EVIDENCE FOR THE DOMAINS SUPPORTING

THE CONSTRUCT OF INTRINSIC CAPACITY

Matteo Cesari1,2,3,4, Islene Araujo de Carvalho5,

Jotheeswaran Amuthavalli Thiyagarajan5, Cyrus Cooper6, Finbarr C Martin7,

Jean-Yves Reginster8, Bruno Vellas1,2, John R Beard5

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1
Gérontopôle, Centre Hospitalier Universitaire de Toulouse, Toulouse, France

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2
Université de Toulouse III Paul Sabatier, Toulouse, France

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3
Geriatric Unit, Fondazione Ca’ Granda - Ospedale Maggiore Policlinico, Milano, Italy
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Department of Medical Sciences and Community Health, Università di Milano, Milano, Italy
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Department of Ageing and Life Course, World Health Organization, Geneva, Switzerland
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6
Medical Research Council Lifecourse Epidemiology Unit, University of Southampton,

Southampton, United Kingdom

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Division of Health and Social Care Research, King’s College, London, United Kingdom
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Department of Public Health, Epidemiology and Health Economics, University of Liege, Liege,
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Belgium
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Address for correspondence: Matteo Cesari, MD, PhD. Geriatric Unit, Fondazione IRCCS Ca'

Granda - Ospedale Maggiore Policlinico; Via Pace 9, 20122 Milano (MI), Italy. Phone: +39 02

50320735; email: macesari@gmail.com

Running title: The clinical construct of intrinsic capacity

© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of
America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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 ABSTRACT

Healthy ageing can be defined as “the process of developing and maintaining the functional

ability that enables wellbeing in older age”. Functional ability (i.e., the health-related attributes that

enable people to be and to do what they have reason to value) is determined by intrinsic capacity

(i.e., the composite of all the physical and mental capacities of an individual), the environment (i.e.,

all the factors in the extrinsic world that form the context of an individual’s life), and the

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interactions between the two. This innovative model recently proposed by the World Health

Organization has the potential to substantially modify the way in which clinical practice is currently

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conducted, shifting from disease-centered towards function-centered paradigms. By overcoming the

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multiple limitations affecting the construct of disease, this novel framework may allow the
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worldwide dissemination of a more proactive and function-based approach towards achieving

optimal health status.

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In order to facilitate the translation of the current theoretical model into practice, it is

important to identify the inner nature of its constituting constructs. In this paper, we consider
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intrinsic capacity. Using the International Classification of Functioning, Disability and Health (ICF)

framework as background and taking into account available evidence, five domains (i.e.,
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locomotion, vitality, cognition, psychological, sensory) are identified as pivotal for capturing the
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individual’s intrinsic capacity (and therefore also reserves) and, through this, pave the way for its
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objective measurement.

Keywords: Disablement Process; Health Services; Public Health; Successful Aging;

Healthy Ageing

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 1. Introduction

The World Health Organization (WHO) recently published the World Report on Ageing and

Health 1. This document considers the health of older people from a functional rather than disease-

based perspective 2. It defines healthy ageing as “the process of developing and maintaining the

functional ability that enables wellbeing in older age”. The concept of functional ability is then

introduced as all the health-related attributes that enable people to be and to do what they have

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reason to value. Functional ability is in turn determined by: 1) the intrinsic capacity (i.e., the

composite of all the physical and mental capacities of an individual), 2) the environment (i.e., all the

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factors in the extrinsic world that form the context of an individual’s life), and 3) the interactions

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between the two 2.
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This innovative model has the potentiality to substantially modify the way in which clinical

practice is conducted 3. Current models of care are designed to anticipate (through screening for
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specific disease biomarkers) or react to a disease when it is clinically manifest. In contrast, the

healthy ageing approach is characterized by the longitudinal observation of the individual’s

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trajectories with the aim of supporting proactive and personalized interventions for the enhancement

of capacities and abilities, independently of clinical phenotypes. The core of this novel theoretical
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framework resides in the comprehensive assessment of the different domains of intrinsic capacity
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and functional ability. It is noteworthy that holistic approaches in the evaluation of older persons

generate better outcomes compared to traditional disease-based model of care 4, 5. At the same time,
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the model proposed by the WHO has great potential for supporting behavior modification towards

healthy lifestyles by raising awareness about potentially deleterious declines in capacity, and

empowering the individual to take earlier action as these become apparent. In fact, if the individual

is enabled to understand and follow the trajectories of his/her health status (defined in terms of

functions and personal values rather than as complex nosological entities), he/she may take

responsibility for its maintenance at optimal levels.

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 However, before these concepts are translated into practice, it is necessary to define their

constituent natures. In particular, the constituent elements of the central construct of intrinsic

capacity have to be described in order to guide what to observe, measure, and monitor.

The purpose of the present article is to provide the framework for supporting the future

assessment of intrinsic capacity in the clinical and research setting. Available evidence is used to

identify and describe which health domains are the most useful for adequately and objectively

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measuring the individual’s intrinsic capacity.

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2. Development of the intrinsic capacity construct

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As said, intrinsic capacity is the composite of all the physical and mental capacities of an
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individual. But which are the physical and mental capacities constituting intrinsic capacity? Which

are these characteristics that can comprehensively describe the overall biological, personal, and
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psychological status of the individual?

