Rojano i Luque et al. BMC Geriatrics (2023) 23:106 BMC Geriatrics https://doi.org/10.1186/s12877-023-03799-0 RESEARCH Open Access Identification of decreased intrinsic capacity: Performance of diagnostic measures of the ICOPE Screening tool in community dwelling older people in the VIMCI study Xavier Rojano i Luque1,2, Sergi Blancafort‑Alias1,2*, Susanna Prat Casanovas3, Susanna Forné4, Nuria Martín Vergara5, Pilar Fabregat Povill6, Maria Vila Royo7, Rosa Serrano8, Dolores Sanchez‑Rodriguez9,10,11, Montserrat Vílchez Saldaña12, Iris Martínez4, Mariola Domínguez López6, Francesc Riba Porquet6, Aimar Intxaurrondo González1,2 and Antoni Salvà Casanovas1,2 Abstract Background The World Health Organization (WHO) has developed the Integrated Care for Older People (ICOPE) strategy to face the challenges of ageing societies. This strategy is focused on person centered care and the assess‑ ment intrinsic capacity (IC). Early identification of five domains of IC (cognition, locomotion, vitality, sensory (hearing and vision), and psychological) has been shown to be related with adverse outcomes and can guide actions towards primary prevention and healthy ageing. IC assessment proposed by the WHO ICOPE guidelines is composed by two steps: First, Screening for decreased IC by the ICOPE Screening tool; second, by the reference standard methods. The aim was to assess the performance of diagnostic measures (sensibility, specificity, diagnostic accuracy, and agreement of the ICOPE Screening tool) compared to the reference standard methods in European community-dwelling older adults. Methods Cross-sectional analysis of the baseline of the ongoing VIMCI (Validity of an Instrument to Measure Intrinsic Capacity) cohort study, which was carried out in Primary Care centers and outpatient clinics from 5 rural and urban territories in Catalonia (Spain). Participants were 207community dwelling persons ≥ 70-year-old with Barthel ≥ 90, without dementia or advanced chronic conditions who provided their consent to participate. The 5 IC domains were assessed by the ICOPE Screening tool and the reference methods (SPPB, gait speed, MNA, Snellen chart, audiometry, MMSE, GDS5) during patients’ visit. Agreement was assessed with the Gwet AC1 index. Results ICOPE Screening tool sensitivity was higher for cognition (0.889) and ranged between 0.438 and 0.569 for most domains. Specificity ranged from 0.682 to 0.96, diagnostic accuracy from 0.627 to 0.879, Youden index from 0.12 to 0.619, and Gwet AC1 from 0.275 to 0.842. Conclusion The ICOPE screening tool showed fair performance of diagnostic measures; it was helpful to identify those participants with satisfactory IC and showed a modest ability to identify decreased IC in older people with high degree of autonomy. Since low sensitivities were found, a process of external validation would be recommended to *Correspondence: Sergi Blancafort‑Alias sergi.blancafort@uab.cat Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 2 of 11 reach better discrimination. Further studies about the ICOPE Screening tool and its performance of diagnostic meas‑ ures in different populations are urgently required. Keywords Intrinsic capacity, ICOPE, Screening, Sensitivity, Specificity, Person-centered care, Agreement, Diagnostic accuracy, Psychometrics Background decreased IC in older people and provide appropriate The World Health Organization (WHO) launched the care to reverse or slow down the decline. Secondly, as World Report on Ageing and Health in 2016 [1, 2], which a support for the inclusion of services to prevent care- recommended major systemic changes in the health dependency and the creation of a partnership involving systems in order to adopt person-centered care models older people, primary health-care professionals, fam- which enable “healthy ageing”. Healthy ageing [1] is the ily, and community. Thirdly, ICOPE interventions are overall goal of the Global Strategy and Action Plan on designed to be provided through models of care that Ageing and Health [3] and the current Decade of Healthy prioritize primary and community-based care. The Ageing plan developed by the WHO [4] and is defined ICOPE Screening tool is in process of being tested as a as “the process of developing and maintaining the func- pilot instrument in few countries [10, 11]. Preliminary tional ability that enables well-being in older age”. Func- findings highlight its potential as an inexpensive, fea- tional ability is determined by three factors: Intrinsic sible tool, easy to be administered