Intrinsic Capacity in Older Adults: Recent Advances

Abstract

The global increase in the aging population is expected to result in a shift from disease-centered to function-centered approaches in response to intensive aging. Thus, the World Health Organization (WHO) has proposed a novel concept, intrinsic capacity (IC), which refers to the combination of one's physical and mental abilities. The IC framework comprises cognition, mobility, psychological, vitality, and sensory functions. WHO also issued the Guidelines on Integrated Care for Older People (ICOPE) in 2017 and the Handbook: Guidance on person-centred assessment and pathways in primary carein 2019 to provide recommendations for community-level interventions and clinical practice, respectively. Recently, studies on the assessment of IC and verification of IC measurement have been proliferating. In this study, we reviewed the recent advances in IC research with older adults.

Full text

http://dx.doi.org/10.14336/AD.2021.0818
*Correspondence should be addressed to: Dr. Lina Ma, Department of Geriatrics, Xuanwu Hospital, Capital Medical University, 45
Changchun Street, Xicheng District, Beijing 100053, China. E-mail: malina0883@126.com.
Copyright: © 2021 Zhou Y and Ma L. This is an open-access article distributed under the terms of the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
ISSN: 2152-5250 353
Opinion
Intrinsic Capacity in Older Adults: Recent Advances
Yaru Zhou, Lina Ma*
Department of Geriatrics, Xuanwu Hospital, Capital Medical University, National Clinical Research Center for
Geriatric Disorders, Beijing, China.
[Received June 14, 2021; Revised August 17, 2021; Accepted August 18, 2021]
ABSTRACT: The global increase in the aging population is expected to result in a shift from disease-centered
to function-centered approaches in response to intensive aging. Thus, the World Health Organization (WHO)
has proposed a novel concept, intrinsic capacity (IC), which refers to the combination of one’s physical and
mental abilities. The IC framework comprises cognition, mobility, psychological, vitality, and sensory functions.
WHO also issued the Guidelines on Integrated Care for Older People (ICOPE) in 2017 and the Handbook:
Guidance on person-centred assessment and pathways in primary care in 2019 to provide recommendations for
community-level interventions and clinical practice, respectively. Recently, studies on the assessment of IC and
verification of IC measurement have been proliferating. In this study, we reviewed the recent advances in IC
research with older adults.
Key words: intrinsic capacity, healthy aging, integrated care, frailty, resilience, older adults
The global population is rapidly aging [1]. According to
the World Health Organization (WHO), older adults aged
≥ 60 years will account for 12% in 2015 to 22% in 2050
(2 billion) of the world’s population (www.who.int/news-
room/fact-sheets/detail/ageing-and-health). To formulate
public health strategies in response to the aging
population, WHO has proposed the concept of healthy
aging as the process of developing and maintaining the
functional ability required for the healthy life of older
adults (apps.who.int/iris/handle/10665/186463).
Functional ability depends on intrinsic capacity (IC) and
the environment, as well as the interaction between them.
IC refers to the sum of an individual's physical and mental
abilities. Evidence shows that focusing on the IC of older
adults is more effective than focusing on specific chronic
diseases [2-4]. Therefore, WHO proposed Guidelines on
Integrated Care for Older People (ICOPE) for the
maintenance of IC (apps.who.int/iris/handle/10665/
258981). However, research on IC assessment and on the
development of interventions to improve IC is still in its
infancy. This article reviews the progress of research on
IC as well as its implications for clinical work.
Healthy Aging and Intrinsic Capacity
Intrinsic capacity
The World Report on Ageing and Health by WHO
proposed the novel concept of healthy aging, as the
process of developing and maintaining the functional
ability that enables well-being in old age
(apps.who.int/iris/handle/10665/186463). Accordingly,
functional ability is described as “the health-related
attributes that enable people to be and to do what they
have reason to value” [5]. Furthermore, IC refers to the
sum of the physical and mental capacities of an individual,
determining the functional ability combined with
environmental factors and their interaction (apps.who.int/
iris/handle/10665/186463). Older adults can achieve
higher quality of life in their later years, when they are
within a suitable environment and have reached the peak
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Aging and Disease • Volume 13, Number 2, April 2022 354
of each health phase, thus reducing the burden of the
society. The existing care model for older adults is to
predict and respond to diseases by targeting specific
disease markers. Wang et al [6] reviewed that the shift
from disease-centered care to IC has major implications
for nursing practice in older hospitalized adults. However,
the new WHO care model of healthy aging involves a
longitudinal observation of the individual's trajectory,
with the goal of implementing active and personalized
interventions that improve older adults’ IC and functional
ability (apps.who.int/iris/handle/10665/186463).