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2.1. The International Classification of Functioning, Disability and Health (ICF) as

starting point for the framework of intrinsic capacity

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In 2001, the WHO published the International Classification of Functioning, Disability and
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Health (ICF) 6. In this document, disability was described as the umbrella term for impairments,
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activity limitations, and participation restrictions. Disability denoted an impaired interaction of the

individual affected by a health condition with contextual factors (both environmental and personal).

The proposed framework (Figure 1) was constituted by multiple interacting elements determining

the manifestation of the health status.

Moving the focus onto healthy ageing, the measurement of intrinsic capacity has to follow

an opposite methodological approach. Whereas the definitions of diseases and disabilities are

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 traditionally captured by more or less overt deficits and limitations, the concept of intrinsic capacity

emphasizes the presence of positive attributes, upon which the individual’s reserves are based.

2.2. Why the disease construct is inadequate to define intrinsic capacity

In a framework based on the longitudinal evaluation of health trajectories, the categorical

notion of disease seems out of place and restrictive. Limited access to care, lack of diagnostic

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instruments, and evolving knowledge of the pathophysiological mechanisms are only a few of the

multiple factors challenging the robustness of nosological conditions as cornerstones of the medical

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approach 7. Moreover, the aging process exponentially increases these limitations because

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increasing variability and diagnostic uncertainty in clinical manifestations 8–10.
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Nosological conditions are designed as dichotomous variables for cross-sectionally

describing a clinical phenotype and support the development of decisional algorithms in the clinical
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setting. However, they are a sub-optimal, insensitive construct for directly serving as clinically

relevant endpoints and/or to judge the effectiveness of interventions 7.

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The construct of intrinsic capacity is based on a longitudinal pattern consistent with the

continuous process of individual aging. In other words, the risk profile is not measured on a single
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assessment conducted at a specific time, but evaluated through multiple observations of the
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individual over time. The longitudinal design of intrinsic capacity strongly promotes the transition
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from a reactive towards a preventive model of medicine. In fact, whereas the clinical manifestation

of disease typically results in a medical alert and response, a reduction of intrinsic capacity (i.e.,

abnormal deviation of a trajectory) may lead to a remedial/recuperative intervention even in the

absence of a specific clinical phenotype. Furthermore, the design of interventions based on multiple

evaluations of the individual will be better tailored and more responsive to his specific needs and

priorities.

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 It is also noteworthy that the diagnosis of a disease requires the evaluation by a medical

professional and/or diagnostic infrastructures, which may not always be available in areas with

limited access to care. The monitoring and collection of preclinical parameters descriptive of the

individual’s health profile might overcome such limitation, especially if considering the possibilities

offered by technological advancements. This approach may enable better targeting of these

resources when changes in intrinsic capacity suggest the need for clinical evaluation and expert

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advice.

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2.3. Focus on body functions

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The intrinsic capacity model is an evolution of previous WHO recommendations, namely

the ICF framework (Figure 1) 11. As above discussed, the health conditions (i.e., diseases) included
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in the ICF model are clearly of limited interest for capturing the complexity of intrinsic capacity.
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Similarly, contextual factors are excluded from the construct of interest because part of the

environment, interacting with intrinsic capacity for determining functional ability. Activities (i.e.,
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the execution of a task or action by the individual) are also unsuitable as they are better considered

as outputs of, rather than components of, intrinsic capacity. Thus, only the notion of body functions
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(i.e., the physiological functions of body systems) meets the defining criteria of intrinsic capacity as
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described in the World Report on Ageing and Health 1. In fact, the interactions of the individual’s
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health characteristics (including pathophysiological patterns as well as health-related behaviors,

traits, skills) determine his/her intrinsic capacity. If the individual’s body functions could be

assessed and merged into a holistic entity, they might generate a powerful marker (i.e., intrinsic

capacity) to track the individual’s health status and support proactive interventions with the aim of

preserving function. In order to support this model, the intrinsic capacity definition should 1)

optimally capture the multiple physiological domains most influencing the health status of the

individual, and 2) feed the subsequent actions with insights about the components that more than

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 others have determined the deviation of the trajectory in both quantitative (e.g., how much) and

qualitative (e.g., how rapidly) terms.

3. Process leading to the identification of defining characteristics of intrinsic capacity

A non-systematic literature review was conducted to investigate which body functions are

more strongly determinant for the maintenance of independent and healthy life. In particular,

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special attention was focused at identifying those functions whose impairment was most strongly

associated with incident functional loss and care dependence. The search of the evidence was made

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more definitive by including the list of body functions provided by the ICF. Analysis of the

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literature took advantage of the multiple and regularly updated systematic reviews exploring the
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risk factors for incident disability, functional loss, and/or care dependence in older persons. At the

same time, the ICF body functions were individually searched in PubMed (updated up to February
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2017) in combination with the keywords “disability”, “dependence”, or “functional loss” for

retrieving potential articles of interest.

