Vision impairment

Falls

Caregiver stress

Urinary incontinence

Sub-threshold depression

Cognitive impairment

Undernutrition

Mobility impairment

Fig. 3: Assessment of systematic review quality using the 11 questions of the AMSTAR checklist tool9

11 . “

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5. “W

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Study 10

Cadore et al.

Chou et al.

Daniels et al.

de Vries et al.

Gine-Garriga et al.

Howe et al.

Van Abbema.

Liu C et al.

Burton et al.

Forbes et al.

Pitkala et al.

Milne et al.

Baldwin et al.

Munk et al.

Gillespie et al.

Martin et al.

Kurz et al.

Ekers et al.

Cuijpers et al.

van Zoonen et al.

Wallace et al.

Ostaszkiewicz.

Eustice et al.

Ostaszkiewicz et al.

Dumoulin et al.

Mason et al.

Shaw et al.

Sorensen et al.

Pinquart et al.

Lopez-Hartmann et al.

Smeeth et al.

Barker et al.

Yes No Unclear

Key:

9 Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol. 2007;7(1):10. doi:10.1186/1471-2288-7-10. 10 For full study details, see the ICOPE evidence profiles available at http://www.who.int/ageing/health-systems/icope.

44 Integrated care for older people

Activities of daily living (ADLs): The basic activities necessary for daily life, such as bathing or showering,

dressing, eating, getting in or out of bed or chairs, using

the toilet, and getting around inside the home.

Behavioural activation: A behavioural treatment for depression in which guidance is given to increase the

number of rewarding activities in the person’s life.

Bladder training: A form of behavioural therapy to treat urinary incontinence that aims to increase the

interval between voids. This training is composed of

patient education, scheduled voiding and positive

reinforcement.

Caregiver: A person who provides care and support to someone else. This may include the following:

• helping with self-care, household tasks, mobility, social participation and meaningful activities;

• offering information, advice and emotional support as well as engaging in advocacy, facilitation of

decision-making and peer support, and helping with

advance-care planning;

• offering respite services; and

• engaging in activities to foster intrinsic capacity. Caregivers may include family members, friends,

neighbours, volunteers, care workers and health care

professionals.

Caregiver stress: The cumulative effect of the physical, emotional and economic pressures put on a caregiver.

Case finding: A strategy for targeting resources at individuals or groups who are suspected to be at risk for

a particular disease or adverse health outcomes. It

involves actively, systematically searching for at-risk

people, rather than waiting for them to present with

symptoms or signs of active disease or health conditions.

Care dependence: This arises when functional ability has fallen to a point where an individual is no longer

able without assistance to undertake the basic tasks

necessary for daily living.

Chronic condition: A disease, disorder, injury or trauma that is persistent or has long-lasting effects.

Comprehensive geriatric assessment: A multidimensional assessment of an older person that

includes medical, physical, cognitive, social and spiritual

components; may also include the use of standardized

assessment instruments and/or an interdisciplinary

team to support the process.

Cognitive behavioural therapy (CBT): A type of psychological therapy that involves identifying and

correcting distorted maladaptive beliefs, while using

thought exercises and real experiences to facilitate

symptom reduction and improved functioning.

Cognitive impairment: A loss or abnormality in attention functions, memory functions or higher-level

cognitive functions.

• Attention functions are mental functions that focus on an external stimulus or internal experience for a

specific period of time.

• Memory functions are mental functions that register and store information and retrieve it as

needed.

• Higher-level cognitive functions, often called executive functions, are mental functions that

involve the frontal lobes of the brain. They include

complex goal-directed behaviours such as decision-

making, abstract thinking, making and carrying out

plans, mental flexibility and deciding which

behaviours are appropriate under specific

circumstances.

Cognitive rehabilitation: A method to maximize memory and cognitive functioning despite neurological

difficulties. Cognitive rehabilitation focuses on

identifying and addressing individual needs and goals,

Glossary

45 Glossary

which may require strategies for taking in new

information, or compensatory methods such as using

memory aids.

Cognitive stimulation: Participation in a range of activities designed to improve cognitive and social

functioning.

Cognitive training: Guided practice of specific standardized tasks designed to enhance particular

cognitive functions.

Community health worker: Individuals who provide health education, referral and follow up, case

management, and basic preventive health care and home-

visiting services to specific communities. They provide

support and assistance to individuals and families in

navigating the health and social services system.

Depressive symptoms: The presence of distress or some degree of impaired functioning in the absence of

depressive episode/disorder.

Dietary advice: Recommendations for a healthy diet to help protect against malnutrition and undernutrition as

well as noncommunicable diseases.

Falls: Inadvertently landing on the ground, floor or other lower level.

Functional ability: The combination and interaction of intrinsic capacity with the environment a person

inhabits.

Geriatric syndromes: Complex health states that tend to occur only later in life and that do not fall into discrete

disease categories; often the consequence of multiple

underlying factors, and dysfunction in multiple organ

systems.

Habit retraining: A form of toileting assistance given by a caregiver to adults with urinary incontinence. This

method involves identification of an incontinent person’s

natural voiding pattern and the development of an

individualized toileting schedule, which pre-empts

involuntary bladder emptying.