in settings with lim- capacity (IC), which is “the composite of all the physical ited resources, which requires no specific training, and is and mental capacities of an individual”, the environment, extremely time-efficient. However, the ICOPE Screening and the interactions between both. IC is composed by tool is relatively new, and the evidence about its perfor- five domains: Cognition, locomotion, vitality (related mance of diagnostic measures still remains unavailable; to energy balance and metabolism), sensory (related to gathering information about them is crucial, since it pro- vision and audition), and psychological (related to mood vides data that will help proceed towards the implemen- and depressive symptoms) [5]. Declines in IC of any of its tation of the the first step of the ICOPE strategy. domains have been shown to be related to adverse health The objective was to assess the performance of diag- outcomes [6]; Importantly, decreased IC is reversible and nostic measures (sensibility, specificity, diagnostic accu- can be counteracted when early identification and treat- racy, and agreement) of the ICOPE Screening tool, ment are applied [7]. recommended by the WHO ICOPE guidelines, to detect For this reason, the WHO has fostered the Integrated decreased IC, compared to the reference standard meth- Care for Older People (ICOPE) strategy [8], the WHO ods, in European community-dwelling older adults from ICOPE Guidelines on Community-Level Interventions the VIMCI (Validity of an Instrument to Measure Intrin- to Manage Declines in Intrinsic Capacity[7], and the sic Capacity) cohort study. WHO ICOPE Guidance for person-centered assessment and pathways in Primary Care[9], aimed at the preserva- tion of IC in community-dwelling older populations. The Methods Settings WHO ICOPE strategy is based on five consecutive steps: Cross-sectional analysis of the baseline data of the 1) Screen for declines in IC; 2) Undertake a person-cen- VIMCI study, a cohort study aimed at assessing the per- tered assessment in Primary Care; 3) Define care goals formance of diagnostic measures of the ICOPE Screen- and tailor a personalized care plan; 4) Ensure a referral ing tool and the changes in intrinsic capacity during a pathway and care plan monitoring, with links to special- 12-month follow-up. Baseline assessment was conducted ized geriatric care; 5) Engage communities and support between April and September 2021. The study included caregivers. community-dwelling older people aged 70 or over with a In order to carry out the first step, the WHO has devel- Barthel index ≥ 90, recruited in Primary Care centers and oped the ICOPE Screening tool [9], an evidence-based outpatient clinics from five rural and urban territories in 9-item questionnaire which uses the principles of com- Catalonia (Spain). Participants with dementia, advanced prehensive geriatric assessment to identify deficiencies chronic conditions, or a life expectancy < 12 months were in the 5 IC domains., and which is recommended in the excluded. The VIMCI study is part of the larger European WHO ICOPE guidelines [7, 9]. APTITUDE project[12], aimed at preventing the depend- The ICOPE strategy has been described as potentially ency on older people by creating a network to promote beneficial in a primary care context for several rea- care, training, research, and innovation in the areas of sons [9]. First, as a simple and low-cost way to identify public health and gerontology. Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 3 of 11 Sampling options to assess each of the domains during the screen- An intended convenience sample of 250 participants was ing, only one of the two was chosen for each participant. determined for the study, and 207 were finally included. In the case of audition, the whisper test, which does The use of a convenience sample was determined by not need additional equipment, was the only proposed budgetary constraints, the requirement to recruit par- option. ticipants within a limited timeframe and the fact that we didn’t have access to the full target population to create a representative sample. IC assessment by the reference standard methods For each IC domain, the reference standard methods IC assessment were administered according to the recommendations IC assessment according to the WHO ICOPE guide- of the WHO ICOPE guideline [13]. For each participant, lines comprised two steps: First, screening by the ICOPE each domain was considered normal or altered according Screening tool