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In 1999, Stuck and colleagues 12 conducted a systematic review of the literature aimed at

measuring the strength of evidence linking different risk factors to functional decline in older
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persons. The study importantly contributed a few years later to the preparation of an evidence report
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by the WHO Regional Office for Europe 13. In particular, Stuck and colleagues 12 identified
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impairments in mood (i.e., depressive symptoms), sociality (i.e., participation in social activities),

cognition, physical performance, homeostatic balance (i.e., weight loss, abnormal body mass

index), and vision (i.e., reduced visual acuity) as strong predictors of care dependence. These results

have been confirmed and consistently replicated in subsequent studies. Analyzing data from the

Health and Retirement Study (n=11,093, representing 34.5 million older Americans), Cigolle and

colleagues 14 found that cognitive impairment, vision impairment, hearing impairment, and

undernutrition were associated with ADL dependency. In 2010, Chaudhry and colleagues 15 reported

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 that impairments in muscle strength, physical capacity, cognition, vision, hearing, and mood were

found to be associated with an increased risk of incident mobility disability (i.e., severe difficulty or

inability to climb 10 steps or walk ¼ of mile) and/or incident loss of ADL. More recently, a

systematic review conducted by van der Vorst and colleagues 16 explored the risk and protective

factors for the development of ADL limitation in community-dwelling older persons aged 75 years

and older. After having screened almost 7,000 studies, the authors focused on 25 articles and

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identified a list of factors positively and negatively contributing to the disabling cascade. Here,

several functions again emerged as predictive of subsequent onset of disability, in particular: social

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participation, mood, cognition, muscle strength and physical performance, body weight, nutritional

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status, hearing impairment, and vision impairment. Interestingly, similar results have also been
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reported from low-and-medium-income countries. Data from population-based cohort studies

conducted in Cuba, Dominican Republic, Venezuela, Mexico, Peru, India, and China showed that
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weight loss, slow gait speed, sensory impairment, and cognitive impairment were significant

predictors of incident dependence in older people 17.

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Taking into account and organizing the retrieved evidence, five different domains can be

proposed as of primary interest for better defining the intrinsic capacity framework: 1) cognition, 2)
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psychological (including mood and sociality), 3) sensory function (including vision and hearing), 4)
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vitality (i.e., homeostatic regulation, or balance between energy intake and energy utilization), and
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5) locomotion (including muscular function).

Each of these five domains (depicted in Figure 2) will be individually examined in the

following sections. However, it is necessary to acknowledge that the five components of intrinsic

capacity should not be considered as standalone silos. In fact, each domain closely interacts with the

others as part of a dynamically interrelated environment, the living organism. In other words, each

specific domain will fail to provide an exhaustive picture of the health status of the individual,

mainly because it would omit the information provided by the interactions across systems 10.

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 4. The body functions defining the construct of intrinsic capacity

Please note that in the scientific literature, the term “disability" is often used with a meaning

different from the one described in the ICF, and frequently for indicating the impairment in

Activities of Daily Living (ADLs). In the following sections describing the links between body

functions and functional loss, the use of "disability" may reflect the sense coming from the

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literature, which might be narrower and more specific than what the ICF model implies.

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4.1. Cognition

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Cognitive function undergoes extremely heterogeneous patterns of modification with aging
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. Persons experiencing steeper declines in cognitive function are exposed to a higher risk of

negative health-related outcomes 19. Thus, cognitive function may perfectly contribute to the design
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of an age-independent, individual-specific, and dynamic risk profile. At the same time, cognition is

influenced and can directly affect the other functions composing intrinsic capacity 20–23. It is also
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important to mention the large body of evidence showing how cognition is strongly affected by

exogenous stressors 24. In fact, the environment plays a major role in determining the cognitive
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performance level. Acting on the environment may potentially enhance cognition (and consequently
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intrinsic capacity), thus improving the individual’s functional ability.

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4.2. Psychological

Episodes of affective disorder become increasingly prevalent with older age. Differently

from younger adults, older people often present depressive symptoms without meeting the

diagnostic criteria for a depressive disorder 25, the so-called condition of “sub-threshold depression”
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. Depressive symptoms may have a strong relationship with the functional status of the individual
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. They may represent an independent risk factor for disability, or synergistically act with other

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 conditions in the determination of the functional loss 28. The reciprocal and synergistic effects of

depressive symptoms and disability have been described by Ormel and colleagues 29. The severity

of depressive symptoms experienced by the older persons showed a gradient of risk for subsequent

physical decline, even among individuals with no ADL or mobility disability 30. These findings

suggest that the psychological assessment may support strategies for the early identification of

individuals at risk of negative outcomes. Interestingly, secondary analyses conducted in the

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Women’s Health and Aging Study showed that emotional vitality could be preserved in the

presence of severe disability 31. This implies that the capacity of the individual to maintain and

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develop social interactions may serve for differentiating health profiles and adequately contribute to

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a more comprehensive measure of intrinsic capacity.
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4.3. Sensory
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Sensory deficits (predominantly, vision impairment and hearing loss) are associated with

great disparities in health, activities, and social roles, especially when both are present 32. Thus,
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poor vision and hearing capacity have important implications for the health status and functioning

of the individual 32.

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A recent population-based study conducted in community-dwelling adults (age 57-85 years)

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reported that in two-thirds of the cases, sensory impairments are not isolated 33. Moreover, the
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simultaneous impairment of vision and hearing synergistically interfere with physical and cognitive

function 34. In 2015, sense organ disorders represented the second leading cause of years lived with

disability and counted for more than 68 million disability-adjusted life-years 35.

4.3.1. Vision

The prevalence of vision impairment significantly increases with age 14, 36, and this trend is

reported worldwide 37. Its detrimental effects are not only due to the presence of environmental

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 barriers. In fact, vision impairment may be associated with negative health-related outcomes by

acting on/enhancing different clinical mediators (e.g., depression 38, mobility impairment 36, 39, falls
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). Vision impairment has special implications for health policy and practice because it negatively

impacts quality of life of the individual and substantially increases healthcare costs 41. Interestingly,

the prevalence of vision impairment has been decreasing over the last twenty years in high- as well

as in low-and-medium-income countries 37, suggesting the great potential for improving the

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populations’ health status by intervening on this attribute 35.

