1.7 Sadana Etal Overview March2017

WHO WORKING GROUP ON METRICS AND RESEARCH STANDARDS FOR HEALTHY
AGEING, 27-31 MARCH, 2017 WHO GENEVA, SWITZERLAND
Measuring Healthy Ageing - Overview to Inform Working Group on Metrics

and Research Standards for Healthy Ageing
Background Paper
Authors: Ritu Sadana, Somnath Chatterji, Mike Martin, Alarcos Cieza,

Luis Miguel Gutierrez-Robledo and Ana Posarac*
World Health Organization
March 2017
Work in progress. Not for circulation or referencing beyond the Working

Group on Metrics and Research Standards for Healthy Ageing
* Drawing on the World Report on Ageing and Health, on inputs by all members of the Working
Group on Metrics, Monitoring and Research (1) held in Kobe, Japan, July 2016, and with
reference to all other Background Papers (2) prepared for the Working Group on Metrics and
Research Standards for Healthy Ageing, Geneva, 27-31 March 2017
WHO W ORKING GROUP ON METRICS AND RESEARCH STANDARDS FOR HEALTHY AGEING 27-31 March, 2017 WHO Geneva
(1) KOBE Working Group Members, July 2016:
-Jane Barratt, Secretary General, International Federation on Ageing
-Somnath Chatterji, Coordinator, SAGE multi-country study, WHO, Geneva
-Alarcos Cieza, Coordinator, Disability and Rehabilitation, WHO, Geneva
-Luis Miguel Gutierrez-Robledo, Director General, National Institute of Geriatrics, National

Institutes of Health, Mexico
-Haruhiko (Hal) Inada, Deputy Director for Global Health, International Affairs Division, Ministry of
Health, Labour, and Welfare, Japan
-Katsunori Kondo, Professor, Chiba University, Chiba, Japan
-Jinkook Lee, Director, Program on Global Aging, Health & Policy, University of Southern
California, USA; Senior Economist, RAND
-Matilde Leonardi, Head Neurology, Public Health, Disability Unit, Foundation IRCCS
Neurological Institute Besta, Milan, Italy
-Mike Martin, Director, Gerontology Competence Center, University of Zurich, Switzerland
-Jean-Pierre Michel, EU Geriatric Medicine Society; University of Geneva; French National

Academy of Medicine
-Ritu Sadana, Working group coordinator, Ageing and Life Course, WHO, Geneva
-Haidong Wang, Institute of Health Metrics and Evaluation, Seattle, USA
1 W ORK IN PROGRESS. NOT FOR CIRCULATION OR REFERENCING BEYOND THE W ORKING GROUP ON METRICS AND RESEARCH
STANDARDS FOR HEALTHY AGEING
(2) Background Papers prepared for the Working Group on Metrics and Research
Standards for Healthy Ageing, March 2017
Papers:
1.1 Intrinsic Capacity - how to operationalize it at a population level, criteria for measurement
and monitoring over time, and key gaps - Somnath Chatterji, Felix Caballero, Emese Verdes
1.2 Operationalising the concept of intrinsic capacity in clinical settings – Islene Araujo de
Carvalho (overall coordination), Finbarr C Martin, Matteo Cesari, Yuka Summi, Jotheeswaran A
Thiyagarajan, John Beard
1.3 Towards operationalizing functional ability- Alarcos Cieza, Kaloyan Kamenov, Alana Officer,
Megumi Rosenberg, and Anne Margriet Pot
1.4 Intrinsic Capacity and Functional Ability – how to operationalise it through the use of individual
data, criteria for measurement, data standards and use in modelling outcomes of interest, and
key gaps - Mike Martin, Daniel K. Mroczek, Linda Clare
1.5 Intrinsic capacity and Functional ability - how to operationalize it at the community level -
tools, testing, analysing and using information to support decisions and older adults in the
community – Rachel Albone and and Jonna Bertfelt
1.6 Healthy Ageing and Functioning: WHO International Classification of Functioning, Disability,
and Health-learning from selected EU research to inform the basis forIntrinsic Capacity and
Functional Abilityfor measurementand interpretation - Matilde Leonardi and Rui Quintas
1.7 Measuring Healthy Ageing: Overview to Inform WHO Working Group Meeting On Metrics
And Research Standards For Healthy Ageing
Shorter notes:
2.1 Monitoring population health, health behaviors, and environment: Lessons from the Health
and Retirement Study (HRS) family of studies - Jinkook Lee, Drystan Phillips, Jenny Wilkens
2.2 Updating evidence synthesis methods to be inclusive of older adult-specific issues, need for a
common non-disease-specific metric inclusive of older adults, and opportunities for including
recommendations from this working group as part of research and evidence synthesis - Tracey
Howe, Vivian Welch and Sue Marcus
2.3 Conceptual note on applying the International Classification of Functioning, Disability,and

Health on the documentation of functioning - Gerold Stucki and Jerome Bickenbach
Summary
This overview is to inform the WHO Working Group Meeting on Metrics and Research Standards
for Healthy Ageing, 27-31 March 2017, Geneva. It draws on the World Report on Ageing and
Health, the discussion paper prepared by all members of the Working Group on Metrics,
Monitoring and Research, held in Kobe, Japan, in July 2016, and it refers to all Background
Papers prepared for the March 2017 meeting. This overview is not intended as a summary of all
papers listed on the previous page.
It is intends to document some advances since the Kobe Working Group, connect various topics
to advance operationalizing concepts of healthy ageing, and highlight key issues that will be
addressed during the Geneva Meeting. Key issues include clarifying concepts; considering
important components of each concept that describe healthy ageing at the individual level and
within a person’s environment; how each component or domain can be measured in a valid and
reliable way, meeting various other criteria; whether these measures can be quantified, scaled
and used as metrics across individual, clinical, community and population levels; or within and
across countries, and eventually, over time. Ultimately, the metrics should inform descriptions,
decisions, and accountability, useful to different stakeholders, including older adults themselves.
This will be an important step towards the mandate WHO has to develop recommendations and
standards to measure, report and compare information on Healthy Ageing, and document a
baseline across countries by 2020.
The overview is structure along the three objectives of this Working Group Meeting:
Section 1 introduces WHO’s mandate in this area and the challenges, priorities, and
recommendations from the Kobe Working Group.
Section 2 provides an brief overview of current efforts to identify a concise set of indicators
of Healthy Ageing spanning concepts, link to existing classifications, multi-domain profiles for
each concept, ways to measure and score each domain, and indicators for use at individual,
clinical, community or population levels. The starting point is what is found in the World Report
on Ageing and Health, 2015 on the concepts of intrinsic capacity and functional ability and initial
measures of intrinsic capacity. This section refers to all of the background papers prepared for
the Geneva Working Group. It does not repeat recommendations from each background paper.
Section 3 as a place holder, lists some opportunities to disseminate, test, and refine the
indicators by 2020. This section will be elaborated through participants’ contributions and the
development of objectives and proposals for an inter-related set of surveys and other
collaborative initiatives.
Section 4 is also a placeholder for further areas of research to build up standards to measure
Healthy Ageing. This could inform the aims of an International Consortium on Healthy Ageing
Metrics.
A few annexes are included. The first is an excerpt from the WHO Global Strategy and Action
Plan on Ageing and Health, broad areas of concensus on what to do to advance strategic
objective 5 on metrics, monitoring and research. Other annexes provide additional details on
criteria, domains and measures, available to operationalize intrinsic capacity and functional
ability, supplementing materials found in the other Background Papers.
1 Introduction
1.1 Setting the scene: mandate, challenges, priorities, recommendations and

mechanisms
Mandate. The World Health Organization (WHO) published its first World Report on Ageing and
Health in September 2015, and all Member States endorsed its first Global Strategy and Action
Plan on Ageing and Health in May 2016. This solidified Member States’ commitment and
identified specific areas for collaborative actions across Member States, WHO and other UN
secretariats, and Non-State Actors (see Box 1).
Box 1. Member State Commitment
The WHO report and strategy promote healthy ageing as a person-centered concept, based on life course
and functional perspectives, that can be applied to all people in all settings. Rather than a focus on
morbidity or disease, Healthy Ageing is defined as “the process of developing and maintaining the
functional ability that enables well-being in older age, with functional ability determined by the intrinsic
capacity of the individual, the environments they inhabit and the interaction between them.” Healthy ageing
is inclusive of people with multiple morbidities and those who need medical care and longer term medical
and social support.
In May 2016, WHO Member States endorsed this perspective on healthy ageing at the World Health
Assembly, including a shared vision that “all people can live long and healthy lives” and agreed on two
goals for policy coherence and collective action during 2016-2020, in order to maximize functional ability of
populations:
1. Five years of evidence-based action to maximize functional ability that reaches every person.
2. By 2020, establish evidence and partnerships necessary to support a Decade of Healthy Ageing from
2020 to 2030.
With support from the Government of Japan, WHO held a meeting on Ageing and Health, 5-6
July 2016, in Kobe City, Japan. The Kobe meeting discussed proposed actions and timelines to
implement key recommendations from the Report and Strategy. The Kobe meeting refined
recommendations for overall implementation of the WHO strategy and action plan during 2016-
2020. It also highlighted priorities to advance the global health agenda during the Japanese
Presidency of the G-7.
One of the six working groups focused on Metrics, Monitoring and Research, and was tasked to
identify top level priorities for action and pathways to implement Strategic Objective 5, covering
the following sub-objectives (see Annex I):
• Strategic objective 5.1 - Agree on ways to measure, analyze, describe and monitor Healthy Ageing
• Strategic objective 5.2 - Strengthen research capacities and incentives for innovation
• Strategic objective 5.3 - Research and synthesize evidence on Healthy Ageing
Moreover, work in the area of metrics, monitoring and research is cross cutting, and is
expected to underpin the concepts, standards, models, and incentives to strengthen capacities,
establish evidence on what can be done, inform policies and programs, and enable accountability
within and across countries. Thus, work in this area will also inform developments across all other
strategic themes and objectives including:
• Strategic Objective 1 - Commitment to action, in particular sub-objective1.2 -Strengthen national