Research on the evaluation of intrinsic capacity
IC is a strong predictor for health outcomes from the
perspective of function. There are several complex IC
indicators; therefore, which of these can be used
specifically to evaluate the overall physical and mental
state of an individual? Cesari [7] used the International
Classification of Functioning, Disability and Health
framework as a base, combined it with available evidence,
and identified the five IC domains (locomotion, vitality,
cognition, psychological, and sensory) as the key to
controlling and maintaining the IC of older adults, thereby
permitting subsequent evaluation of IC. Similarly, Beard
[8] assessed walking speed, chair-stand test, balance, grip
strength, forced expiratory volume, blood assay, sensory,
cognitive function, and sleep in the English Longitudinal
Study on Ageing (ELSA) and found that five subfactors
(psychological, sensory, cognitive, vitality, and
locomotor) formed a structure to better predict future
functioning, which is consistent with the findings of
Cesari. A recent Chinese study also validated this
structure using the same method as in ELSA [9]. Based on
these studies, researchers from different countries have
evaluated and verified the predictive value of the decline
of IC and its domains in older adults.
Table 1 presents the longitudinal studies on IC.
Although diverse assessments of IC were employed in
these studies, IC decline was commonly associated with
adverse outcomes, such as falls, and deterioration in
activities of daily living (ADLs) and instrumental
activities of daily living (IADLs) [8-13]. Furthermore, a
high IC score was associated with decreased risk of 1-year
mortality [13]. Therefore, IC demonstrated strong
potential to predict negative outcomes among older adults
in different clinical settings.
Table 1. Longitudinal studies on intrinsic capacity in older adults
Autho
r/year
Country/
region
Study
Follow
-up
time
Research
setting
Participan
ts and
sample
size
IC assessment
Main
outcome
measure
Results
Beard
et al.
2019
United
Kingdom
ELSA
2 years
Community
≥ 60 years
N = 2560
Walking speed,
chair-stand test,
balance, grip
strength, FEV,
blood assay,
sensory, cognitive,
affect, sleep
ADL,
IADL
IC had a direct relationship
with the outcome.
Multimorbidity had an
independent direct relationship
with incidence loss of ADLs
but not IADLs, and it also
operated through IC.
IC mediated more of the
indirect effect of personal
characteristics on incidence
loss of ADLs and IADLs than
multimorbidity.
Liu et
al.
2021
Beijing,
China
-
2 years
Community
> 75 years
N = 212
MMSE, SPPB,
MNA-SF, GDS-15,
vision and hearing
evaluation
Katz
ADL
index
Falls
Orientation and memory
impairment were associated
with a higher probability of
functional decline.
The impaired chair stand test,
weight loss, and little interest in
doing things were significantly
associated with falls.
Yu
et al.
2021
Hong
Kong,
China
The
MrOS
and
MsOS
(Hong
Kong)
study
7 years
Community
≥ 65 years
N = 3736
Cognition: MMSE
Locomotor:
walking speed,
chair stands,
dynamic balance
Vitality: grip
strength, adiposity
to muscle ratio,
body fat/ASM
IADL
IC predicted incident IADL
limitations directly.
The direct effect of IC on IADL
was larger than the direct effect
of the number of chronic
diseases.

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Aging and Disease • Volume 13, Number 2, April 2022 355
Sensory: binocular
visual acuity,
stereopsis
Psychological:
GDS-15
Beard
et al.
2021
China
CHARLS
2 years
Community
≥ 60 years
N = 7643
Walking speed, the
chair-stand test,
balance, grip
strength, FEV,
hemoglobin,
hearing and vision
impairments,
episodic memory,
intact mental status,
affect and sleep
quantity/quality.
ADL,
IADL
IC predicted the declining
performance in ADL and IADL
both directly and indirectly.
The direct effect was much
larger than the indirect effect of
IC through multimorbidity.
Both multimorbidity and IC
independently predicted the
declining ADLs and IADLs.