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4.3.2. Hearing

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Multiple age-related modifications occur in the peripheral auditory system, potentially

leading to deficits in perception 42. Compared to vision problems, hearing impairment is more
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prevalent in the older population, but has a weaker association with physical function loss 14.
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Nevertheless, hearing impairment is still directly and independently involved in the process

determining the disabling cascade 43. By challenging communication, hearing impairment might
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lead to social isolation and generate a vicious cycle characterized by a sense of inadequacy, anxiety,

depression, cognitive decline, and physical function loss 44, 45. Systematic reviews and meta-
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analyses have also demonstrated that amplification is beneficial in individuals with untreated
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sensineural hearing loss in terms of quality of life by acting on the reduction of psychological,

social, and emotional burdens of the condition 46, 47.

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4.4. Vitality

With the term “vitality” is intended the body functions devoted to metabolizing dietary

intakes in order to produce the required amount of energy for the maintenance of an optimal

homeostatic level. Modifications occurring in energy expenditure and metabolism are part of the

aging process 48. A decline of energy expenditure (due to the parallel reductions of resting

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 metabolic rate and activity energy expenditure) occurs with age across species 49. In order to

maintain proper functioning, the organism needs to adequately balance the energy intake and

expenditures, and markers of malnutrition (e.g., weight loss, low body mass index,

overweight/obesity) are frequently indicated as targets of intervention for preventing the disabling

cascade 12, 50.

It is also noteworthy that malnutrition may be caused by social (e.g., isolation, poverty,

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reliance on others), physiological (e.g., diseases, anorexia, dysphagia) and psychological (e.g., poor

motivation, depressive symptoms) conditions affecting the eating process 51. Diseases (e.g.,

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cardiorespiratory conditions, hormonal abnormalities) also affect the energy homeostasis of the

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organism by influencing nutrition-related mechanisms (e.g., increasing metabolism, reducing

appetite, generating swallowing difficulties, producing malabsorption) 52.

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Interventions focused on nutrition and aimed at restoring the metabolic balance are able to
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delay care dependency, reverse frailty, and potentially improve intrinsic capacity 1. Modifications of

the energy and protein intake have shown to directly affect the biological mechanisms of aging,
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probably through anti-inflammatory and anti-oxidative effects 53.

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4.5. Locomotion
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Mobility is a function common to the largest part of living beings 54, and strongly associated

with the health status of the organism across species 55, 56. Measures of mobility, such as the gait
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speed, present a linear relationship with the risk of negative health-related outcomes 57. In pooled

analyses of 9 cohort studies, Studenski and colleagues 58 demonstrated that it is possible to

accurately estimate the life expectancy of an older individual by simply knowing age, gender, and

gait speed. Consistent findings have also been reported for other outcomes, including incident

disability and care dependence 59. A large body of evidence demonstrates the relationship between

measures of mobility with subclinical pathophysiological modifications, such as increased

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 atherosclerotic formation 60, decreased aerobic capacity 61, or inflammatory status 62. Similarly, age-

and sex-dependent trajectories have been described for muscle strength. The rapid increase of

muscle strength during the first decades of life and its gradual decline after the age of 40 have been

consistently shown in literature, independently of the world regions 63. At the same time, muscle

strength is a strong predictor of negative outcomes, even over the long term 64. It is noteworthy that

the physical decline of the individual (in terms of increasing muscle weakness and poor mobility)

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has been repeatedly evoked as an “additional vital sign” for older persons 65 and a key component

of the comprehensive geriatric assessment 66.

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5. Intrinsic capacity in relation to other theoretical constructs of health in older people

The concept of intrinsic capacity is designed to have a “positive” connotation, focusing on

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the measurement of the residual biological capacities of the organism rather than on its
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impairments/deficits. In the present article, the putative domains in the intrinsic capacity model are

supported by data showing how their impairment becomes deleterious for the health status. Such
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apparent contradiction is mainly due to the fact that traditional medicine and related research is

specifically focused at the identification and treatment of deficits (being reactive) rather than at the
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residual wellness of the organism (primary interest in the healthy ageing preventive approach).
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The impairments in the domains identified as potentially relevant for the construct of

intrinsic capacity have repeatedly been advocated as components of frailty 50, 67–70. However, the
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intrinsic capacity model should not be perceived as the mere reciprocal of frailty (Table 1). Within

the intrinsic capacity model are indeed nested and reorganized multiple aspects of the various frailty

theories and operationalizations proposed over the last two decades. For example, the

multidimensional nature of the intrinsic capacity model can be found in the comprehensive

approach proposed by Rockwood and Mitnitski 71. At the same time, intrinsic capacity as part of the

healthy aging model perhaps includes the biological state that underpins the frailty phenotype

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 proposed by Fried and colleagues 72. The definition of the healthy aging trajectory taking into

account the clinical, biological, and environmental specificities of the individual is consistent with

the integrated Bio-Psycho-Social model proposed by Gobbens and colleagues 73.

An additional remark should be made in relationship to so-called “resilience” (Table 1).