and second, to undertake a complete to the thresholds for the initial validation for each refer- person-centered assessment by the reference standard ence standard method. methods. In the VIMCI study, the ICOPE Screening tool was administered before the reference standard meth- • Cognitive domain: Mini Cognitive Examination ods during the same visit. The whole assessment of each (MEC), which is a Spanish adaptation of the Mini participant was performed by one single person. Par- Mental State Examination (MMSE) was used and a ticipants using sensory or mobility aids (i.e., glasses and MEC score < 24 indicated an altered domain [14, 15]. canes) were allowed to use them during the assessments • Locomotion domain: Short Physical Performance to ensure participants’ safety. Table 1 summarizes the IC Battery (SPPB) [16], a 3-step composite test that assessment by the ICOPE Screening tool and the refer- assesses balance, gait speed, and lower limb strength. ence standard methods in the VIMCI study. Both SPPB total score and gait speed alone and were used as reference tests for this domain. A SPPB IC Screening by the ICOPE Screening tool score < 10 or a gait speed ≤ 0.8 m/s, respectively, were The screening of decreased IC was performed by the used as thresholds[17, 18]. ICOPE Screening tool, following the standardized pro- • Vitality domain: The Mini Nutritional Assessment cedures detailed in the WHO ICOPE guideline [13]. (MNA) by using a threshold MNA score < 12 was The ICOPE Screening tool is a 9-item instrument which used [19]. assesses the domains of cognition (2 items), mobility (1 • Sensorial domain—Audition: The Hearing test Audi- item), vitality (2 items), sensorial (1 item for vision and 1 ogram App [20]using a wired headphone connected item for audition), and psychological capacity (2 items). to a smartphone was used. The App uses pure tones The result of the ICOPE Screening tool classifies each at 125, 250, 500 Hz and 1, 2, 3, 4 and 8 kHz. The App IC domain as normal or altered. An altered domain creates an audiogram and provides a score between indicates that a further assessment with the reference 1 (very severe hearing loss) to 8 (hearing better than standard method is required; for purpose of analysis, average). To assess frequency of sensory problems both the screening and the reference standard method the data of hearing and vision tests was combined, were administered to all study sample, independently of considering the domain normal when both tests were the result obtained in the screening. In presence of two negative; altered when one met decreased IC criteria; Table 1 IC loss criteria Domain ICOPE Reference Cognition - Any time or space orientation failure OR—not recalling 3 words MEC score < 24 Locomotion Spend > 14 s in 5 times chair rise - SPPB score < 10 OR—gait speed ≤ 0.8 m/s Vitality - Unintentional loss of > 3 kg over the last 3 months OR—Appetite loss MNA score < 12 Sensory—Vision Reporting sight problems visual acuity < 6/60 in tumbling E chart Sensory—Hearing Failing to repeat a minimum of 4 words spelled in a whisper voice with at least one light hearing loss in one ear (Hearing test ear audiogram score < 6) Psychological Being bothered over the past two weeks – feeling down, depressed or hopeless OR – GDS5 ≥ 2 little interest or pleasure in doing things MEC Mini Cognitive Examination, SPPB Short Physical Performance Battery, MNA Mini Nutritional Assessment, GDS5 5-item version of the Geriatric Depression Scale Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 4 of 11 and missing when one was normal and the other had subjects had missing reference tests. In those cases, sub- no data. jects with missing information for a reference test were • Psychological domain: The 5-item version of the Ger- excluded for the analysis of agreement and diagnostic iatric Depression Scale (GDS5) was administered and measures of the affected domain but were used for the a threshold of GDS5 ≥ 2 was used [21]. analysis of the other domains for which data was avail- • Demographic, social, and health variables were gath- able. Statistical analysis was performed using R 4.2.1 and ered. Level of education was determined accord- epiR 2.0.52 and irrCAC 1.0 libraries. ing to self-declared level of finished studies. Risk of social isolation was classified according to the Lub- Results ben Social Network Scale–Revised (LSNS-R)) [22] as Two hundred seven participants (61% women) were low (31—60 points), moderate (26—30), high (21— included in the study and their