capacities to formulate evidence-based policies; and,
• Support metrics, monitoring, innovation, evidence generation, synthesis and sharing, across
Strategic Objectives 2 (age friendly environments), 3 (health systems) and 4 (long term care).
Challenges and Priorities. The Kobe Meeting proposed specific sub-goals for metrics,
monitoring and research for the overall strategy and action plan’s implementation (see Box 2).
Box 2. Proposed sub-goals for Metrics, Monitoring and Research
1. Set standards and metrics for healthy ageing enabling description, decisions, analysis
and accountability
2. Ensure monitoring of healthy ageing within and across countries over time, including its
determinants, outcomes and consequences
3. Identify what policies and actions work to improve healthy ageing through new research,
evidence synthesis and innovation
4. Build capacities and mechanisms to link, share and translate data, information and
knowledge across countries, sectors, levels, disciplines, professions, organizations and
associations
For the first sub-goal, participants also identified the following challenges:
- No international norms or standards for healthy ageing health outcomes; mostly disease
specific metrics focusing on morbidity and disease
- Geriatrics and health status measurement field use different concepts and terms
- No identification of key process or outcome indicators and appropriate metrics for targets
(such as “4 antenatal care visits”, a vaccination schedule for older adults, or components
of an integrated health and social care package)
- No clear understanding of the fit between person and environment, and interaction
- Existing metrics that have revolutionized population health, including summary measures,
have non-standard data collection and analysis methods, or those that are changing
constantly
- The frequency and approach to data collection largely draws on last century’s techniques
And the following priorities:
- One of the first priorities is in getting wide agreement among all stakeholders on the
outcomes of interest and the measurement framework. While this has been explicitly spelt
out in the International Classification of Functioning, Disability and Health (ICF) and more
recently in the WHO World Report on Ageing and Health, there is a challenge to ensure
diverse stakeholders understand, exchange ideas, and agree to a common way of
measuring these outcomes of interest.
- Consensus should be reached on common terminology and on which metrics, biological
or other markers, data collection measures and reporting approaches are most
appropriate. Improvements will draw on a range of disciplines and fields, and should meet
clear criteria. This includes rigorous analysis of the concept and operational approach to
intrinsic capacity.
- A major challenge for the measurement of functional ability, is simply the absence of
standardized tools, or even a standardized approach, for collecting the right information in
a feasible, practical and affordable manner.
- There is a need to develop appropriate data collection tools. There are at least two
possible approaches we could take. The first would be to develop a standardized semi-
structured interview for clinical purposes. A clinician could feasibly collect functional ability
information through a combination of standard intrinsic capacity clinical assessment tools
and a standardized, semi-structure interview in which the person would be prompted to
describe what he or she actually does in their everyday life, taking full account of all
environmental factors that affect performance.
- Additional work will need to be done to demonstrate the scalability of the metrics from
those in residential care to clinical populations to community dwelling older adults. This
will mean dialogue with clinicians and care providers along with those carrying out
population surveys to develop the final metrics in a nested design.
- Concerning healthy life expectancy, the approach to adjust for less than perfect health,
should be reconsidered from a healthy ageing perspective. Is unhealthy life equated to
years lived with disability, or something else?
- There will need to be additional demonstration of the utility of these measures, the
feasibility of using them and their robustness within and across populations and over time.
This will require secondary analyses of existing data sources and piloting of measures in a
range of settings.
- Agreements will need to be reached over estimation methods that can be easily applied,
both where data is missing, and for making projections including alternative scenarios to
support decision making.
- Member states will need to engage in regular data collection exercises anew or adapt
existing population surveys to incorporate these measures in a standardized manner to
ensure international comparability.
- As evidence builds, accountability frameworks and mechanisms will be needed to monitor
progress. These should incorporate the values enshrined in this strategy, spanning global
targets, universal periodic reviews of human rights, health system performance
evaluations, and commitments to age-friendly cities and communities, among others
- New analytical approaches are also needed to obtain more robust and comprehensive
economic assessments of the impact of poor health on older people and the benefits of
population-wide and clinical interventions
Recommendations - what to do. Based on these challenges and priorities for the first sub-
goal, the Kobe Meeting agreed on the following areas for immediate action:
1. Review existing metrics and measures of heath, and identify which ones can meet the
conceptual, theoretical and psychometric test properties for healthy ageing outcomes of interest,
and be considered meaningful by older adults.
2. Quantify changes in health (in individual or in populations) following interventions (individual

or public health). This is clearly the raison d’etre of health systems – keeping populations at the
highest level of health attainable.
3. Quantify how individuals function in their real world such that assessments can be made
as to what interventions are likely to be most effective in keeping older adults engaged in things
that matter to them for as long as possible. These could be interventions targeting the person or
those aimed at changing the environment. This is key to understanding instrumental gains that
can result from a combination of improving health and creating facilitating environments such
increased productivity.
4. Understand the relationships between capacity, functional ability and well-being such
that interventions can be appropriately designed and delivered and priorities set. This can also be
then used to monitor equitable outcomes and performance of the health (and other) systems.
5. Link tools and interpretation together. Ideally the metrics that are created for all the three
outcomes of interest should be such that they span, and are applicable in, the entire range of the
population from institutional to community settings. Ideally these metrics should be created in a
nested design such that measures from different settings can be transposed to each other. The
inclusion, for example, a short set of items that can be used in long term care homes to quantify
levels in capacity, a comprehensive set in clinical assessments of capacity that can be
incorporated into patient health records and a parsimonious set in population surveys, that have
overlaps and are anchored on the same scale would allow for quantifying the full range of
population health and when incorporated into a health information system can be used to track
population health over time.
Mechanisms - how to do this. To ensure results and set up effective partnerships needed to
prepare for a proposed Decade for Healthy Ageing, the following mechanisms were proposed:
International Consortium of Healthy Ageing Metrics - a collaboration and commitment

to test and evaluate indictors across the life course - including indicators of healthy ageing
-- that will require data collection standards & tools, technologies to support data
exchange & other linkages. This will be discussed during the Geneva meeting.
World Survey on Healthy Ageing – in practice, an inter-related set of surveys (individual,

clinical, community and population levels) building on and linking existing surveys and
creating new opportunities, with the aim to have more than 100 countries included in a
baseline on healthy ageing by 2020. This will be discussed during the Geneva meeting.
Healthy Ageing Monitor - with a global reach, population monitoring and exchange for
individualized interventions, equity analysis, and responding to stakeholder questions,
drawing on big & small data, covering key areas, new analytics including estimations and
future scenarios.
Healthy Ageing Observatory Network – in communities in all WHO regions, connecting

to age-friendly communities & WHO collaborating centers, enabling training, responding
multi-sector questions, providing information to people, practitioners, decision & policy
makers.
Transition to Geneva meeting and Working Group. With support from the Velux Stiftung
(Swiss Foundation), this Geneva meeting and Working Group on Metrics and Research
Standards for Healthy Ageing, addresses the first sub-goal, with the following objectives (see
concept note):
- Identify a concise set of quantifiable indicators of Healthy Ageing, i.e. metrics and
measures assessing intrinsic capacity and functional ability, reflecting agreed upon
criteria.
- For indicators identified, outline a process of dissemination, testing, innovation and

refinement between 2017 - 2020.
- Drawing on the background papers and discussions, note important areas for further in-
depth work to build up standards on healthy ageing data, measures, and metrics.
2. Initial approaches to measure Healthy ageing: from concepts to metrics
What we need. To identify a concise set of quantifiable indicators of Healthy Ageing, ideally,
detailed information is needed on progress to:
- clarify concepts, definitions and terms related to Healthy Ageing
- consider important components of each concept that describe healthy ageing at the individual
level and within a person’s environment
- review how each component - or domain - can be measured in a valid and reliable way,
meeting various other criteria required for intended use
- assess different approaches how these measures can be quantified, scaled and used as
metrics to report on healthy ageing - using questions, tests or other assessment approaches from
existing data that are evaluated as fit for purpose to measure the domain - using methods that
can be replicated by others
- assess to what extent standardized approaches can serve to connect information from
individual, clinical, community and population levels, and support monitoring within and across
these settings
- evaluate to what extent proposed metrics and indicators could be used to describe healthy
ageing trajectories (over time, life stages and life course).
In addition, a concise set of indicators should demonstrate how the information adds value, for
example, provides additional information in relation to existing information on older adults, to
enable:
- better descriptions of healthy ageing - in relation to the concept;
- improve inputs to policies, priorities, programs and other decisions;
- enable better evaluations of the health impact of interventions, whether originating from health
or other sectors;
- increase autonomy of older adults, such as agency to make decisions, and information is used
to enable older persons to do and be what they values; and
- greater accountability on progress towards healthy ageing that in inclusive - whether at local or
global levels - to reduce age based discrimination, and increase health equity.
The following sections provide some insights on where we are.
2.1 Concepts and Definitions. The WHO World Report on Ageing and Health promotes healthy
ageing as person-centered, based on life course and functional perspectives (Box 3), that reflects
interaction between an individual and his or her environment. This interaction is applicable to
every person, everywhere, and over time, results in trajectories of both intrinsic capacity, and
functional ability, whether or not individuals have disease or multiple morbidities. A person’s
intrinsic capacity is viewed as a continuum, neither a relative or absolute threshold.
This is a shift from two previous, prevailing views: the first that older adults must “age
successfully” (and be disease and disability free) often characterized as whether older adults
remain economically active; or the second, that defines ageing through a restricted lens of
disease, disability or morbidity, often reflecting a threshold of chronological age, for example over
age 60 or 65 years, with all persons after this age considered as “dependent” and some, with a
certain “ADL score” considered as “care dependent.”
In contrast, healthy ageing recognizes multiple determinants, the diversity of older adults’
experiences, the importance of health and social care systems, the built environment, and social
policies that should eliminate age-discrimination and ageism, and promote participation.
Box 3 Definitions - Concepts
Healthy Ageing is defined as the process of developing and maintaining the functional ability that enables
well-being in older age, with functional ability determined by the intrinsic capacity of the individual, the
environments they inhabit and the interaction between them.
Functional ability (FA) comprises the health related attributes that enable people to be and to do what
they have reason to value. It is determined by the intrinsic capacity of the individual (i.e. the combination of
all the individual’s physical and mental – including psychosocial – capacities).
Intrinsic capacity (IC) at any point in time is determined by many factors, including underlying
physiological and psychological changes, health-related behaviors and the presence or absence of
disease. These in turn are strongly influenced by the environments in which people have lived throughout
their lives.
Environments comprise all the factors in the extrinsic world (understood in the broadest sense and
including physical, social and policy environments) that form the context of an individual’s life.
Well-being is considered in the broadest sense and includes happiness, satisfaction and fulfilment.
These key concepts need to be clarified in terms of their boundaries and how to describe what
people experience in a comparable way. To improve standardization, these concepts should also
connect to existing international classifications, such as the WHO International Classification of
Functioning, Disability and Health (ICF). These are but some pre-conditions or criteria to
operationalize measurement of healthy ageing and propose WHO recommendations to do so in
a standardized way.
In background paper 1.6, Leondardi and Quintas, discuss to what extent the WHO
International Classification of Functioning, Disability and Health (ICF) can be used as a ruler
to which precise measurement of health, disability/ability and function can be taken, at individual
and population levels. The authors notes that the ICF presents functioning as a continuum,
relevant to the lives of all people, to different degrees and at different times in their lives;
therefore, disability, or limitations in ability, is not a “category” that applies only to a minority of
people. They consider what foundation the ICF gives to operationalize IC and FA, including how
individuals interact with their unique environment. Moreover, they use data from two sets of
surveys to explore key issues, including measures of capacity or performance, and the utility of
combining information from diverse sources and levels, to develop indicators.
Figure 1: Healthy Ageing, from World Report on Ageing and Health, 2015
Towards a model for healthy ageing. The World Report on Ageing and Health, particularly
chapter 2 on Healthy Ageing, defines the concept as noted in Box 3, and outlines its process
(Figure 1). Taking a social determinants of health approach, a contributing paper to the Report
offers one possible model of healthy ageing (Sadana et al. 2016). It combines several theories
that help identify factors that contribute to levels and distribution of healthy ageing: (1) biomedical
causation (privileging genetic endowment, body functions and medical care); (2) social causation
(where social position determines levels of health and its distribution through intermediary
factors); and (3) life course perspectives (recognizing the importance of time and timing in
understanding causal links between exposures and outcomes within an individual’s life course,
across generations, and in population-level trends in health and survival). Together, these form
an eco-social or multi-level, multi-domain framework to highlight factors and plausible pathways to
healthy ageing.
Figure 2 lists contributing factors in four blocks: (1) the natural-socio-economic-political