Personal characteristics
predicted declining ADLs and
IADLs both directly and
indirectly through IC and
multimorbidity.
Charle
s
et al.
2020
Belgian
SENIOR
3 years
Nursing
home
N = 604
Cognition: MMSE
Locomotion: SPPB
Sensory: the self-
report Strawbridge
questionnaire
Vitality: abdominal
circumference,
handgrip strength,
MNA
Psychosocial:
depression (3-point
Likert scale)
Fatigue (two
questions from the
C ES-D)
Death,
falls,
autonomy
decline
A one-unit increase in the
balance performance and
nutrition score decreased the
probability of death (by 12%)
and the risk of fall (by 4%).
No association was found
between IC and repeated falls.
Low scores in nutrition were
associated with a higher
probability of autonomy
decline.
Zeng
et al.
2021
Zhejiang
, China
-
1 year
Hospital
≥ 60 years
N = 329
Cognition: MMSE
Locomotion: B-
POMA, 4-m gait
speed test
Sensory: self-
reported hearing
and vision status
Vitality: handgrip
strength, MNA-SF
Psychological:
GDS-15
ADL,
IADL,
mortality
Low MMSE scores at
admission predicted 1-year new
ADL and IADL dependency.
No significance was observed
between IC domains and
mortality.
Higher IC score at admission
was associated with decreased
risks of 1-year new ADL and
IADL dependency, and
mortality.
Abbreviations: IC, Intrinsic Capacity; ELSA, the English Longitudinal Study on Ageing; FEV, Forced expiratory volume; ADL, activities of daily living; IADL, instrumental
activities of daily living; MMSE, the Mini-Mental-State-Examination; SPPB, Short Physical Performance Battery Test; MNA-SF, Mini-Nutritional Assessment Short Form;
GDS-15, Geriatric Depression Scale-15; CES-D, Epidemiologic Studies Depression scale; MrOS and MsOS (Hong Kong), the Mr. Osteoporosis and Ms Osteoporosis (Hong
Kong) study; ASM, appendicular skeletal muscle mass; CHARLS, the China Health and Retirement Longitudinal Study; SENIOR, Sample of Elderly Nursing home
Individuals: an Observational Research; MNA, Mini Nutritional Assessment; B-POMA, balance subscale of Tinetti Performance-Oriented Mobility Assessment.
A general IC index, rather than simple effects of
different subdomains added together, may provide better
predicted value. Thus far, no global IC index has been
validated for clinical or research purposes [14]. Therefore,
more research on the validation of IC concepts and
constructs is required, along with further quantitative
evaluation of IC and its domains in different settings.
Intrinsic capacity, frailty, and physical resilience
IC and frailty
IC, represents the amount of resources available to a
person over a lifetime, is a dynamic concept, and its
trajectory can provide information about the entire
lifespan to clinical and public health activities, at an
individual or a national level [15]. Clinicians can detect
deviations from the norm before clinical manifestations,
evaluate the effectiveness of interventions, and take
preventive measures to achieve healthy aging. As a novel
concept, IC has plenty of distinctions as well as
commonalities and connections with frailty.
Frailty is a geriatric syndrome in which the gradual
decline of an individual's physiological system makes the
individual more susceptible to stressors and increases the
risk of adverse health outcomes [15]. Furthermore, frailty
is a condition that appears before the onset of disability,
most often associated with the latter phase of life [16].

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Aging and Disease • Volume 13, Number 2, April 2022 356
IC and frailty can be viewed as two sides of the same
coin [10], where the former is an individual’s reserve of
ability, whereas the latter a hindrance that grows with
aging. However, the two concepts are not mutually
exclusive. Belloni [15] argued that IC, to some extent, can
be considered as an evolution of the concept of frailty. The
two concepts are complementary; monitoring IC can
support the concurrent evaluation of individual frailty.
Assessing the IC of a frail individual can also prove
valuable, such as by resulting in the development of an
individual, personalized care plan based on an individual's
thoughts and priorities. Robledo [17] argued that the IC
score acts as a determinant of frailty, pre-frailty, or
robustness among adults, suggesting that the IC indices
were significantly associated with frailty. Thus,
further studies are needed to untangle
the intricate relationship between IC and frailty.