characteristics are shown 25), and isolated (0—20). Loneliness was assessed by in Table 2 and 3. Men were affected by more severe con- De Jong Gierveld Loneliness Scale (JGLS) [23] con- ditions than women, although no differences were found sidering four levels: absent (0 – 2 points), moderate in health state perception (rated positively in 66% of (3 – 8), severe (9 – 10), and very severe (11 points). cases) nor the amount of health issues. Nearly one in four Self-perceived health and amount of health problems participants (24%) reported some degree of isolation and were self-reported. Severity of comorbidities were more than a third (37%) felt lonely. assessed with the Charlson index[24]. Figure 1 shows for each domain the distribution of participants in four categories according to the results of screening and reference tests ( Domains are sorted by Outcome measure their average diagnostic accuracy. Purple bars on the left The outcome measure was the performance of diagnostic show participants classified in the same way: dark pur- measures of the ICOPE Screening tool compared to the ple show true negative cases (both tests discard the con- reference standard methods for each domain: Sensibil- dition), and light purple true positive (both tests detect ity, specificity, diagnostic accuracy, and the Youden index the condition). Orange bars on the right show discordant [25]. A screening tool is considered to have good perfor- cases: light orange show false positive cases (the condi- mance indicators, if sensitivity and specificity > 80%; fair, tion is detected in the screening, but not by the refence if sensitivity or specificity < 80% but both values > 50%; test), and dark orange show false negative cases (the and poor, if sensitivity or specificity < 50% [26]. screening test fails to detect the condition). The Youden index summarizes sensibility and speci- Frequency of decreased IC is shown in Table 4 and ficity, and it is frequently used with dichotomous vari- 5 (sort in descending order according to reference ables instead of Receiver Operating Characteristic (ROC) method). Seventy percent and 79% of participants curves. A Youden index of 1 indicates perfect sensibility showed at least one domain with decreased IC according and specificity, and a value of 0 indicates that the test is to the ICOPE Screening tool and the reference standard not useful at all. methods, respectively. These percentages dropped to 52% Agreement between the ICOPE Screening tool and and 60% if sensory domain was not considered. Among the reference standard methods was assessed using the participants with decreased IC in least one domain, the GwetAC1 index [27], a chance corrected indicator anal- mean number of domains affected were 2.1 using ICOPE ogous to Cohen’s kappa but more robust to sample dis- Screening tool and 1.8 using the reference standard tribution[28]. Higher values indicate better agreement methods (1.8 and 1.4 excluding the sensory domain). (usually 0.4 to 0.6 are considered moderate, 0.6 to 0.8 Sensibility, specificity, diagnostic accuracy, Youden good, and 0.8 to 1 very good). In the case of the mobil- and Gwet AC1 indexes are shown in Table 2 and 3. The ity domain, the performance of diagnostic measures domains are sorted by Youden’s index. Sensitivity ranged and agreement were calculated for both SPPB and gait for most domains between 0.438 and 0.569 being higher speed. For the audition domain, additional analysis con- for cognition (0.889). Specificity ranged from 0.682 to sidering the results of the audiogram in the best ear was 0.96, diagnostic accuracy from 0.627 to 0.879, Youden conducted. index from 0.12 to 0.619, and Gwet AC1 from 0.275 to 0.842. Statistics Figure 2 shows the boxplot and density distribution Quantitative variables were analyzed using the Mann of reference tests -on the vertical axis- according to the Whitney U test. Qualitative variables were analyzed results of the ICOPE Screening test. For all domains using Pearson’s Chi-squared test or Fisher’s exact test. All but psychological (where a higher score indicates participants underwent the ICOPE assessment, but some higher risk), the area over the dashed line shows the Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 5 of 11 Table 2 Characteristics of the participants Characteristic Overall, N = 207 Men, N = 81 Women, N = 126 p-value Age 76.7 (74.1 to 79.9) 77.4 (74.8 to 80.4) 76.3 (73.3 to 79.4) 0.072 Level of education No studies 30 (14%) 12 (15%) 18 (14%) 0.598 Primary 107 (52%) 38 (47%) 