environments, or overall context; (2) genetic inheritance and socioeconomic position; (3)
intermediary determinants, and (4) healthy ageing outcomes of interest, namely intrinsic
capacity and functional ability, further discussed in this section.
Developing a framework for action, to improve healthy ageing, will therefore require good
measures of the outcomes, intrinsic capacity and functional ability, knowledge of what can
make a difference in diverse settings, and ways to evaluate the impact over time.
Figure 2. A possible model for healthy ageing that considers inequalities and inequities
Source: Sadana et al., 2016
Importantly, the Geneva meeting will focus on indicators of the outcomes of interest (IC and FA),
not its determinants. Nevertheless, understanding pathways and what determinants can be
shaped, or where interventions can make a difference, are distinct and important tasks.
Outcomes of interest within a public health framework. A series of figures from the WHO
Report illustrate how some of these might be conceptualized for an individual’s life course and at
the population level, along with additional figures reflecting new analysis of intrinsic capacity and
functional ability at the population level, from 2015. Figure 3 (below, from Report) shows three
hypothetical trajectories of physical capacity (it could be reflecting all intrinsic capacities) for
individuals beginning from the same starting point in midlife. As noted in the Report, “individual
A can be considered as having the optimal trajectory, in which intrinsic capacity remains high until
the end of life. Individual B has a similar trajectory until a point when an event causes a sudden
fall in capacity, followed by some amount of recovery and then a gradual deterioration.
Individual C has a steady decline in function.
Each trajectory sees the person die at around the
same age, but the levels of physical capacity they
have enjoyed in the interim are very different.
From the original starting point in Figure 3, the
goal would be for each individual to experience
the same trajectory as individual A.”
Figure 3
The Report notes that “experience in monitoring

trajectories of intrinsic capacity suggests that it is
already possible to assess individuals and predict
their likely future trajectories given information on
behaviours, health characteristics, genes and
personal factors. Such predictive models are likely to be increasingly accurate and useful as more
data are collected. These models could provide the opportunity to intervene in specific ways to
help achieve this ideal goal.”
Figure 3 “also shows alternative trajectories for individuals B and C. For individual B, a more
positive trajectory might, for example, result from access to rehabilitation, and a negative
trajectory might result from a lack of access to care (perhaps through rationing in a poor
community or within a socially excluded subgroup of the population). For individual C, a more
positive trajectory might result from a change in a health-related behaviour or having access to
medication. Measuring functioning over time, understanding the plausible pathways that have led
to it, and evaluating the influence of events at different points in time can thus help identify the
interventions that have the most significant impacts during a person’s life.”
To support concepts, theories and standardization of terms and approaches, it will be useful to
clarify and agree to what extent "Body Functions & Structure" (in the ICF) overlaps with "intrinsic
capacity" and "Activity & Participation" (also in the ICF) overlaps with "functional ability.” In the
background note 2.3 by Stucki and Bickenbach, the authors outline the opportunities of using
the ICF as “a health information reference system for the psychometrically sound reporting of
data and a valid approach on how to document intrinsic capacity and functional ability” to link with
data collection approaches, outline four steps to do so, and illustrate the approach in the context
of spinal cord injury.
Figure 4 (next page, also from Report) illustrates conceptually that “when considering the
population as a whole, functional ability and intrinsic capacity can vary across the second half of
the life course. These general trajectories can be divided into three common periods: a period of
relatively high and stable capacity, a period of declining capacity, and a period of significant loss
of capacity. It is important to note that these periods are not defined by chronological age, are not
necessarily monotonic (that is, continually decreasing) and that trajectories will differ markedly
among individuals (and may be disrupted entirely by an unexpected event such as an accident).”
“Numerous entry points can be identified for actions to promote Healthy Ageing, but all will have
one goal: to foster functional ability. The focus of public-health strategies targeting people with
high and stable levels of intrinsic capacity should be on building and maintaining this for as
long as possible. Public-health interventions -- whether led by health services or the broader
environment --
targeting the
segment of the
population with
declining capacities
need a different
emphasis.”
Figure 4
“For example,
during this stage,
diseases may have
become
established, and the
emphasis of health
systems will
generally shift from
prevention or cure
to minimizing the
impacts of these conditions on a person’s overall capacity. Furthermore, the role of the
environment in enabling functional ability will broaden with declining capacity, with strategies
that help people overcome these decrements becoming increasingly important. Whereas the
focus of a public-health response to the needs of older people who have, or are at high risk of,
significant losses in capacity will be the provision of long-term care and removing barriers in
the environment to compensate for loss of capacity.”
2.2 Measures and metrics of intrinsic capacity. Using SAGE wave 1 data, the remaining
figures in this section reflect an initial attempt to measure intrinsic capacity (physical and mental)
at the population level, based on nationally representative cross sectional data from the WHO
Study on Global Ageing and Adult Health (SAGE), wave 1 (2007-2010), in all six participating
countries (China, Ghana, India, Mexico, Russia, South Africa). As an example of how this
trajectory might be constructed, drawing on data from SAGE, the Report provides exploratory
analysis and illustrates data that “have combined a range of measures, including physical and
cognitive assessments and biometric measures, to develop a single vector that summarizes the
key domains of intrinsic capacity.” Domains included to represent intrinsic capacity are listed in
Box 4, and the full set of questions from SAGE listed in Annex II as reported in Beard et al., 2015
in The LANCET. The score is developed through latent variable analysis, re-scaled 0-100, with a
higher score being better intrinsic capacity.
Box 4: Domains included within intrinsic capacity, WHO World Report on Ageing and Health, 2015
Domains (self-reported): Domains (measured tests):
Mobility Mental (cognitive):
Self-care - Verbal recall
Pain and discomfort - Digit span - digits forward and digits backward
Cognition - Verbal fluency
Interpersonal activities
Physical:
Sleep and energy
- Timed walk - normal and rapid walk (with aids)
Affect
- Grip strength - each hand
Vision (with aids)
In addition to work at WHO, other efforts exist to draw on domains and indicators to estimate an
underlying latent variable, representing health more generally, or capacity more specifically, for
older adults. See Meijer et al., Poterba et al., and Juerges, whose efforts and comparisons focus
on physical capacity, largely drawing on data representing adults 50 years of age and over,
primarily from high income countries.
Figure 5
Figure 5 (right from Report) shows

that for the six countries
participating in SAGE, cross
sectional data shows there was a
gradual decline in average intrinsic
capacity by age, combined for both
sexes. “For the population as a
whole, the average decline is
gradual: there is no age when most
people suddenly have less [intrinsic]
capacity and become “old.” Just as
importantly, the observed patterns of
capacity are different for each
country.”
Measuring these more complex assessments of capacity over time, using longitudinal data, will
allows us to ask why is this the case.
Although average level of intrinsic capacity by age provides information useful for national or
global monitoring, the distribution (composite score of intrinsic capacity) in each country provides
additional information on differences within and across countries. For example, Figure 6 (next
page, from Sadana and Posarac in preparation) uses country specific SAGE data for adults 50
years and over, age-standardized to the World Population Standard. It illustrates different
distributions of intrinsic capacity in each country (a histogram of intrinsic capacity score
developed for the World Report, that spans 0-100, combined for both sexes.) From a population
perspective, efforts to push the distribution to the right would improve average levels (closer to
100), and approaches to narrow the range of the distribution, would reflect a reduction in
inequalities.
Figure 6
Distribution of
Intrinsic
Capacity Score
6 countries
2007-2010
Moreover, these differences in

the distribution of intrinsic
capacity within and across
countries and at different ages,
is not random. For example,
Figure 7 (left, from Report)
uses aggregated SAGE data to
explore the correlation between
the vector of intrinsic capacity
and socioeconomic status,
reported by household wealth
quintiles. “This illustrates that
intrinsic capacity in someone
with a low socioeconomic
position peaks at a far lower
level than it does in someone
with a higher socioeconomic
position”, and this differential is
maintained across all age
groups.
Figure 7
Figure 8
Using SAGE wave 1 data focusing on

50+ age group, from India and Russia,
Figure 8 (left, from Sadana and
Posarac, in preparation) illustrates that
the level of intrinsic capacity also differs
by sex and wealth quintile, in a
systematic pattern - also referred to a
“social gradient”. In both countries,
women have lower intrinsic capacity
than men, in the same socioeconomic
quintile.
More detailed analyses, based on data from longitudinal cohort studies, can provide insight on
potential inequalities and inequities, and establish cause and effect. Evaluation of interventions,
or major policy changes, could also provide information on what course of action may improve
capacity that benefit those in most need, and across the level across the social gradient.
Background paper 1.1 by Chatterji, Caballero and Verdes, extends the initial analysis found in
the World Report on Ageing and Health, and considers how to monitor intrinsic capacity from
population representative surveys. It uses SAGE and ELSA data and offer illustrative results.
The paper first describes the construction of a metric of intrinsic capacity, applied to 6 waves of
English Longitudinal Study of Ageing (ELSA) data. In the additional material (overview of
domains), the authors provide a list of domains and items for measuring capacity, from illustrative
longitudinal studies of ageing (ELSA, HRS, SAGE). This paper and overview of domains will be
important to consider in Working Groups.
Several tests to assess the degree to which criteria are met, for example, on unidimensionality,
parsimony, goodness of fit, or overcoming missing data. Four potential Baysesian multilevel IRT
model are considered, refined and evaluated based on many criteria and tests. Individual
scores across the 6 waves are also calculated by different sub-groups, such as those with eight
chronic conditions separately, groups of chronic conditions, and socio-economic backgrounds,
and results support overall hypothesis, e.g., the results compare and discuss capacity scores with
known conditions, prior events (such as falls), and socio-economic backgrounds.
Similar to the results in the Report, analysis of SAGE data (single wave) show that “controlling for
age, sex, education, household wealth and place of residence, health conditions and multi-
morbidity have a significant impact on capacity.” The authors assert that they have demonstrated
the approach identifies different trajectories of ageing and the characteristics of people who follow
these different trajectories. Further understanding of how these updated analysis differ from what
was calculated for the Report in 2015, and the benefits of “machine learning techniques … to
assess concurrent validity and identify factors and their patterns that may be related to the metric
of health“ will be useful.
They make specific recommendations to advance metrics and monitoring of intrinsic capacity,
including, that with agreement on standardized domains, it is possible to be flexible, and include
“individual items to measure capacity in these domains” and that these “can be defined
specifically for use in community dwelling adults, clinical populations and those in long term care
or living in institutions.” And in agreement with Background paper 1.4 by Martin, Mroczek and
Clare, they conclude that “wearable devices to collect data on different domains of functioning in
a very fine grained manner to enable better prediction than is possible with population surveys or
even clinical assessments.”
Interestingly, comparing 3 methods (valuation, psychometric, GBD estimations) to quantify health