IC and physical resilience
Physical resilience is a new concept in the field of
geriatrics introduced by the National Institute on Aging
(NIA)[18]; it is defined as the ability to recover from
physically or psychologically traumatic events [19].
Consistent with IC, physical resilience also focuses on
positive health attributes, and it targets function instead of
diseases [20]. Chhetri [20] demonstrated that IC is a major
determinant of physical resilience via physiological
reserve. Therefore, we can assume that appropriate
actions that improve IC can also improve physical
resilience. However, more evidence and verification are
required on this topic. Table 2 presents the comparisons
among IC, frailty, and physical resilience.
Table 2. Comparisons of intrinsic capacity, frailty, and physical resilience.
Intrinsic capacity
Frailty
Physical resilience
Concept
A composite of all mental and
physical capacities.
A clinical syndrome that reflects a state of
increased vulnerability to multiple adverse
outcomes.
An ability to recover from physically
or psychologically traumatic events.
Characteristic
Positive attributes
Negative effects
Positive attributes
Context
Healthy aging
Opposite of successful aging
Successful aging
Trajectory
Throughout the lifespan
Later phase of life during the downhill
trajectory before disability occurs
Throughout the lifespan but a
response after external stressors
Indicators/
Measurement
Approaches
Mobility: balance, chair stand, gait
speed
Cognition: time orientation, three-
word recall
Vitality: grip strength, BMI
Psychological: low energy/fatigue,
depression
Sensory: vision, hearing
Biological factors: individual factors,
nutrition, medical conditions, physical
abilities
Psychological factors: cognition,
depression, emotional regulation,
motivation, stress appraisal
Social factors: community, social status,
social connections, family/friend support
Phenotypes: frailty, robustness,
fatigability
Age discrepancy: biological vs.
chronological age
Trajectory: after prior or
experimental stressors
Abbreviations: BMI, body mass index.
Intrinsic capacity screening tools
The 2019 Integrated Care for the Elderly (ICOPE)-
Guidance on person-centred assessment and pathways in
primary care introduced by WHO prepared a quick and
easy screening tool for IC. The WHO ICOPE screening
tool for IC was validated among Chinese adults [21],
which indicated that the proportion of decline in mobility,
cognition, vitality, hearing, vision, and psychology was
25.3%, 46.8%, 16.2%, 15.4%, 11.7%, and 12.0%,
respectively; furthermore, lower IC scores were
associated with increasing age, slow walking speed, poor
grip strength, and frailty [21]. This was the first study to
validate the ICOPE screening tool, suggesting that the tool
proposed by WHO can be effective in identifying people
exhibiting decline in IC. A 2-year study with 212 adults
aged ≥ 75 years validated this prediction for functional
decline and fall [10]. Similarly, the Multidomain
Alzheimer Preventive Trial, for older 759 adults (70–89
years old) with memory issues, reported that the
frequencies of cognitive decline, limited mobility,
malnutrition, visual impairment, hearing loss and
depressive symptoms were 52.2%, 20.2%, 6.6%, 18.1%,
56.2%, and 39%, respectively, using the ICOPE screening
tool [22]. Thus, we require additional validation studies
with larger sample sizes that explore pragmatic ways to
implement the ICOPE screening tool within various
contexts.
Intrinsic capacity biomarkers
IC reflects an individual's biological aging process, and its
evaluation may provide an innovative mechanism for
encouraging adults to adopt healthy lifestyles.

Zhou Y and Ma L Intrinsic Capacity in Older Adults.
Aging and Disease • Volume 13, Number 2, April 2022 357
Identification of potential biomarkers of IC decline may
provide simple and objective measurements of an
individual's biological age and health status and may
guide the development of strategies to minimize IC
decline, even delay progress toward disability [23].
However, research on the identification of IC biomarkers
is rare.
In a 5-year follow-up study, participants with
elevated homocysteine or C-reactive protein (CRP) levels
demonstrated a decrease in IC, and this decrease was more
significant among those exhibiting higher CRP levels
combined with hyperhomocysteinemia [24]. Moreover,
participants with deteriorating IC reported significantly
higher levels of plasma N-terminal pro-B-type Natriuretic
Peptide (NT-proBNP) than those with normal IC, and the
former were associated with abnormal mobility, hearing,
vision, and psychological function [25]. In addition,
increased serum tumor necrosis factor receptor 1
(TNFR1) levels were independently associated with
reduced IC, suggesting that chronic inflammation may be
the basis for decline in IC [26]. Based on this evidence,
some studies have proposed lifestyle interventions [27-
29] or supplements of omega-3 (ω-3) polyunsaturated
fatty acid (PUFA)— known for its anti-inflammatory
effects [30-34]—to mitigate the effects on cognitive
impairment [27-30,34] and other domains [31-33].