Considering that the focus of intrinsic capacity is on the residual biological reserves of the organism

rather than on its deficits, intrinsic capacity may also be seen as sharing some commonalities with

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the concept of resilience 74–77. However, resilience is a concept that extends well beyond the

biological status of the organism, and spreads over its social network, cultural background,

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economical capacities, and living environment.

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6. Future perspectives

The present article defines the components defining intrinsic capacity. To translate this first
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step into practice, it is necessary that validated measures for adequately capturing each intrinsic

capacity domain will be identified. The WHO is currently working with several panels of experts
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for generating recommendations about the metrics of intrinsic capacity. This task is extremely

challenging given the need to find among the multiple available instruments the most validated and
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acceptable tools that can be applied worldwide. In parallel, as recently exemplified 3, statistical
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approaches must be tested and optimized to enable easy computation of intrinsic capacity once the
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defining tools have been identified.

The novel construct of intrinsic capacity should also be considered in the context of the

advancements and large-scale diffusion of technologies. Today, multiple devices commonly used in

daily life (e.g., smartphones, actimeters) are able to automatically capture a wide range of data

about our functions. Analysis of such information may inform public health actions (when used to

observe population-merged data 78, 79) as well as potentially drive personalized interventions (if

connected to other clinical information about the individual 80, 81). Moreover, in those regions where

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 healthcare access might be more difficult, the possibility of measuring at distance the intrinsic

capacity of the individual may serve for promoting the case-finding of individuals experiencing

abnormal functional trajectories.

Finally, the possibility of developing some disease paradigms into novel nosological

conditions benefiting from the clustering of functional data should not be underestimated. In fact,

the definition of the clinical profile might be improved by exploring the complex interactions of the

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individual’s functions allowing more personalized approaches.

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7. Conclusions

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The intrinsic capacity model is extremely promising and potentially able to reshape the
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future medical approach. Its framework is, to date, still theoretical and needs to be translated into an

operational instrument for feeding clinical and research practice. In order to render it objective, it is
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important to determine which body functions should be included in it. In this context, cognitive,

psychological, locomotion, sensory, and vitality functions can be proposed as the components of
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intrinsic capacity corroborated (to date) by a larger body of evidence.

This first discussion about the construct of intrinsic capacity is proposed to stimulate
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exchanges among researchers and clinicians in order to consensually develop instruments for future
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healthcare, paying attention to generating models that can be adoptable worldwide independently of
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social, economic, and cultural diversities. The intrinsic capacity construct may indeed represent a

unique opportunity for reorganizing our knowledge about age-related conditions, and designing

instruments and models of care in support of improved person centered integrated care approaches

in our aging societies.

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 ACKNOWLEDGEMENTS

The views expressed in this paper are those of the authors and do not necessarily reflect the

views of WHO. We acknowledge the significant contributions of the many other people who

participated in the consultation meeting held in Geneva. We are particularly grateful for the

technical contribution provided by the following members of the WHO Clinical Consortium on

Healthy Ageing: Roberto Bernabei, Olivier Bruyere, Bill Piu Chan, Roger Fielding, Linda Fried,

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Andrea Gasparik, Luis Miguel Gutierrez Robledo, Mikel Izquierdo, Jean-Marc Kaufman, Eugene

McCloskey, Jean-Pierre Michel, John Morley, Ian Philp, Anne Margriet Pot, Martin Prince, René

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Rizzoli, Leocadio Rodriguez Manas, Ritu Sadana, Alan Sinclair, Yuka Sumi, Enrique Vega Garcia,

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Renuka Visvanathan, Chang-Won Won, Jean Woo.
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 REFERENCES

1. World report on ageing and health. Geneva, Switzerland: World Health Organization; 2015.

2. Beard JR, Officer A, de Carvalho IA et al. The World report on ageing and health: a policy

framework for healthy ageing. Lancet. 2015;387 (10033):2145-2154.

3. Beard JR, Bloom DE. Towards a comprehensive public health response to population ageing.

Lancet. 2015;385(9968):658-661.

t
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4. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric

cr
assessment: a meta-analysis of controlled trials. Lancet. 1993;342(8878):1032-1036.

5. Stuck AE, Minder CE, Peter-Wüest I et al. A randomized trial of in-home visits for disability

us
prevention in community-dwelling older people at low and high risk for nursing home
an
admission. Arch Intern Med. 2000;160(7):977-986.

6. The International Classification of Functioning, Disability and Health. Geneva, Switzerland:

M

World Health Organization; 2001.

7. Cesari M, Pérez-Zepeda MU, Marzetti E. Frailty and multimorbidity: different ways of

ed

thinking about geriatrics. J Am Med Dir Assoc. 2017

pt

8. Fulop T, Larbi A, Witkowski JM et al. Aging, frailty and age-related diseases.

Biogerontology. 2010;11(5):547-563.
ce

9. Cesari M, Vellas B, Gambassi G. The stress of aging. Exp Gerontol. 2013;48(4):451-456.

Ac

10. Kirkwood TB. A systematic look at an old problem. Nature. 2008;451(7179):644-647.

11. How to use the ICF: a practical manual for using the International Classification of

Functioning, Disability and Health (ICF). Exposure draft for comment. Geneva (Switzerland):

World Health Organization; 2013.

12. Stuck AE, Walthert JM, Nikolaus T, Büla CJ, Hohmann C, Beck JC. Risk factors for

functional status decline in community-living elderly people: a systematic literature review.