of older adults, they find that for 5 of the 6 SAGE countries, “combining of different domains within
the valuation or psychometric space produce near identical results for HLE [healthy life
expectancies] but show substantial differences compared to those derived from the top-down
GBD approach.” Although beyond the scope of the Geneva meeting, developing healthy ageing
measures that can also be used efficiently and accurately within summary measures, is needed.
Background paper 1.2 by Araujo de Carvalho et al., provides another approach to

operationalize intrinsic capacity, with the aim to identify individuals who may benefit from
interventions. It is important to note that the authors also draw on ELSA to identify risk factors for
care dependency in a generally healthy community dwelling population, and supplement analysis
from the Toulouse Frailty Clinic, France to identify factors associated with prevalent care
dependency, and then further test the results using data from the Hertfordshire Ageing Study
(UK). The paper makes a sincere attempt to bring together the approaches used by traditional
clinical evaluation (often single disease), geriatric assessments (a mix of determinants and
outcomes, often used to classify older adults as care dependent or not), with the new approach to
monitor intrinsic capacity to support monitoring a unifying outcome within integrated, person
centered care that reflects a multi-dimensional approach.
The authors combine empirical and theory driven approaches to identify domains of intrinsic
capacity (in light of many biomarkers and measured tests), and then calculate domain scores and
overall composite score. They compare the composite and domain scores and its predictive
value, to typical geriatric and clinical assessment tools (ADLs, IADLs, Fraility index, etc.), and to
the number of chronic diseases (not severity) that an individual may have. These comparisons
attempt to help interpret the new intrinsic capacity (based on biomarkers) scores and document
the added value that information on intrinsic capacity and trajectories of capacity may provide to
clinicians. They report that the “biomarker score was a significant predictor of subsequent
outcomes after accounting for multimorbidity” or even chronologic age. The authors note that
although biomarkers used in this analysis were chosen opportunistically, as they were present in
the ELSA data, the results are promising.
Concerning the analysis of Frailty, using data from France and the UK, the authors conclude that
“the IC score (derived in the same manner as used in the Toulouse Frailty Clinic analysis) was
strongly predictive of subsequent declines in the Strawbridge physical domain. This suggests that
an operational definition of intrinsic capacity using measures of cognition, gait speed, grip
strength, BMI, urinary incontinence and depressive symptoms may be useful in identifying older
people with, or at high risk of, care dependence.”
Drawing on Stuck et al., 1999, the authors propose five different domains as of primary interest
for framing the biological background of intrinsic capacity and conduct further analysis:
1)cognition; 2) mood; 3) sensory; 4) vitality/energy balance, and 5) locomotion. They note that
the domains of “cognition, mood/depressive symptoms, mobility and muscle strength, sensory,
and energy utilization seem the most robust candidates corroborated (at this time) by a larger
body of evidence.” Based on the criteria and analyses conducted, a relevant conclusion is that
“assessment of intrinsic capacity appears to have clinically relevant predictive value beyond that
provided by traditional disease based assessments.” Supplementary information outlines
recommended domains and metrics for IC within clinical settings.
Interpretation and use. Intrinsic capacity is to be understood as a feature of the individual. It is

what a person can (or cannot) do in terms of carrying out tasks and actions given the person’s
underlying health condition (understood as disease, disorder, injury or changes in physiological
status as in the case of ageing) as well as body functions such as the sensation of pain and
others that can be assessed through biomarkers. Given the background papers, it can be
described in different domains of functioning, emotional, cognitive and physical, and summarized
into a single measure of a person’s overall health status. It is assessed, as far as possible,
divested of environmental influences (although, environmental factors can determine and shape
intrinsic capacity, see Figure 2) .
Given this, how can levels of intrinsic capacity be interpreted? To what extent will gender,
employment conditions, place of residence (in one’s own home, another family member’s home,
or within an institution) or a person’s subjective well-being, matter? Moreover, norms and
standards may differ depending on the intended use, whether for national accountability,
evaluation of a specific intervention or program, or clinical decision making, among others (as the
various approaches in the Background Papers document).
Figure 9
One attempt at interpretation at an aggregate level, given other characteristics (Sadana and
Posarac forthcoming.) uses SAGE wave 1 pooled data focusing on 50+ age group for all six
countries, both sexes. Figure 9 (above) illustrates the distribution of intrinsic capacity scores
(over 35,000 people from the 6 countries) and points out the average intrinsic score for different
profiles. For example, across countries, people who report that they do not have paid
employment due to a health problem or disability, have a lower intrinsic capacity score (44.9),
compared to women who do not have paid employment yet who do provide care to a family
member (56.1). Reflecting employment conditions, men who work in the private sector, on
average have an intrinsic capacity score of 8 points higher than men who work in the informal
sector (59.8 vs. 52.4). Other criteria to consider when evaluating interventions and impact on IC
(or FA for that matter), is what effect size is expected and meaningful.
Background paper 1.5 by Albone and Bertfelt, offers insight on how information on intrinsic
capacity (and functional ability) can be collected through 6 domains assessing capacity and
functioning, within diverse communities, with the primary purpose to inform HelpAge
programming and influence policymakers and service providers at various levels. Besides the
approach to develop and pilot a tool in communities in eight countries - including 3 rounds in
Colombia, Bolivia and Tanzania, 2 in Ethiopia, Mozambique, Zimbabwe, Uganda and India
covering almost 3000 people - the background paper offers insights on how information collected
influences efforts of older people themselves within their communities to support decisions.
The results from this paper are very relevant for selecting domains and essential measures, and
how information is used locally, rather than comparisons across communities in different
countries (due to different sampling strategies and sub-populations). The paper documents use of
information to support older adults, for example, in the Thar Desert region, India, within GRAVIS
(Gramin Vikas Vigyan Samiti) an important social development program to empower desert
communities. The paper includes several recommendations, including that tools to measure
healthy ageing should be designed to serve a number of purposes, and that support should
be provided to older people to use data collected. The paper includes an annex with domains
and measures used.
2.3 Revisiting concept of functional ability. Functional ability is what happens when a
person health plays out in their real life environment. This is reflected in how an individual actually
carries out tasks and actions in the individual’s physical, built, social and attitudinal environment
given all the facilitators and barriers that may be in place. This can also be described in a multiple
domains, and again, could also be summarized into a single overall measure of ability - a
reflection of the interaction between the person and the environment).
For measurement purposes WHO could propose to use the construct of performance found in the
International Classification of Functioning, Disability and Health (ICF) to operationalize functional
ability. As discussed in section 2.1, the construct of capacity describes the intrinsic health state of
an individual, and performance describes what a person does (or does not) do in their real life
environment. The ICF notion of capacity could be considered identical to that of intrinsic capacity
used in the World Report on Ageing and Health, and thus, for measurement purposes could be
treated in the same manner. Performance, as a measureable construct, captures the interaction
of a person’s capacity (intrinsic capacity) within the actual environment. For the purposes of
developing a metric of functional ability, therefore, functional ability could be seen as equivalent to
the ICF construct of performance. Yet this needs to be carefully considered. See Background
papers 1.6 by Leondardi and Quintas, and 2.3 by Stucki and Bickenbach.
An important point is that within the WHO World Health Survey (around 2002) and the SAGE
survey, capacity has been measured with available personal aids. See Annex II with questions to
assess vision, mobility assessment (timed walk), etc. This means that the measure of intrinsic
capacity, includes some elements of a person’s environment. The Geneva meeting could
reconsider this point.
2.4 Measures and Metrics of Functional Ability. Setting ICF aside, functional ability
information is important for health services and social care, at the clinical, community and
population levels. Functional ability information gives us a more complete picture of how health
and other interventions affect the individual’s overall lived experience, within their actual context,
and over time. Underlying the notion of functional ability is the powerful intuition that intrinsic
capacity matters to people principally because of its impact on their lives. This overall experience
– how health plays out in a person’s life – is what the construct of functional ability denotes.
Moreover, by comparing the increment of improvement in intrinsic capacity with the overall
improvement in functional ability, it is possible to evaluate the impact of individual health
improvements and positive environmental change on the person’s life, and this is the impact that
supports healthy ageing, e.g. the positive difference between functional ability and intrinsic
capacity.
Yet some caution, as in the literature, there are descriptions of instruments that purport to collect
information about ‘functioning’ or even ‘functional ability’ – for example the Modified Barthel
Index1 for mental health and the Functional Independence Measure for ADLs. Although
standardly used, these tools do not collect data about functional ability. Instead they collect data
about intrinsic capacity and in some cases, separately collect information about environmental
factors. This confusion on concepts, domains, and actual measures, is not new. (See Annex IV
providing an overview of studies on ageing and instruments to measure health, all using different
domains and measures).
WHO has developed a person-centered approach to consider functional ability, within the Model
Disability Survey (MDS). Using this tool, cognitive testing and pilot tests with relatively small
samples and large representative samples in Sri Lanka and Chile, appear to work well and
reliably capture the constructs of interest – both intrinsic capacity or functional ability. Figure 10,
panel a, shows the levels of functional ability in representative, cross-sectional samples of Chile
(N=12265) and Sri Lanka (N=3000). Figure 10, panel a, shows that functional ability drops
steeper in Sri Lanka than in Chile after the age of 64. This drop is also noted in internal capacity
(Figure 10, panel b), however, the differences between Chile and Sri Lanka are smaller. (Cieza
et al., prepared for the Kobe Meeting in 2016). Further analyses document the effect of the
environment in contributing to those differences, and also considers what are the potential
interventions needed to prevent decreases, or further decreases in functional ability.
Figure 10 panel a: Composite functional Figure 10 panel b: Composite intrinsic

ability score for Chile and Sri Lanka capacity score for Chile and Sri Lanka
Discussions during 2016 noted that it will be important to have additional details, including the
domains and assessment approaches, and model assumptions, to operationalize intrinsic
capacity and functional ability within the MDS, and ways to interpret and compare both outcome
measures within the same country and across countries. This will be critical in order to
understand the extent of unique information provided by both measures, that is meaningful for
description as well as relevant for policy and programme inputs or evaluation.
The WHO World Report on Ageing and Health (see chapter 6) identifies five domains -- or
abilities -- as essential to build and maintain functional ability. This implies measurement at the
individual level and could be used to operationalize functional ability in five domains:
- Meeting basic needs