Healthy Ageing: The process of developing and maintaining the intrinsic capacity and functional ability

that enables well-being in older age.

Hearing loss: Loss or abnormality in sensory functions relating to perception of the presence of sounds or

discriminating the location, pitch, loudness or quality of

sounds.

Intrinsic capacity: The combination of the individual’s physical and mental, including psychological, capacities.

Malnutrition: Deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients. The term

malnutrition covers two broad groups of conditions. One

is “undernutrition” – which includes stunting (low height

for age), wasting (low weight for height), underweight

(low weight for age) and micronutrient deficiencies or

insufficiencies (a lack of important vitamins and minerals);

the other is overweight, obesity and diet-related

noncommunicable diseases (such as heart disease, stroke,

diabetes and cancer).

Mealtime enhancement strategy: Interventions to improve the mealtime routine, experience or

environment by providing assistance (directly or

indirectly): encouragement with eating, a more

stimulating environment to eat in, increased access to

food, more choice of food or more appealing food

(visually, sensorially).

Mild cognitive impairment: A disorder characterized by memory impairment, learning difficulties and reduced

ability to concentrate on a task for more than brief

periods. There is often a marked feeling of mental

fatigue when mental tasks are attempted, and new

learning is found to be subjectively difficult even when

objectively successful. None of these symptoms is so

severe that a diagnosis of either dementia or delirium

can be made.

Mobility loss: A loss or abnormality in any form of moving by changing body position or location or by

transferring from one place to another, by carrying,

moving or manipulating objects, by walking, running or

climbing, or by using various forms of transportation.

Multimorbidity: The co-occurrence of two or more chronic medical conditions in one person.

Multimodal exercise training: Exercise interventions composed of multiple modalities such as strength

training, aerobic training, balance training or flexibility

exercises.

Multifactorial assessment: A comprehensive assessment to define all possible factors that may be

causing a specific symptom or condition.

Multifactorial intervention: An intervention to address multiple contributing factors; an approach may

include modification plus education, or action to

minimize risk factors.

46 Integrated care for older people

Non-specialist health care providers: General physicians, family physicians, nurses and other clinical

officers working in a health centre or as part of a clinical

team, commonly within a primary health care setting.

Older person: A person whose age has passed the median life expectancy at birth.

Person-centred services: An approach to care that consciously adopts the perspectives of individuals,

families and communities, and sees them as participants

in, as well as beneficiaries of, health care and long-term

care systems that respond to their needs and preferences

in humane and holistic ways. To ensure that person-

centred care is delivered requires that people have the

education and support they need to make decisions and

to participate in their own care. Person-centred care is

organized around the health needs and expectations of

people rather than diseases.

Pelvic floor muscle training (PFMT): Exercises that involve contraction and relaxation of the pelvic muscles,

aiming to strengthen the muscles and enable increased

urethral-closing pressure.

Primary care professionals: Members of a primary care team, a group of professionals with complementary

contributions, mutual respect and shared responsibility

in patient care. Primary care teams are patient-centred,

so their composition and organizational model can

change over time.

Progressive resistance training: A type of exercise in which participants exercise their muscles against a force

or some type of resistance that is progressively increased

as strength improves.

Problem-solving therapy: A type of psychological therapy in which the person systematically identifies

their problems, generates alternative solutions for each

problem, selects the best solution, develops and

conducts a plan, and evaluates whether this has solved

the problem.

Psychological therapies: Interpersonal, individualized treatments to help with a psychiatric or psychological

disorder, problem or adverse circumstance. Treatments

may include cognitive behavioural therapy, problem-

solving therapies, interpersonal therapy or integrative

therapeutic techniques.

Physical activity: Any bodily movement produced by skeletal muscles that requires energy expenditure –

including activities undertaken while working, playing,

carrying out household chores, travelling or engaging in

recreational pursuits.

Physical exercise: Subcategory of physical activity that is planned, structured, repetitive and aims to improve or

maintain one or more components of physical fitness.

Primary health care: A concept based on the principles of equity, participation, intersectoral action, appropriate

technology and a central role played by the health

system. Patients usually have direct access without the

need for referral.

Prompted voiding: A non-pharmacological, behavioural-therapy approach to urinary incontinence

using verbal prompts and positive reinforcement, for

people with or without dementia.

Respite care: Time off from caregiving responsibilities so that caregivers can restore and maintain their own

physical and mental health.

Undernutrition: A global problem that is usually caused by a lack of food, or a limited range of foods with

inadequate amounts of specific nutrients or other food

components, for example protein, dietary fibre and

micronutrients.

Urinary incontinence: Involuntary leakage of urine. The majority of causes can be divided into three types:

• urge incontinence: involuntary leakage of urine associated with, or immediately following, a sudden

compelling need to void;

• stress incontinence: involuntary leakage when performing physical activity, coughing or sneezing;

and

• mixed urinary incontinence: a combination of urge incontinence and stress incontinence.

Visual impairment: A loss or abnormality in sensory functions relating to the perception of the presence of

light, or to sensing the form, size, shape or colour of the

visual stimuli.

World Health Organization

Department of Ageing and Life Course

Avenue Appia 20

1211 Geneva 27

Switzerland

Email: ageing@who.int

Website: www.who.int/ageing

ISBN 978-92-4-155010-9