Soc Sci Med. 1999;48(4):445-469.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

by Mount Royal University user
on 06 February 2018
 13. Heikkinen E. What are the main risk factors for disability in old age and how can disability be

prevented? http://www.euro.who.int/document/E82970.pdf.

14. Cigolle CT, Langa KM, Kabeto MU, Tian Z, Blaum CS. Geriatric conditions and disability:

the Health and Retirement Study. Ann Intern Med. 2007;147(3):156-164.

15. Chaudhry SI, McAvay G, Ning Y, Allore HG, Newman AB, Gill TM. Geriatric impairments

and disability: the cardiovascular health study. J Am Geriatr Soc. 2010;58(9):1686-1692.

t
ip
16. van der Vorst A, Zijlstra GA, Witte N et al. Limitations in Activities of Daily Living in

Community-Dwelling People Aged 75 and Over: A Systematic Literature Review of Risk and

cr
Protective Factors. PLoS One. 2016;11(10):e0165127.

us
17. AT J, Bryce R, Prina M et al. Frailty and the prediction of dependence and mortality in low-
an
and middle-income countries: a 10/66 population-based cohort study. BMC Med.

2015;13:138.
M

18. Heuninckx S, Wenderoth N, Debaere F, Peeters R, Swinnen SP. Neural basis of aging: the

penetration of cognition into action control. J Neurosci. 2005;25(29):6787-6796.

ed

19. Han L, Gill TM, Jones BL, Allore HG. Cognitive Aging Trajectories and Burdens of

Disability, Hospitalization and Nursing Home Admission Among Community-living Older

pt

Persons. J Gerontol A Biol Sci Med Sci. 2016;71(6):766-771.

ce

20. Langa KM, Levine DA. The Diagnosis and Management of Mild Cognitive Impairment: A
Ac

Clinical Review. JAMA. 2014;312(23):2551-2561.

21. Gill TM, Williams CS, Richardson ED, Tinetti ME. Impairments in physical performance and

cognitive status as predisposing factors for functional dependence among nondisabled older

persons. J Gerontol A Biol Sci Med Sci. 1996;51(6):M283-8.

22. Njegovan V, Hing MM, Mitchell SL, Molnar FJ. The hierarchy of functional loss associated

with cognitive decline in older persons. J Gerontol A Biol Sci Med Sci. 2001;56(10):M638-43.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

by Mount Royal University user
on 06 February 2018
 23. Atkinson HH, Rosano C, Simonsick EM et al. Cognitive function, gait speed decline, and

comorbidities: the health, aging and body composition study. J Gerontol A Biol Sci Med Sci.

2007;62(8):844-850.

24. Rowe JW, Kahn RL. Human aging: usual and successful. Science. 1987;237(4811):143-149.

25. Fiske A, Wetherell JL, Gatz M. Depression in older adults. Annu Rev Clin Psychol.

2009;5:363-389.

t
ip
26. Crocco EA, Castro K, Loewenstein DA. How late-life depression affects cognition: neural

mechanisms. Curr Psychiatry Rep. 2010;12(1):34-38.

cr
27. Vaughan L, Corbin AL, Goveas JS. Depression and frailty in later life: a systematic review.

us
Clin Interv Aging. 2015;10:1947-1958.
an
28. Schillerstrom JE, Royall DR, Palmer RF. Depression, disability and intermediate pathways: a

review of longitudinal studies in elders. J Geriatr Psychiatry Neurol. 2008;21(3):183-197.

M

29. Ormel J, Rijsdijk FV, Sullivan M, van Sonderen E, Kempen GI. Temporal and reciprocal

relationship between IADL/ADL disability and depressive symptoms in late life. J Gerontol B
ed

Psychol Sci Soc Sci. 2002;57(4):P338-47.

30. Penninx BW, Guralnik JM, Ferrucci L, Simonsick EM, Deeg DJ, Wallace RB. Depressive
pt

symptoms and physical decline in community-dwelling older persons. JAMA.

ce

1998;279(21):1720-1726.
Ac

31. Penninx BW, Guralnik JM, Simonsick EM, Kasper JD, Ferrucci L, Fried LP. Emotional

vitality among disabled older women: the Women’s Health and Aging Study. J Am Geriatr

Soc. 1998;46(7):807-815.

32. Crews JE, Campbell VA. Vision impairment and hearing loss among community-dwelling

older Americans: implications for health and functioning. Am J Public Health.

2004;94(5):823-829.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

by Mount Royal University user
on 06 February 2018
 33. Correia C, Lopez KJ, Wroblewski KE et al. Global Sensory Impairment in Older Adults in the

United States. J Am Geriatr Soc. 2016;64(2):306-313.

34. Lin MY, Gutierrez PR, Stone KL. Vision impairment and combined vision and hearing

impairment predict cognitive and functional decline in older women. J Am Geriatr Soc.

2004;52:1996-2002.

35. GBD DALYAHALEC. Global, regional, and national disability-adjusted life-years (DALYs)

t
ip
for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic

analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1603-1658.

cr
36. Maino JH. Visual deficits and mobility. Evaluation and management. Clin Geriatr Med.

us
1996;12(4):803-823.
an
37. Stevens GA, White RA, Flaxman SR et al. Global prevalence of vision impairment and

blindness: magnitude and temporal trends, 1990-2010. Ophthalmology. 2013;120(12):2377-

M

2384.

38. Renaud J, Bédard E. Depression in the elderly with visual impairment and its association with
ed

quality of life. Clin Interv Aging. 2013;8:931-943.