- Learn, grow and make decisions
- Be mobile
- Build and maintain relationships
- Contribute
Background paper 1. 4 by Cieza and colleagues, advances work in this area with greater
details, and uses the MDS to explore 1) how intrinsic capacity, environments and functional
ability can be measured and 2) what is the statistical relationship among the three.
Towards the first aim, the paper uses two approaches to measure environments. Approach A
comprised three steps: identification of specifications, categorization, and mapping. The five
domains of functional ability (FA) from the World Report were the starting point, with the domains
identified corresponding well with the Age-friendly City/Communities domains and core indicators
outlined in WHO guidance (see panel A). Whereas approach B, followed the assessment
procedure of the MDS, made up of four groups of environmental factors. Approach B also covers
some of the major Age-friendly City domains/core indicators, though not to the same extent that
the factors identified through Approach A do (e.g. urban development, social protection, etc.)
indicating gaps in information on environmental factors (See panel B).
Approach “A” Domains Approach “B” Domains

- Transport; - General environment;
- Social protection and assistance; - Social support;
- Health and LTC; - Attitudes;
- Housing; - Assistive products.
- Urban development;
- Information and communication;
- Education and Labour;
- Attitudes of service providers, family, friends etc.
- Personal characteristics.
For the second aim, to investigate the relationship among intrinsic capacity, environments and
functional ability, the authors use two multivariate approaches, Structural Equation Model (SEM)
and Linear Regression. Using SEM, capacity is a mediating factor between the environment and
the functional ability domains. Using Linear Regression, a composite score for intrinsic capacity
and the environmental factors’ scores and performance’s score as described in Approach B were
used - performance was the dependent variable and capacity and the environmental factors were
the independent variables. The analyses documents the mediating effect of capacity, and all
environmental factors have a significant effect mediated by capacity on performance. The
background paper identifies limitations and areas for further work. It is important to note that the
MDS and SAGE surveys approach to measuring intrinsic capacity is not the same.
The paper provides details on the domains and measures proposed, and the construction of the
metrics.
Background paper 1.4 by Martin, Mroczek and Clare considers that with the advancement of
technology to collect and process large amounts of individual data -- from brains over traits to
environments and real life activity tracking -- for the first time ever is it feasible to combine the
acquisition and analysis of high density data on real life activity outcomes, with individual data on
multiple psychological and biological functions, skills, impairments, and contexts for even millions
of older individuals. This provides a new way to capture individual real life activity patterns in an
efficient way, at the population scale. The paper discusses several approaches to advance this
agenda, spanning technologies, intervention studies, analysis, and visualizations, including:
1- Activity measurement devices - can be used to collect physical (doing) and cognitive (being)
activities. The authors point out the need for rapid prototyping guidelines for healthy aging activity
data and devices, programs, algorithms, open access, etc. Table 1 in the paper, provides an
example of acquiring mobility activity data.
2. Semantic Activity Analytics – a new approach, and candidate for an important research
initiative / innovation challenge to address core areas of functional abilities such as physical and
mobility activities, social activities, intellectual activities, and emotion-regulation activities.
Innovative ways to analyze data via activity measurement devices can open up new insights. For
example, the authors provide the following example:
“This group is calculating the randomness or entropy of the sequence of activities over the
five days. They find that 80-year-olds with severe pain have a highly predictable, regular
non-random pattern of physical activities, whereas non-pain individuals have a much more
random pattern of physical activities. This is because individuals with severe pain would
try to be physically active despite the pain, but also purposefully rest at specific times,
whereas if unlimited by pain, individuals can respond to the randomly occurring activity
opportunities in their environment.”
3. Core Functional Ability Profiles - Table 2 in the paper, outlines for one domain, mobility
profiles that assess the environment, functional ability, and aspects of intrinsic capacity, and the
specific instruments to make the assessment.
4. Integrative Analytics - approaches to quickly model individual healthy ageing dynamics on the
population scale. This could be a forward looking group to consider models, criteria and decision
making.
5. Intervention evaluation designs - exploiting the strengths of population-level systematic

individualization of healthy aging interventions, supporting being and doing in each individual
what “they have reason to value.”
Other WHO efforts use the community level as the unit of analysis, and focus on indicators of
age-friendly communities and environments. Figure 11 (below) lists the domains and outcomes
proposed to assess the age-friendliness of cities (accessible physical environment and inclusive
social environment), that take into account differences within a community (WHO, 2015).
Figure 11
Several national efforts exist to assess limitations in capacity and functional ability. A major effort
include data drawn from the Mexican Health and Nutrition Examination Survey, 2012 and
Mexican Census, 2010 and its midterm census, 2015. Table 1 illustrates distribution of
functional limitations and number of disabilities, due to a range of impairments and limitations
(defined in table’s footnotes) and counts of disabilities, by age groups, both sexes.
Table 1. Percentage distribution of limitations associated with disability by age groups.

Mexico, ENSANUT 2012
Distribution of Functional Limitations

Number of disabilities
Functional Ability Older adults
Joint ≠
Instrumental Activities with some
Cognition* Eyesightⱡ Hearing§ # Activities of Daily Living ∞
problems of Daily Living 1 2 or more disability
& &
Age groups Limitation Dependent Limitation Dependent
60-69 11.9 12.9 4.9 1.1 16.0 2.2 13.8 1.0 19.7 16.3 36.0
70-79 20.9 16.9 11.8 3.6 25.7 5.3 26.5 2.2 19.8 32.9 52.6
80+ 33.5 26.5 31.4 8.2 32.9 14.7 38.1 11.0 19.5 57.9 77.3
Total 18.2 16.3 11.3 2.8 21.7 5.1 21.7 3.0 19.7 28.1 47.8
Frequency~ 1943.6 1741.0 1208.2 268.2 2327.5 549.2 2314.1 318.4 2105.3 36.7 5112.0
* Includes cognitive impairment, dementia, difficulty to communicate or memory problems

ⱡ Includes those who even using glasses have difficulties seeign well or are blind
§ Includes those who even using a hearing aid have difficulties heaing or are deaf
# Includes motor functions and joint problems
& Dependent: refers to subjects who due to their limitations need the help of others to perform daily activities
≠ AcƟviƟes of Daily Living includes: walking, dressing, geƫng in and out of bed and bathing/shower
∞ Instrumental AcƟviƟes of Daily Living includes: preparing a hot meal, shopping, taking own medicine and managing own money
~ Frequency total in thousands
SOURCE: Gutiérrez Robledo, L.M., Téllez-Rojo, M.M. Manrique Espinoza, B., Acosta Castillo, I., López Ortega, M., Salinas
Rodríguez, A., Sosa Ortiz, A.L. 2012. Discapacidad y dependencia en adultos mayores mexicanos: un curso sano para una vejez
plena. Available at: http://ensanut.insp.mx/doctos/analiticos/DiscapacidAdultMayor.pdf
It is relevant to point out that based on the WHO proposed terms and conceptual definitions (Box
3), the data labelled “distribution of functional limitations” would be considered as limitations in
intrinsic capacity, along with assessment based on “activities of daily living” under the column
“Functional ability”; whereas, the data labelled as “instrumental activities of daily living” might be
considered “intrinsic capacity” or “functional ability” depending on the details of the questions and
consideration of the actual context of the individual.
Another example is reporting data on individuals, pooled or aggregated by municipalities, to

support identification and response. Using the WHO tool, Urban Heart, and drawing on the
JAGES (Japan Gerontological Evaluation Study), Figure 12 (below) shows the prevalence of
older people with a low frequency for social participation (less than 4 times in a month), among
31 Japanese municipalities, and that this varied between 56.4 - 84.8%. This data can also serve
either a baseline, or to support effectiveness evaluations of individual and community based
interventions (see Hikichi et al. 2015).
Figure 12
Source: http://sdh.umin.jp/heart/Single_map.html; http://www.who.int/kobe_centre/ageing/j_ages_heart/en/
Efforts by regional entities, such as European Commission and Non-governmental organizations,

are also important to consider. For example, the Global AgeWatch Index, 2015, attempts to
summarize the conditions of older people in different countries, with assessments focusing on
four domains: income security, health status, capability and enabling environment. It will be
important to understand and clarify to what extent intrinsic capacity or functional ability is similar
to “capability” and whether functional ability is the result of interacting with an “enabling
environment” and vice versa, in the discussion towards internationally accepted terms and
standards.
2.4 Need for clarity and standardization. The diverse use of concepts and approaches pre-
dates the new concepts and definitions proposed by WHO in the World Report. This does not in
any way diminish the importance of data collected and analysed using diverse terms. On the
contrary, the experiences from different countries and research groups, should be reviewed and
understood, as part of the discussion and debate towards recommending international norms and
standards.
Yet the lack of standardized approaches to measure healthy ageing outcomes has several
limiting consequences. The Background note 2.2 by Howe, Welch and Marcus, points out
some of these particularly in the research to evidence to policy cycle. As older adults are already
underrepresented in clinical research: this can result in treatment plans for older adults based on
data from studies involving primarily younger, participants with different capacities and health
conditions.
Relevant to the Geneva meeting, the challenge to select appropriate outcomes for studies
involving older people is more complex than that for younger age groups. The authors note that
studies involving older people should not just include outcomes such as disease state or life
expectancy but should also cover all aspects of the WHO’s International Classification of
Functioning. They also state that “in the absence of a core standardised set of outcome
measures for functional ability, researchers are faced with the dilemma of whether to choose
objective measures that are single tasks (e.g. chair rises, box stepping, walking), dual tasks (e.g.
walking and talking), combinations of functional activities e.g. Timed Up-and-Go test (Podsiadlo
1991) or composite measures e.g. Short Physical Performance Battery (Guralnik et al. 1994).”
“This dilemma frequently results in the selection by researchers to use multiple measures of
function in the same study or use of composite or surrogate measures (Howe and Skelton 2011).
From their perspective of coordinating Cochrane Global Ageing, the authors point out “a number
of vital future needs to enable comparison and pooling of the results of trials of interventions
designed to improve the health of older people: these include developing and adherence to
consensus guidelines, including a set of core outcome measures for functional ability, intrinsic
capacity and well-being including benefits and harms.
Section III. Opportunities (initial list)
Currently several alternative approaches have been used to measure capacity in population
surveys of older adults. Typically, these surveys collect data on Activities of Daily Living (ADLs),
Instrumental Activities of Daily Living (ADLs), self-reported difficulties in carrying out some actions
and tasks including cognitive tasks, difficulties in sensory functioning, self-reported emotional
functioning and some measured tests of capacity such as walking speed, cognitive tests and tests
of strength. The exact nature of the items included in each survey vary from survey to survey
though there is an increasing trend towards harmonising these in international longitudinal studies
on ageing.
HRS: For example, Annex III, lists health measures available from the Health and Retirement
Study (HRS) family of datasets. Background Paper 2.1 by Lee, Phillips and Wilkens provides
an overview of the data available, particularly indicators of healthy aging from HRS nationally
representative studies.
While these studies report the prevalence of limitations in ADLs and IADLs (or in individual
domains of functioning such as cognitive functioning or in specific areas such as gait speed or
balance) and trends in these over time, there has been limited work done to create a composite
measure from all these different items. The measure of limitations in ADLs and IADLs suffers
from a floor effect since not many individuals in the general population have these limitations and
even when they do they appear prominently only after age 65 and hence fail to capture those with
mild to moderate levels of decline in health. All these surveys include an overall question on self-
reported health but is seldom used alone to quantify population levels of health despite its ability
to predict fairly well some outcomes such as mortality.
Other national and regional efforts: that are looking at ways to operationalize healthy ageing.
For example, the Mexican Instituto Nacional de Geriatría has a working group to operationalize a
definition of healthy/successful aging, that can be used within the region and in diverse
populations. A collaboration with the International Mobility in Aging research group (IMIAS,
Quebec, Canada), is gathering qualitative evidence on lay perspectives for an operational
definition (of intrinsic capacity) and associated determinants (context), that are mainly modifiable
by society groups or stakeholders. Both the IMIAS and Mexican groups, have large databases
with follow-up that will enable quantitative testing of a definition reflecting qualitative studies from
Montreal and eventually in Mexican older adults.
o Up-to-date components of the definition are: disability, mobility disability, pain, self-
rated health, cognitive status, depression, productive social engagement,
satisfaction with social relationships, life satisfaction, locus of control/resilience.
(see comparison with Box 3).
o Determinants are further divided in non-modifiable (age and sex) and modifiable
(age-friendly environments, financial status, health services, social services,
education). (see comparison with a model for healthy ageing, Figures 1 and 2).
o The Mexican Instituto Nacional de Geriatría also convened a meeting of experts in
order to add new insights to this operational definition. Experts agreed upon the
need to add chronic diseases to the definition of domains, and particularly control
and absence of complications of resulting from chronic diseases. These actions
will lead in the short term to an operational definition to be tested in other countries
in order to have a global definition. It will be important to understand to what