However, a 3-year study with French community-
dwelling participants, free of major neurocognitive
disorders, reported no improvement in IC after
undergoing ω-3 supplementation and multidomain
lifestyle intervention [31-33]. Furthermore, no existing
study has examined the effect on the decline in overall IC
[35]. Therefore, further investigation is required on the
biomarkers for IC decline and the development of
interventions to delay overall IC decline.
Integrated care for older people (ICOPE)
ICOPE Handbook-Guidance on person-centred
assessment and pathways in primary care
To address the adverse events due to the decline of IC,
WHO issued the ICOPE guidelines to manage IC decline
in 2017 (apps.who.int/iris/handle/10665/258981).
Thirteen recommendations were provided, including
reducing mobility loss, reducing malnutrition,
maintaining visual and hearing ability, preventing
cognitive decline and depression, management of age-
related conditions and falls, and provision of support to
caregivers. WHO also published the Handbook:
Guidance on person-centred assessment and pathways in
primary care in 2019 to help community-health and care
workers implement the ICOPE recommendations
(apps.who.int/iris/handle/10665/326843). It outlines a
healthcare pathway for managing critical health
conditions associated with IC decline. Personalized care
plans integrate strategies to reverse, delay, or prevent
further decline.
The worldwide implementation of the ICOPE guidelines
Researchers from various countries have made innovative
efforts to implement the ICOPE guidelines. The INStitute
for Prevention healthy agIng and medicine REjuvenative
(INSPIRE) initiative in France aimed to build a bio-
resource research platform for healthy aging by gathering
biological, clinical, and digital resources to identify
markers of aging, age-related diseases, and IC evolution
[36,37]. Scientists plan to conduct a large-scale clinical
survey of ICOPE using the ICOPE screening tool with
older adults every 4 months for 10 years. INSPIRE will
demonstrate the feasibility of screening and assessing IC
level in primary care services, as well as conduct remote
and long-term monitoring of this population’s IC [38]. In
collaboration with the INSPIRE program, Tavassoli [37]
examined IC in 962 older adults from Occitania, in
accordance with the 5-step ICOPE guidelines, and found
that most older adults demonstrated a decline in at least
one IC subdomain, with decline in vision, hearing, and
cognitive function being most commonly reported. The
ICOPE Monitor, a new technology derived from the
INSPIRE program, has been developed to assess
individuals’ IC [36]. The ICOPE application is another
tool developed by WHO [39]. These two applications are
readily available free of charge in the Apple or Android
Store [40]. China has proposed the “Medical and old-aged
care integration model” as a strategy and implemented it
as a policy in the recent years. China has incorporated the
novel concept of healthy aging, put forth by WHO, into
its existing care model and modified it to be people-
centered so that older adults can both achieve healthy
aging and enjoy their old life better [41]. Further research
on the implementation of abovementioned new platform
and technology within clinical settings and households is
required.
Conclusion
Active management of the aging population has become a
challenge. IC, the sum of all physical and mental
functions, is of great value in predicting subsequent care
dependence rather than the single or multiple disease
investigation approach. To this end, WHO issued the
ICOPE guidelines and handbook in 2017 and 2019,
respectively, to aid primary healthcare workers, who
provide care for older adults, using recommendations for
the management and care of decline in different IC
subdomains, as well as a care pathway for identifying and
screening IC in order to assess, manage, and provide

Zhou Y and Ma L Intrinsic Capacity in Older Adults.
Aging and Disease • Volume 13, Number 2, April 2022 358
appropriate support to caregivers. Future research should
focus on the development of interventions and integration
of novel concepts in clinical and routine care provision for
older adults.
Acknowledgments
This work was supported by National Key R&D Program
of China (2020YFC2008604), Beijing Natural Science
Foundation (7202059) and Beijing Municipal Health
Commission (Jing2019-2).
Competing and conflicts of interest statement
None of the authors have any conflicts or competing
interests in the article.
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