An integrated approach to managing frailty and intrinsic capacity: Interview with Associate Professor Laura Tay
22 August 2024
To unlock not just longer but healthier lives, it is crucial to prevent or slow declines in older adults’ physical and mental capacities, or their intrinsic capacity. This is at the heart of the World Health Organization (WHO)’s Integrated Care for Older People (ICOPE) framework, which guides practitioners and policymakers on intrinsic capacity screening, and providing personalised and coordinated care.
GERI is the implementation research partner for the INFINITY-ICOPE research project (Optimising INtrinsic Capacity for Functional INdependence and to Impede FrailTY in Older Adults: Adaptation of the WHO-ICOPE for Healthy Ageing in Singapore)*, which seeks to adapt and implement the WHO ICOPE framework in the community. INFINITY-ICOPE aims to help older adults maintain their functional independence. Programme components include screening and interventions that allow primary and community-care partners to manage frailty and intrinsic capacity in an integrated way.
In this two-part feature series, we speak to INFINITY-ICOPE's Principal Investigator, Associate Professor Laura Tay (Head and Senior Consultant, Geriatric Medicine, Sengkang General Hospital; Lead Scientist, GERI). She shares her insights on how promoting intrinsic capacity can change the way we manage frailty, how INFINITY-ICOPE supports Singapore’s national strategies on healthy ageing, and more. Read part one with Associate Professor Tay below.
* Supported by the National Medical Research Council Singapore, under the National Innovation Challenge on Active and Confident Ageing.
GERI: There has been a lot of attention on the spike in frailty in Singapore, but we do not always hear intrinsic capacity discussed in the same breath. Why is intrinsic capacity important when it comes to managing frailty in older adults?
Associate Professor Laura Tay: Intrinsic capacity (IC) supports early identification of older adults with or at risk of developing frailty, enabling targeted intervention and personalised care. More broadly, IC and frailty are the main determinants of functional ability, which needs to be developed and maintained for well-being in older age. Thus, IC is also critical for healthy ageing, and has been identified as a key priority by the WHO.1
IC may be viewed as a natural evolution of frailty. Declining levels of IC make a frail older person extremely vulnerable to adverse outcomes. IC decline is also highly prevalent. It increases the risk of developing frailty and contributes to negative health events such as disability, falls and increased healthcare utilisation. Hence, integrating IC and frailty presents a valuable opportunity.
Our study2 has shown that 45% of robust older adults naturally transitioned to pre-frailty/frailty within just two years, so robustness alone as an indicator of well-being – without assessing IC levels – may offer false reassurance. The same study also found that incident frailty is associated with cumulative IC deficits. Thus, while seemingly distinct, both frailty and IC represent correlated points on a continuum: IC is an indicator of one's bodily reserves, and frailty indicates the health deficits that accumulate with ageing. Efforts to promote IC and prevent frailty therefore cannot be mutually exclusive.
By considering IC and frailty on a common trajectory, three major periods of IC states can be defined to guide specific goals and tailor intervention plans. This complementary perspective has practical clinical implications: (i) monitoring IC to support early identification of individuals with frailty or at-risk of frailty; and (ii) IC assessment of a frail individual supports targeted and personalised care plans.
The INFINITY-ICOPE project is happening amidst the roll-out of HealthierSG and the Action Plan for Successful Ageing. How is the ICOPE framework particularly relevant for our health and social systems? How do you foresee ICOPE playing a role in supporting population health and healthy ageing in Singapore?
The WHO ICOPE framework3 has an eye towards preventive health, personalised care, as well as primary and community care, underscoring its relevance to Singapore. The framework is a prevention programme that is evidence-based, function-centered and person-centered, aimed for implementation before frailty occurs. It has also been specifically designed for clinical practice in primary and community care of older people.
In the immediate term, the WHO ICOPE framework advocates for an easily-administered yet comprehensive screening strategy, with digitally-supported guidance and interventions. This will facilitate primary care partners in preventive care delivery, aligned to Healthier SG.