extent person-centered and disease-specific approaches can be combined to
represent intrinsic capacity.
Efforts at the clinical level, including acute and long-term care, several comprehensive
geriatric assessments include items on functioning that overlap considerably with items that are
being used in surveys such as ADLs, IADLs, measured tests of balance, strength, cognition and
sensory function. There are a mix of research and commercial efforts with large data bases that
could support secondary analysis of existing data, as well as testing and refinement of WHO
initial recommendations.
Assessments of institutionalised populations often focus on an expanded list of ADLs and
measures that indicate the level of independence of persons. While again there is an overlap with
some survey and clinical assessments, they include items that capture the more severe end of
declines in capacity given the nature of the target population.
Working with other UN agencies and International Partners: At the recent 48th Session of
the UN Statistical Commission (March 2017), a side event on “Exploring the case for a City Group
on Ageing and Age-disaggregated Data” was formally supported by Denmark, Namibia, Japan.
Uganda and the Philippines. This group would work with National statistics offices to take
advantage of the forthcoming 2020 Census round to develop methodologies to better use
available data and statistics on older persons. It would also offer a clear avenue to consult on
SDG indicators to be added by 2020. A meeting this August in Titchfield, England, will consider
the approach, with WHO involvement.
Section IV. Further areas of research (place holder)
Annex I. Action Plan adopted by WHO Member States, extract on Strategic Objective 5,
Global Strategy and Action Plan on Ageing and Health 2016-2020
Strategic objective 5: Improving measurement, monitoring and research on Healthy

Ageing
Member States Secretariat (WHO and National and international

other bodies of the partners
United Nations
system)
5.1 Agree on Ensure national vital Convene and liaise Empower older people to
ways to registration and statistics across specialized participate and share best
measure, are disaggregated by age agencies of the United practices to experience
analyse, and sex throughout the Nations system and Healthy Ageing
describe and life course, and by other development
monitor important social and partners to foster a
Healthy economic characteristics consensus on metrics
Ageing and methods Provide qualitative and
Encourage monitoring, quantitative information to
surveillance and reporting Review existing data track progress towards
in line with agreed global sources, methods and Healthy Ageing and
metrics indicators and advocate for accountability
promote the sharing by all stakeholders
Encourage data-sharing of data and methods
and linkages across for global, regional,
sectors (such as health, national and
social welfare, labour, community-based Work with partners to
education, environment, monitoring and improve measuring,
transportation) surveillance of Healthy monitoring and reporting
Ageing systems, including enabling
Conduct periodic, age- and gender-sensitive
population-based analysis
monitoring of older Develop norms,
people, including those in metrics and new
long-term care analytical approaches
institutions to describe and Support policy
monitor Healthy development by reporting
Link the monitoring of Ageing, including on trends and emerging
Healthy Ageing metrics to levels and issues
the evaluation of national distributions, and
sectoral, intersectoral ways to combine and
and multisectoral policies report information on
and programmes, and link intrinsic capacity,
to other international functional ability and
efforts (such as the length of life
Sustainable Development
Develop resources,

United Nations
system)
Goals) including standardized

survey modules, data
and biomarker
collection instruments
and analysis programs
Prepare a global
situation report on
Healthy Ageing by
2020 reflecting
metrics, data
availability and
distribution within and
across countries, and
new evidence on what
can be done to
support Healthy
Ageing
5.2 Incorporate older people Advocate for Encourage older people to

Strengthen in all stages of research strengthened research participate in research and
research and innovation, including funding, capacities, identify research questions
capacities and their needs and methods and and the need for
incentives for preferences collaboration to foster innovation, including
innovation Healthy Ageing and developing study designs
Ensure older people are combat ageism,
meaningfully and including through a
statistically represented network of WHO
in population-based collaborating centres
Support training and
studies with sufficient on ageing and health,
capacity development
power to analyse data, pilot countries from all
efforts, including networks
and included in clinical WHO regions, and civil
of academics, researchers
trials society organizations
and trainers that
incorporate low- and
Support international middle-income countries
cooperation to foster
Strengthen research technological Ensure that older people
funding, capacities and innovation, including participate in clinical trials
collaborations to address by facilitating the and evaluation of new
Healthy Ageing transfer of expertise technologies that take
and technologies such account of the different

United Nations
system)
Create incentives and as assistive devices, physiology and needs of

support innovation that information and older men and women
meet the needs of communication
different age groups, technology and Support small- and large-
including older people, scientific data, and the scale innovations
through multisectoral and exchange of good
intersectoral actions, practices
including technological
and social innovations for Encourage the
home- and community- participation of older
based services for older Develop ethical people in the development,
populations frameworks to identify design and evaluation of
health and social services, technologies or
services that respond products
to the needs and
Support voluntary and rights of older people
mutually agreed and to prioritize what
technology transfer that is included within Promote innovation to
includes services, national benefit accelerate the
innovations, knowledge packages and development of new and
and best practices universal health improved assistive
coverage technologies and
Guide research and interventions to support
innovation to ensure Contribute to older people
public and private sector development and
developers and providers sharing of new
(including health and care methods and
services, devices, and approaches to:
drugs) meet the specific
needs of all older people,
- deliver integrated
including those with
person-centred health
limited resources
care and long-term
care services
Build national capacity to Collaborate to shape the
synthesize research, as global research and
inputs to knowledge - shape clinical innovation agenda on
translation and evidence research to be more Healthy Ageing, and
based policies (link to SO relevant to older advocate and support
1) people
funding and capacity
strengthening
- finance health
services and long-term
care within universal

United Nations
system)
schemes
- meet older peoples’

needs and
expectations in
communities, cities
and rural areas that
facilitate ageing in
place, with regard to
issues such as health,
land use, housing,
transportation and
broadband
- establish the
prevalence and
prevention of elder
abuse
- quantify the
contributions of older
people and the
investments required
to provide services
they need
- combine multiple
disciplines and
qualitative and
quantitative data to
communicate older
peoples’ diverse needs
and expectations
Convene and work

with partners to
develop and
communicate a global
research agenda on
healthy ageing

United Nations
system)
5.3 Research Establish regular Organize and Collaborate and participate

and synthesize longitudinal population participate in in research design and
evidence on surveys, measuring health international forums implementation, including
Healthy status and related needs to raise awareness of evaluation of what works in
Ageing of older people and to research priorities for different settings
what extent needs are Healthy Ageing
being met
Contribute learning gained

Coordinate priority from associations and
Reflecting older peoples’ multicountry research organizations addressing
needs and expectations, and evaluation efforts, riskfactor-, disease- or
shape, fund and for example building condition-specific issues,
implement national on the WHO study on that are inclusive of older
research and innovation global ageing and people (including
priorities on Healthy adult health or dementia, elder abuse and
Ageing extending other self-help approaches)
existing efforts
Promote and support Develop and test

research to identify the Collaborate with innovative approaches to
determinants of Healthy stakeholders to strengthening institution-,
Ageing and to evaluate identify the range and community- and home-
interventions that can potentially common based care to implement
foster functional ability trajectories of intrinsic the most appropriate
capacity and interventions and increase
functional ability, and access to essential
their broader social, medicines for older people,
Promote and support economic and including pain relief
multisectoral and environmental medicines such as opioids
intersectoral determinants in
collaboration with diverse different populations
stakeholders to design and contexts
and evaluate actions to Support research and
foster functional ability dissemination of evidence
on the impact of health
Advocate for and services, long-term care
enable research to and environmental
Provide forums for the scale up interventions interventions on
exchange of experiences, and strengthen trajectories of healthy

United Nations
system)
good practices and national health ageing.

lessons learned systems, including
health workers,
informal caregivers
Promote research into and long-term care
innovations that (home-, community -
contribute to age- and institution- based)
friendly environments, towards meeting the
including at the needs of older people Engage in dialogue within
workplace communities and the
media, and use effective
Synthesize research and communication techniques
disseminate evidence on Review and share to convey messages about
Healthy Ageing that models of care that Healthy Ageing
addresses important have been shown to
policy questions and be effective in
older people’s supporting intrinsic
expectations capacity
Reflecting global evidence

on what works in diverse
contexts and basic Develop and identify
standards, encourage evidence-based
testing of approaches to approaches to
further develop systems intersectoral action to
of long-term care (home-, maximize functional
community- or ability, particularly in
institution- based) resource-poor settings
Document health
inequalities and
inequities, and their
impacts across the life
course on Healthy
Ageing, and report
how these can be
mitigated by health
and social
interventions and by
multisectoral and