39. Salive ME, Guralnik J, Glynn RJ, Christen W, Wallace RB, Ostfeld AM. Association of
pt

visual impairment with mobility and physical function. J Am Geriatr Soc. 1994;42(3):287-
ce

292.
Ac

40. Reed-Jones RJ, Solis GR, Lawson KA, Loya AM, Cude-Islas D, Berger CS. Vision and falls:

a multidisciplinary review of the contributions of visual impairment to falls among older

adults. Maturitas. 2013;75(1):22-28.

41. Prince MJ, Wu F, Guo Y et al. The burden of disease in older people and implications for

health policy and practice. Lancet. 2015;385(9967):549-562.

42. Chisolm TH, Willott JF, Lister JJ. The aging auditory system: anatomic and physiologic

changes and implications for rehabilitation. Int J Audiol. 2003;42 Suppl 2:2S3-210.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

by Mount Royal University user
on 06 February 2018
 43. Liljas AEM, Carvalho LA, Papachristou E et al. Self-reported hearing impairment and

incident frailty in English community-dwelling older adults: a 4-year follow-up study. J Am

Geriatr Soc. 2017;65:958-965.

44. Ryan EB, Giles H, Bartolucci G, Henwood K. Psycholinguistic and social psychological

components of communication by and with the elderly. Language Communication. 1986;6

(1):1-24.

t
ip
45. Gopinath B, Schneider J, McMahon CM, Teber E, Leeder SR, Mitchell P. Severity of age-

related hearing loss is associated with impaired activities of daily living. Age Ageing.

cr
2012;41(2):195-200.

us
46. Johnson CE, Danhauer JL, Ellis BB, Jilla AM. Hearing Aid Benefit in Patients with Mild
an
Sensorineural Hearing Loss: A Systematic Review. J Am Acad Audiol. 2016;27(4):293-310.

47. Chisolm TH, Johnson CE, Danhauer JL et al. A systematic review of health-related quality of
M

life and hearing aids: final report of the American Academy of Audiology Task Force On the

Health-Related Quality of Life Benefits of Amplification in Adults. J Am Acad Audiol.

ed

2007;18(2):151-183.

48. Riera CE, Dillin A. Tipping the metabolic scales towards increased longevity in mammals.
pt

Nat Cell Biol. 2015;17(3):196-203.

ce

49. Manini TM. Energy expenditure and aging. Ageing Res Rev. 2010;9(1):1-11.
Ac

50. Ferrucci L, Guralnik JM, Studenski S et al. Designing randomized, controlled trials aimed at

preventing or delaying functional decline and disability in frail, older persons: a consensus

report. J Am Geriatr Soc. 2004;52(4):625-634.

51. Nieuwenhuizen WF, Weenen H, Rigby P, Hetherington MM. Older adults and patients in

need of nutritional support: review of current treatment options and factors influencing

nutritional intake. Clin Nutr (Edinburgh, Scotland). 2010;29(2):160-169.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

by Mount Royal University user
on 06 February 2018
 52. Thomas DR, Ashmen W, Morley JE, Evans WJ. Nutritional management in long-term care:

development of a clinical guideline. Council for Nutritional Strategies in Long-Term Care. J

Gerontol A Biol Sci Med Sci. 2000;55(12):M725-34.

53. Swan M. Meeting report: American Aging Association 40th Annual Meeting, Raleigh, North

Carolina, June 3-6, 2011. Rejuvenation Res. 2011;14(4):449-455.

54. Dickinson MH, Farley CT, Full RJ, Koehl MA, Kram R, Lehman S. How animals move: an

t
ip
integrative view. Science. 2000;288(5463):100-106.

55. Justice JN, Cesari M, Seals DR, Shively CA, Carter CS. Comparative Approaches to

cr
Understanding the Relation Between Aging and Physical Function. J Gerontol A Biol Sci Med

us
Sci. 2016;71 (10):1243-1253.
an
56. Carey JR, Papadopoulos N, Kouloussis N et al. Age-specific and lifetime behavior patterns in

Drosophila melanogaster and the Mediterranean fruit fly, Ceratitis capitata. Exp Gerontol.
M

2006;41(1):93-97.

57. Abellan van Kan G, Rolland YM, Andrieu S et al. Gait speed at usual pace as a predictor of
ed

adverse outcomes in community-dwelling older people an International Academy on Nutrition

and Aging (IANA) Task Force. J Nutr Health Aging. 2009;13(10):881-889.

pt

58. Studenski S, Perera S, Patel K et al. Gait speed and survival in older adults. JAMA.
ce

2011;305(1):50-58.
Ac

59. Perera S, Patel KV, Rosano C et al. Gait Speed Predicts Incident Disability: A Pooled

Analysis. J Gerontol A Biol Sci Med Sci. 2016;71 (1):63-71.

60. Elbaz A, Ripert M, Tavernier B et al. Common carotid artery intima-media thickness, carotid

plaques, and walking speed. Stroke. 2005;36(10):2198-2202.

61. Coen PM, Jubrias SA, Distefano G et al. Skeletal Muscle Mitochondrial Energetics Are

Associated With Maximal Aerobic Capacity and Walking Speed in Older Adults. J Gerontol

A Biol Sci Med Sci. 2013;68 (4):447-455.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

by Mount Royal University user
on 06 February 2018
 62. Cesari M, Penninx BW, Pahor M et al. Inflammatory markers and physical performance in

older persons: the InCHIANTI study. J Gerontol A Biol Sci Med Sci. 2004;59(3):242-248.