The ICOPE framework also aligns with the three "C"s of the refreshed Action Plan for Successful Ageing: Care through empowering older adults in their health, as they are made aware of their individual IC trajectory; opportunity to Contribute as they are supported to maintain functional independence, and leveraging support networks to keep them Connected, as encapsulated in Step Five4 of the Framework.
The focus on community and primary care settings will ensure accessibility, with sustainability and scaling attainable through SingHealth’s extensive community collaborations, and our partnership with GERI to facilitate national translation efforts.
In the long term, the WHO ICOPE framework dovetails with MOH’s “3 Beyonds” strategy:
Reorient health and social services (beyond hospital to community) towards person-centred care;
Optimising the functional ability of older people (beyond healthcare to health), and
Addressing diverse and complex needs by integrating health and social care pathways adaptable to our local population (beyond quality to value).
Could you share more about the involvement of community and primary care partners in INFINITY-ICOPE?
The training of community partners and primary care providers will be necessary to facilitate screening for frailty and IC decline, and support person-centred management. We will work closely with Active Ageing Centres to deliver the screening systematically to their older adult residents, and ensure that older adults with identified IC deficits receive appropriate assessments to clarify and manage their deficits.
The latter will leverage on our Community Health Posts including community nurses and well-being coordinators, primary care partners and community care providers (such as Community Outreach Teams (CREST) and day rehabilitation).
In particular, we have partnered with the Agency for Integrated Care to support the coordination of community services required by older adults post-screening.
Our partnership with the Singapore University of Social Sciences will ensure sustainability of training to support the delivery of ICOPE as certified by the WHO, while existing networks of primary care partners ensure capacity to provide Comprehensive Geriatric Assessment for frail older adults.
In developing care pathways for integrated care in the community, while specific pathways for each IC domain will be modelled after the ICOPE handbook, these will be adapted to ensure that they can be well-supported by our community and primary care partners.
What has working with GERI been like for this project?
Our collaboration with GERI will strengthen the implementation research capabilities for the conduct of INFINITY-ICOPE. This is essential for a complex programme such as this. By concurrently evaluating the intervention and implementation outcomes, we aim to accelerate translational gains for the scaling of the programme in real-world settings, as well as provide important information on implementation strategies for key stakeholders.
The pre-implementation qualitative study conducted by GERI has identified key barriers and enablers among stakeholder implementers, which have guided the selection and development of implementation strategies according to evidence-based frameworks. GERI’s support has been instrumental in ensuring rigour to the implementation science, bringing in appropriate theory and frameworks that will account for contextual factors.
Context matters, as it brings with it a dynamic and diverse range of elements beyond evidence-based interventions that work out for and against implementation efforts.
I am very much appreciative of this opportunity to work closely with GERI, and have also personally gained significant insights from the academic exchanges.
Read part two of this story here, where our Research Associate Dr Mimaika Ginting talks about strategies for implementing healthcare innovations into local practice, as part of her research for the INFINITY-ICOPE study team.
1 World Health Organization (WHO)’s Public Health Framework for Healthy Ageing (2015), which aims to foster the functional ability of older adults at the individual level. and environmental level. Read the report here.
2 Tay L, Tay EL, Mah SM, Latib A, Koh C, Ng YS. "Association of Intrinsic Capacity with Frailty, Physical Fitness and Adverse Health Outcomes in Community-Dwelling Older Adults." J Frailty Aging. 2023;12(1):7-15. doi: 10.14283/jfa.2022.28.
3, 4 The WHO ICOPE framework, released in 2017, is aimed at enhancing IC, promoting functional ability and minimising care dependency through evidence-based tools and guidance specific to every level of care. It comprises of five steps: Step One – screening for declines in IC domains; Step Two – in-depth assessment of participants with IC deficits identified during screening; Step Three – development of a personalised care plan; Step Four – monitoring of the care plan; Step Five – transversal engagement of communities and caregivers. Read more here.