United Nations
system)
intersectoral actions
Annex II: Domains and specific questions and assessment tests from SAGE WAVE 1
used to calculate intrinsic capacity in the WHO Report on Ageing and Health, 2015
Also see additional material 1.1 from Chatterji et al on Overview of Domains for IC.
MOBILITY
o q2002 Overall in the last 30 days, how much difficulty did you have with moving around?
o q2003 Overall in the last 30 days, how much difficulty did you have in vigorous activities
('vigorous activities' require hard physical effort and cause large increases in breathing or
heart rate)?
SELF-CARE
o q2004 Overall in the last 30 days, how much difficulty did you have with self-care, such as
bathing/washing or dressing yourself?
o q2005 Overall in the last 30 days, how much difficulty did you have in taking care of and
maintaining your general appearance (for example, grooming, looking neat and tidy)?
PAIN AND DISCOMFORT

o q2007 Overall in the last 30 days how much of bodily aches or pains did you have?
o q2008 Overall in the last 30 days how much bodily discomfort did you have?
COGNITION
o q2010 Overall in the last 30 days, how much difficulty did you have with concentrating or
o remembering things?
o q2011 Overall in the last 30 days, how much difficulty did you have in learning a new task
(for example, learning how to get to a new place, learning a new game, learning a new
recipe)?
INTERPERSONAL ACTIVITIES
o q2012 Overall in the last 30 days, how much difficulty did you have with personal
relationships or participation in the community
o q2013 Overall in the last 30 days, how much difficulty did you have in dealing with conflicts
and tensions with others?
SLEEP AND ENERGY

o q2016 Overall in the last 30 days, how much of a problem did you have with sleeping, such
as falling asleep,
o waking up frequently during the night or waking up too early in the morning?
o q2017 Overall in the last 30 days, how much of a problem did you have due to not feeling
rested and refreshed during the day (for example, feeling tired, not having energy)?
AFFECT
o q2018 Overall in the last 30 days, how much of a problem did you have with feeling sad, low
or depressed?
o q2019 Overall in the last 30 days, how much of a problem did you have with worry or
anxiety?
VISION: as when wearing glasses/contact lenses if used: more like functional ability
o q2023 In the last 30 days, how much difficulty did you have in seeing and recognising an
object or a person you know across the road (from a distance of about 20 meters)?
o q2024 In the last 30 days, how much difficulty did you have in seeing and recognising an
object at arm's length (for example, reading)?
VERBAL RECALL
We are now going to test your memory. I know these questions may be difficult to answer, but please try
to provide an answer. I am going to read you a list of words. Listen to them carefully and try to remember
as many of them as you can, not necessarily in order. I will ask you to repeat them again after some time.
List of words is as follows: Arm, Bed, Plane, Dog, Clock, Bike, Ear, Hammer, Chair, Cat – participants have 3
trials, where the interviewer reads the list again and asks which words can be recalled.
o q2525 Number of words recalled correctly in Trial 1.
DIGIT SPAN - DIGITS FORWARD and DIGITS BACKWARD

The interviewer gives 3 numbers in a particular order and a particular voice cadence (example letting their
pitch drop at the last digit in the series), and the respondent is to emulate them exactly. Each correct
answer moves to the next series for a total of 7 series, each with a higher number of components. The
respondent has two trials with different series for each test. For digits forward, the respondent emulates
the interviewer exactly, for digits backward, the respondent repeats the digits in a backward order. The
total score for both is recorded as the series number in the longest series repeated without error in Trial 1
or 2.
VERBAL FLUENCY
The respondent is asked to think of animals and name as many as they can. They are given one minute
and scored on the number of animals they manage to name correctly.
TIMED WALK: Normal and Rapid walk

Normal walk – Respondent is asked to walk 4 meters over a flat straight surface at a pace they would
normally use. They were also asked to use any aids they usually rely on when walking. The respondent is
then timed on the speed at 4 m (Again, IC or FA ? )
Rapid walk – Respondent walks the same distance at a rapid pace and their speed is recorded
GRIP STRENGTH
Two tests in left hand (in kg), separately recorded
Two tests in right hand (in kg), separately recorded
Annex III. List of Health Measures Available from the HRS family of datasets
Also see Background paper 2.1 by Lee, Philllips and Wilkens
Self-reported
Self-reported health: is an individual’s self-reported general health status using a scale ranging from poor
to excellent. This measure has been found to predict mortality and morbidity very well, but subject to
biases associated with self-report.
Self-reports of whether health limits work: indicates an impairment or health problem limiting the kind or
amount of paid work.
Activities of daily living (ADLs): refer to everyday activities, such as walking across a room, dressing,
eating, getting in and out of bed, using a toilet, and taking a shower/bath. Difficulties associated with ADLs
are considered as key factor of independent living. Wallace and Herzog (1995) proposed a summary
measure by counting the number of activities with difficulties and some variations of summary measure are
widely used. Similarly, Wallace and Herzog construct summary measures for instrumental activities of daily
living, mobility, and large muscle index.
Instrumental activities of daily living (IADLs): include activities requiring greater cognitive demands, such as
using a map, using a telephone, taking medications, managing money, shopping for grocery, and preparing
a hot meal.
Combination of self-reported, professional assessment and/or measured tests and biomarkers
Mobility index: is developed to indicate individual’s mobility, based on their self-reported ability to walk 100
yards, walking across a room, climbing one flight of stairs, and climbing several flights of stairs without rest.
Large muscle index: indicates individual’s functional ability based on self-reports of being able to sit for 2
hours, getting up from a chair, stooping, kneeling, or crouching, and pushing or pulling large objects
activities.
Fine motor index: indicates individual’s ability to use fine motor based on self-reports of the ability to pick up
a coin, eating, and dressing activities.
Depressive symptoms: refer to individual’s self-reports on their feelings and mood over the week. Various
versions of the Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff, 1977) have been
adopted with different response scales and number of items.
Doctor-diagnosed health problems: indicate whether or not a doctor has told an individual respondent
he/she has had a specific condition. Most population aging surveys ask about the following health
problems: hypertension, diabetes, cancer, chronic lung disease, angina, a heart attack, congestive heart
failure or other heart trouble, stroke, emotional, nervous or psychiatric problems, arthritis, Alzheimer’s
disease, dementia, or other serious memory impairment.
Biomarkers and measured tests
Biomarkers: in most developing countries, doctor-diagnosis does not fully reflect population health due to
limited access to health care services. Recognizing this limitation, increasingly number of the HRS family
of surveys have incorporated biomarker measurement. Biomarkers of healthy ageing would be particularly
useful as an outcome measure for particularly developing countries in framing policies aimed at healthy life
span. Available biomarker measures vary across surveys (for details check g2aging.org, Survey at a
Glance Page). Many HRS surveys collect blood specimen, but assay data require calibration across type
of blood specimen (venous versus dried) and laboratories. This work is currently under progress.
Blood pressure and pulse rate: are taken at least twice (many surveys three times) and based on blood
pressure readings, whether an individual is at risk of high blood pressure.
Lung function: tests are administered, using spirometry or peak flow test, and based on these tests,
whether an individual is at risk of obstructive and restrictive lung capacity.
Vision: tests are administered by few HRS family of studies, and based on this test, individual’s visual
acuity is assessed.
Anthropometric measurement: height, weight, waist and hip circumference are most frequently measured.
Waist and hip circumference are used to determine abdominal obesity.
Body mass index: is weight in kilograms divided by the square of height in meters. Many population aging
surveys measure anthropometry, but some surveys depend on self-reports.
Grip strength: has been shown to have predictive validity where low values are associated with falls,
disability, quality of life, prolonged length of stay in hospital, and increased mortality. Grip strength of
dominant (of both) hands are measured twice, using dynamometers.
Balance tests: have been found to be useful predictors of health outcomes, such as risk of falls, disability,
institutionalization, and mortality. Semi-tandem, side-by-side, and full-tandem test are administered to test
balance.
Timed walk: walking speed is predictive of overall health, level of disability, future use of health care and
mortality among older people. Walking speed in normal pace with supportive device is often measured,
with some studies measuring walking speed at faster pace.
Cognitive status: is accessed by administering a number of cognitive tests. Most HRS family of surveys
include the cognitive tests to access orientation, memory, verbal retrieval and proceeding speed, numeracy,
and executive function. A summary cognition index is created based on the correct answers to all
administered cognitive test, as well as cognition score for each individual test is used to measure particular
domain of cognition.
Orientation: questions ask individual respondents to name dates, places, and objects drawn from the Mini
Mental State Exam, MMSE (Folstein, Folstein, & McHugh, 1975).
Memory: is measured by asking individual respondents to listen to a list of 10 words and to repeat as many
words as can be remembered. After about 5 minutes, respondent is asked again to recall as many words
from the initial list for delayed recall. This word recall test is originated from CERAD word recall.
Verbal retrieval and processing speed: are assessed by asking respondents to name as many animals as
possible in a minute (Goodglass & Kaplan, 1983).
Processing speed: is also measured by asking respondents to count backward as fast as possible for 30
seconds (Agrigoroaei & Lachman, 2011) and to subtract 7 from 100 and continue subtract 7 from each
subsequent number for a total of five trials (Ofstedal, Fisher & Herzog, 2005)
Numeracy: is assessed by asking respondents to solve a simple math question of multiplication and
division (Ofstedal, Fisher & Herzog, 2005)
Executive function: is assessed by asking respondents to follow a simple instruction of fold paper (Ofstedal,
Fisher & Herzog, 2005).
Construction praxis: tests the ability of a respondent to copy geometric forms of varying difficulty (Morris et
al.., 1989).
Some cross-sectional and longitudinal studies focusing on populations above 50 are:
- 10/66: 10/66 Dementia Research Group population cohort study

- ALSA: Australian Longitudinal Study of Ageing
- CLESA: Comparison of Longitudinal European Studies on Ageing

- LASA: Longitudinal Aging Study Amsterdam
- Health and Retirement Study (HRS) is a biennial, US nationally representative panel survey of
Americans over the age of 50 and their spouses, conducted since 1992.
- Mexican Health and Aging Study (MHAS) is a longitudinal, nationally representative survey of
Mexicans at age 50 and older and their spouses. The first two waves of data were collected in
2001 and 2003, and these respondents were followed again in 2012-13 with a refresher cohort.
- English Longitudinal Study of Ageing (ELSA) is a biennial, nationally representative panel survey of
persons age 50 and older in England, conducted since 2002. The original ELSA sample was drawn
from the 1998/1999/2001 Health Survey for England.
- Survey of Health, Ageing and Retirement in Europe (SHARE) is a longitudinal, multi-country survey
of persons age 50 and older and their spouses, currently in 19 European countries and Israel,
conducted since 2004.
- Korean Longitudinal Study on Aging (KLoSA) is a biennial, nationally representative panel survey
of community-residing older adults at age 45 and older in the Republic of Korea (South Korea),
conducted since 2006.
- Indonesian Family Life Survey (IFLS) is a nationally representative, panel survey of Indonesians of
all ages conducted in 1993, 1997, 2000, 2007, and 2013. The IFLS survey has become
comparable to the HRS since 2007.
- Japanese Study of Aging and Retirement (JSTAR) is a biennial panel survey of Japanese age 50
and older, conducted since 2007. The baseline sample was randomly drawn from five
municipalities, and since then five additional municipalities were added to the sample.
- Study on global AGEing and adult health (SAGE) is a longitudinal, multi-country survey of persons
age 50 and older, currently in six countries, conducted in 2007 – 2010 and 2013 – 2014: China,
Ghana, India, Mexico, Russian Federation and South Africa. The original SAGE sample was
drawn from the 2002 – 2004 World Health Survey.
- The Irish Longitudinal Study on Aging (TILDA) is a biennial, nationally representative panel survey
of person age 50 and older and their spouses in Ireland, conducted since 2010. This study also
conducts clinical health assessments every other waves.
- Costa Rican Longevity and Healthy Aging Study (CRELES) is a biennial, nationally representative
panel survey of Costa Ricans with two age cohorts. The first cohort is persons age 60 and older,
interviewed in 2005, 2007, and 2009, and the second cohort includes persons at ages of 55-64 and
their spouses, conducted in 2010 and 2012. Only the second cohort of CRELES is comparable to
HRS.
- China Health and Retirement Study (CHARLS) is a biennial, nationally representative panel survey
of Chinese aged 45 and older and their spouses, conducted since 2011. The CHARLS sample was
drawn from 150 counties in 28 provinces.
- Longitudinal Aging Study in India (LASI) is a biennial, nationally representative panel survey of
Indians aged 45 and older and their spouses. A pilot study was conducted in four states in
2010. The national baseline wave is planned for 2014. The baseline sample represents not only
the nation as a whole, but also all states.
Annex IV. Domains and Measures - Need for Standardized Approach
Previous efforts within WHO to measure health through multi-dimensional profiles have been guided by the
following key criteria:
• valid in terms of intuitive, clinical, and epidemiological concepts of health,