63. Dodds RM, Syddall HE, Cooper R, Kuh D, Cooper C, Sayer AA. Global variation in grip

strength: a systematic review and meta-analysis of normative data. Age Ageing. 2016;45

(2):209-216.

64. Rantanen T, Guralnik JM, Foley D et al. Midlife hand grip strength as a predictor of old age

t
ip
disability. JAMA. 1999;281(6):558-560.

65. Studenski S, Perera S, Wallace D et al. Physical performance measures in the clinical setting.

cr
J Am Geriatr Soc. 2003;51(3):314-322.

us
66. Applegate WB, Blass JP, Williams TF. Instruments for the functional assessment of older
an
patients. N Engl J Med. 1990;322(17):1207-1214.

67. Sourial N, Wolfson C, Bergman H et al. A correspondence analysis revealed frailty deficits
M

aggregate and are multidimensional. J Clin Epidemiol. 2010;63(6):647-654.

68. Bergman H, Ferrucci L, Guralnik J et al. Frailty: an emerging research and clinical paradigm--
ed

issues and controversies. J Gerontol A Biol Sci Med Sci. 2007;62(7):731-737.

69. Studenski S, Hayes RP, Leibowitz RQ et al. Clinical Global Impression of Change in Physical
pt

Frailty: development of a measure based on clinical judgment. J Am Geriatr Soc.

ce

2004;52(9):1560-1566.
Ac

70. Morley JE, Vellas B, Abellan van Kan G et al. Frailty consensus: a call to action. J Am Med

Dir Assoc. 2013;14(6):392-397.

71. Mitnitski AB, Mogilner AJ, Rockwood K. Accumulation of deficits as a proxy measure of

aging. ScientificWorldJournal. 2001;1:323-336.

72. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: evidence for a phenotype. J

Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

by Mount Royal University user
on 06 February 2018
 73. Gobbens RJ, Luijkx KG, Wijnen-Sponselee MT, Schols JM. Towards an integral conceptual

model of frailty. J Nutr Health Aging. 2010;14(3):175-181.

74. Lazarus RS. From psychological stress to the emotions: a history of changing outlooks. Annu

Rev Psychol. 1993;44:1-21.

75. Tugade MM, Fredrickson BL. Resilient individuals use positive emotions to bounce back

from negative emotional experiences. J Pers Soc Psychol. 2004;86(2):320-333.

t
ip
76. Conti AA, Conti A. Frailty and resilience from physics to medicine. Med Hypotheses.

2010;74(6):1090.

cr
77. Whitson HE, Duan-Porter WD, Schmader KE, Morey MC, Cohen HJ, Colón-Emeric CS.

us
Physical Resilience in Older Adults: Systematic Review and Development of an Emerging
an
Construct. J Gerontol A Biol Sci Med Sci. 2015

78. Althoff T, Sosič R, Hicks JL, King AC, Delp SL, Leskovec J. Large-scale physical activity
M

data reveal worldwide activity inequality. Nature. 2017;547(7663):336-339.

79. McConnell MV, Shcherbina A, Pavlovic A et al. Feasibility of Obtaining Measures of

ed

Lifestyle From a Smartphone App: The MyHeart Counts Cardiovascular Health Study. JAMA

Cardiol. 2016
pt

80. Hermens H, op den Akker H, Tabak M, Wijsman J, Vollenbroek M. Personalized Coaching

ce

Systems to support healthy behavior in people with chronic conditions. J Electromyogr

Ac

Kinesiol. 2014;24(6):815-826.

81. Lv N, Xiao L, Simmons ML, Rosas LG, Chan A, Entwistle M. Personalized Hypertension

Management Using Patient-Generated Health Data Integrated With Electronic Health Records

(EMPOWER-H): Six-Month Pre-Post Study. J Med Internet Res. 2017;19(9):e311.

Downloaded from https://academic.oup.com/biomedgerontology/advance-article-abstract/doi/10.1093/gerona/gly011/4834876

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 Table 1. Theoretical definitions of intrinsic capacity, frailty, and resilience.

Construct Definition

Intrinsic capacity - The composite of all the physical and mental capacities of an individual 1

Frailty - A progressive age-related decline in physiological systems that results in

decreased reserves of intrinsic capacity, which confers extreme vulnerability

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to stressors and increases the risk of a range of adverse health outcomes 1

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- Frailty is a medical syndrome with multiple causes and contributors that is

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characterized by diminished strength, endurance, and reduced physiologic

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function that increases an individual’s vulnerability for developing increased

dependency and/or death 70

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Resilience - The capacity of metals to resist deformation presaged interest in individual
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differences in the resiliency of people under stress 74

- (Psychological) resilience refers to effective coping and adaptation although

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faced with loss, hardship, or adversity 75

- The human ability to adapt in the face of tragedy, trauma, adversity,

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hardship, and ongoing significant life stressors 76

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- (Physical) resilience is a characteristic at the whole person level which

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determines an individual’s ability to resist functional decline or recover

physical health following a stressor 77

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 Figure 1. The ICF model as basis for the development of the construct of intrinsic capacity.

Figure 2. The five domains (i.e., locomotion, sensory, cognition, psychological, vitality)

constituting the intrinsic capacity construct. Examples of possible subdomains are also provided.

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 Figure 1.

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 Figure 2.

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