• linked to the conceptual framework of the ICF,
• amenable to self-report, observation, or direct measurement,
• comprehensive enough to capture the most important aspects of health states that people value,
• cross-population comparable
However, as the tables show on the following pages, “standardized” tools to measure health operationalize
health through different domains and measures. For a new WHO standardized approach to measuring
healthy ageing, agreement on a standardized set of domains would be a major step forward.
Table 1 compiles different domains used to describe ageing in 10 recently published studies, from 2002 -
2017 (Michel and Sadana, forthcoming, JAMDA). The authors note: “The approach to measurement
should reflect the concept, agreement on how to operationalize it, and then identify specific measures,
tests, questions, assessments, etc., that yields valid and reliable results, fit for purpose, for each life stage,
and across the life course. … It is not surprising that current efforts to assess health outcomes for older
adults draw on four categories: items reflecting the WHO definition of health and well-being; symptom
oriented or considered indicative of illness or morbidity; on fulfilling or performing functions, activities or
roles (such as activities of daily living - ADLs or IADLs); and those concerned with adaptation or coping with
conditions or limitations. Many standardized instruments exit, whether for the general population, specific
diseases or condition, or specific population sub-groups, including older adults. Most combine information
on biomarkers, measured tests, capacity to perform tasks, and subjective evaluation. Data collected
through these instruments are often presented as multiple dimensional profiles. An overview of 10 recent
approaches to assess older adults, (see Table above) illustrates each uses different domains, with different
elements listed within each domain. Not shown is that each includes different items, recall periods,
response scales, and proposed cut-offs to categorize individuals. None listed have produced sufficient
assessments that would document trajectories across the entire life course, or link clinical assessments
with community or population based monitoring.”
Table 2 does the same from standardized instruments to measure health from 1970 - 2000 (Sadana 2002).
Although each instrument covers multiple domains of health, few use the same labels for domains or
scales, or cover the same content in terms of the questions that make up each domain. The range of
domains included across instruments reflect different empirical approaches to define and assess health .
The content covered within each domain varies: some instruments use the same domain label but include
different questions (not shown). The breadth or depth of content covered within each domain also varies:
some include items focusing on a specific function, such as vision, while others encompass items
assessing a range of complex functions and activities, such as understanding and interacting. Others may
create a domain to focus on one aspect, such as performance of activities related to the home, while others
may incorporate performance of activities or roles at work, home or recreation in a single domain. The
same applies to other domains, such as eating or self-care, with the latter usually incorporating questions
addressing eating, bathing, dressing and other similar items. The main point is that no one standard set of
domains and questions to describe health is used to facilitate comparison of multi-dimensional profiles of
health status across populations.
Furthermore, different instruments claim to assess different aspects of health or even well-being: functional
status, health status, well-being, quality of life, or health-related quality of life. Yet operational differences
among these measures are not always based on a clear conceptual basis.
For this reason, the actual content of an instrument should not be judged solely by an instrument’s title. It is
important to note that the instruments developed by WHO thus far, have some domains in common and
others not, and use different sets of questions and recall periods for those domains that are similar
(whether instruments WHO-QOL, WHO-DAS, earlier on, or within major survey initiatives, World Health
Survey, SAGE, or Model Disability Survey).
Table 1 FROM J-P Michel and R Sadana, forthcoming 2017 in JAMDA

Compilation of the different domains used to describe ageing in 10 recently published studies
Phelan Young Sabia Tyrovolas Bousquet Cosco Lara Assmann Tampubolon Jaspers
2002 2009 2012 2014 2015 2015 2015 2016 2016 2017
Education X
Diet X
Physiological/Physical X
Health X X X X
Nl function/markers X X X
CVx X X
Lung/respiratory X X X
Metabolic X X
Endocrine X X
Musculo-Skeletal X X X
Inflammation X X X X
No Chronic Disease X
(CVx, COPD, Cancer, X
diabetes)
No pain
Mental Health
Intact cognition XX X X X X X X
Good mood/emotion X X X X X X X
Preserved autonomy X X
Daily Functioning X
No ADL inability X X X X X
Functional independence X X
Walking speed X X X
FEV1 X X
Personal perception
Feeling X X
Resource X
Engagement X X X X
Goals X
Satisfaction X
Quality of Life X X X
Social life X
Activities participation X X X X
Support X
Relations X
Spirituality X X
Wealth X
Environment
Healthy X
Controlled
Table 2. FROM R SADANA Development of Standardized Health State Descriptions, 2002

Domains of 13 Generic Health Status Instruments
Health Domains QWB McM SIP QLI NHP FSQ CP Duke SF- HUI- WHO EQ WHO
(multi-dimensional ‘70 ‘76 ‘76 ‘81 ‘81 ‘86 ‘87 ‘90 36 III QOL 6D DAS
profile) ‘92 ‘95 ‘96 ‘99 II
‘99
Overall Well-Being
General Health
Change in Health
Physical Health
Activities/roles
Work
Home
Recreation
Ambulation
Eating
Energy/vitality
Dexterity
Hearing
Mobility/fitness
Pain/discomfort
Self Care
Sleep/Rest
Speech
Vision
Social Health
Activities/roles
Communication
Interaction
Support
Mental Health
Activities/roles
Alertness
Anxiety/Depression
Cognition
Emotional status
Outlook
Self-esteem

Understand/Interact
Handicap/Participation
Environmental Context
QWB:Quality of Well-Being Scale, McM: McMaster Health Index, SIP: Sickness Impact Profile, QLI: Quality of Life Index, NHP:
Nottingham Health Profile, FSQ: Functional Status Questionnaire, CP: COOP Charts for Primary Care Practice, Duke: Duke Health
Profile; SF-36:Short-Form 36 Health Survey; HUI-III: Health Utilities Index Mark III; EQ6D: EuroQol 6 Domain Quality of Life Scale (5D
excludes cognition), WHOQOL: WHO Quality of Life Bref Field Trial Version, WHODAS II: WHO Disability Assessment Schedule.

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WHO WORKING GROUP ON METRICS AND RESEARCH STANDARDS FOR HEALTHY

AGEING, 27-31 MARCH, 2017 WHO GENEVA, SWITZERLAND

Measuring Healthy Ageing - Overview to Inform Working Group on Metrics

Authors: Ritu Sadana, Somnath Chatterji, Mike Martin, Alarcos Cieza,

World Health Organization

Work in progress. Not for circulation or referencing beyond the Working

(1) KOBE Working Group Members, July 2016:

-Jane Barratt, Secretary General, International Federation on Ageing

-Somnath Chatterji, Coordinator, SAGE multi-country study, WHO, Geneva

-Alarcos Cieza, Coordinator, Disability and Rehabilitation, WHO, Geneva

-Luis Miguel Gutierrez-Robledo, Director General, National Institute of Geriatrics, National

-Katsunori Kondo, Professor, Chiba University, Chiba, Japan

-Mike Martin, Director, Gerontology Competence Center, University of Zurich, Switzerland

-Jean-Pierre Michel, EU Geriatric Medicine Society; University of Geneva; French National

-Haidong Wang, Institute of Health Metrics and Evaluation, Seattle, USA

2.3 Conceptual note on applying the International Classification of Functioning, Disability,and

1.1 Setting the scene: mandate, challenges, priorities, recommendations and

• Strategic Objective 1 - Commitment to action, in particular sub-objective1.2 -Strengthen national

Box 2. Proposed sub-goals for Metrics, Monitoring and Research

And the following priorities:

2. Quantify changes in health (in individual or in populations) following interventions (individual

International Consortium of Healthy Ageing Metrics - a collaboration and commitment

World Survey on Healthy Ageing – in practice, an inter-related set of surveys (individual,

Healthy Ageing Observatory Network – in communities in all WHO regions, connecting

- For indicators identified, outline a process of dissemination, testing, innovation and

2. Initial approaches to measure Healthy ageing: from concepts to metrics

- clarify concepts, definitions and terms related to Healthy Ageing

- better descriptions of healthy ageing - in relation to the concept;

- improve inputs to policies, priorities, programs and other decisions;

The following sections provide some insights on where we are.

Figure 2 lists contributing factors in four blocks: (1) the natural-socio-economic-political

Source: Sadana et al., 2016

The Report notes that “experience in monitoring

Figure 5 (right from Report) shows

Moreover, these differences in

Using SAGE wave 1 data focusing on

Interestingly, comparing 3 methods (valuation, psychometric, GBD estimations) to quantify health

Background paper 1.2 by Araujo de Carvalho et al., provides another approach to

Interpretation and use. Intrinsic capacity is to be understood as a feature of the individual. It is

Figure 10 panel a: Composite functional Figure 10 panel b: Composite intrinsic

- Meeting basic needs

Approach “A” Domains Approach “B” Domains

5. Intervention evaluation designs - exploiting the strengths of population-level systematic

Table 1. Percentage distribution of limitations associated with disability by age groups.

Distribution of Functional Limitations

* Includes cognitive impairment, dementia, difficulty to communicate or memory problems

Another example is reporting data on individuals, pooled or aggregated by municipalities, to

Source: http://sdh.umin.jp/heart/Single_map.html; http://www.who.int/kobe_centre/ageing/j_ages_heart/en/

Efforts by regional entities, such as European Commission and Non-governmental organizations,

Section III. Opportunities (initial list)

in order to have a global definition. It will be important to understand to what

Section IV. Further areas of research (place holder)

Strategic objective 5: Improving measurement, monitoring and research on Healthy

Member States Secretariat (WHO and National and international

Member States Secretariat (WHO and National and international

Goals) including standardized

5.2 Incorporate older people Advocate for Encourage older people to

Member States Secretariat (WHO and National and international

Create incentives and as assistive devices, physiology and needs of

Member States Secretariat (WHO and National and international

- meet older peoples’

Convene and work

Member States Secretariat (WHO and National and international

5.3 Research Establish regular Organize and Collaborate and participate