69 (55%) Secondary 46 (22%) 19 (23%) 27 (21%) University 24 (12%) 12 (15%) 12 (9.5%) Perceived health Very good 31 (16%) 12 (16%) 19 (15%) 0.747 Good 100 (50%) 41 (54%) 59 (48%) Fair 51 (26%) 18 (24%) 33 (27%) Bad 13 (6.5%) 3 (3.9%) 10 (8.1%) Very bad 4 (2.0%) 2 (2.6%) 2 (1.6%) Unknown 8 5 3 Number of health problems 4.00 (2.00 to 5.00) 3.00 (2.00 to 5.00) 4.00 (2.00 to 6.00) 0.246 Charlson index 1.00 (0.00 to 2.00) 1.00 (0.00 to 2.00) 1.00 (0.00 to 1.00) 0.008 LSNS score 38 (31 to 45) 38 (31 to 44) 38 (31 to 45) 0.838 Unknown 6 4 2 Social isolation risk Low 153 (76%) 58 (75%) 95 (77%) 0.960 Moderate 23 (11%) 10 (13%) 13 (10%) High 17 (8.5%) 6 (7.8%) 11 (8.9%) Isolated 8 (4.0%) 3 (3.9%) 5 (4.0%) Unknown 6 4 2 JGLS score 2.00 (0.00 to 3.00) 2.00 (0.00 to 3.00) 2.00 (0.00 to 4.00) 0.723 Unknown 6 4 2 Degree of loneliness Does not have any 127 (63%) 48 (62%) 79 (64%) 0.935 Moderate 70 (35%) 28 (36%) 42 (34%) Severe 3 (1.5%) 1 (1.3%) 2 (1.6%) Very severe 1 (0.5%) 0 (0%) 1 (0.8%) Unknown 6 4 2 Continuous values expressed as median an interquartile rank. LSNS Lubben Social Network Scale, JGLS De Jong Gierveld loneliness scale proportion of participants with normal scores. Table 3 and 4 shows reference results for each domain accord- ing to the results of its corresponding ICOPE Screening tool. From the 207 participants, 9 (4%) had an altered Table 3 Frequency of decreased IC according to screening and MEC score. Nearly half of participants (48%) showed reference criteria decreased mobility according to SPPB score, mostly with mild severity (78 out 99). Thirty-three participants Domain ICOPEa Referencea had a MNA below 12 points. In relation to sensory Sensory 112/207 (54%) 120/204 (59%) domain, 16% of participants were affected by vision Hearing 67/207 (32%) 104/204 (51%) impairment, mostly slight (84%, 27 out 32); and seven Vision 70/207 (34%) 32/205 (16%) in 10 participants reported hearing problems, mostly Locomotion 57/207 (28%) 107/202 (53%) with minimal or low loss. In all domains, the score in Psychological 49/207 (24%) 34/204 (17%) the reference standard methods was better in the group Vitality 22/207 (11%) 33/206 (16%) with normal results in the screening. Mean differences Cognition 64/207 (31%) 9/202 (4.5%) (95% confidence interval) were: 1.8 points (1.1 to 2.5) a cases/number of observations (valid percent) Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 6 of 11 Fig. 1 Results of assessments for each domain Table 4 Psychometric and agreement indicators †Point estimator with upper and lower limit of 95% confidence interval; ‡Parenthesis indicates reference used (when several) for MEC score; 2.9 (2.3 to 3.5) for SPPB; 0.3 m/s (0.2 to the VIMCI study. The ICOPE Screening tool showed to 0.4) for gait speed; 2.5 points (1.7 to 3.3) for MNA; and have fair performance of diagnostic measures, with a 0.3 (0.1 to 0.6) symptoms for GDS5. modest sensitivity and a good specificity for the screen- ing of decreased IC among this sample of community- dwelling older people. Diagnostic accuracy was found Discussion fair for all domains. Youden’s index followed a gradient The study assessed the performance of diagnostic showing a poor performance for psychological, visual measures (sensibility, specificity, and diagnostic accu- and hearing domains of IC. These relatively modest racy) of the ICOPE Screening tool compared to the results in the ICOPE Screening tool could be explained reference standard method for each IC domain in Euro- by the eligibility criteria and characteristics of the study pean community-dwelling older people participating in sample, which was composed by community dwelling Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 7 of 11 Table 5 Reference tests scores Screening result Reference Normal Altered p-value MEC score n = 141; 29.00 n = 52; 28.00 < 0.001 (28.00 to 30.00) (25.97 to 28.00) MEC altered (0 to 23) 1 (0.7%) 8 (13%) < 0.001 SPPB score n = 149; 10.00 n = 56; 7.00 < 0.001 (9.00 to 11.00) (6.75 to 8.25) SPPB category 0 to 3 points 0 (0%) 5 (8.9%) < 0.001 4 to 6 points 7 (4.7%) 9 (16%) 7 to 9 points 41 (28%) 37 (66%) 10 to 12 points 101 (68%) 5 (8.9%) Maximum speed (m / s) n = 144; 1.01 n = 54; 0.68 < 0.001 (0.86 to 1.17) (0.57 to 0.91) Slowness (≤ 0.8 m/s) 27 (18%) 34 (61%) < 0.001 MNA-SF: score n = 184; 14.00 n = 22; 10.00 < 0.001 (13.00 to 14.00) (9.25 to 12.75) MNA-SF: category Malnutrition 2 (1.1%) 0 (0%) < 0.001 Risk of malnutrition 16 (8.7%) 15 (68%) Normal 166 (90%) 7 (32%) GDS5: symptoms n = 155; 1.00 n = 49; 1.00 0.002 (1.00 to 1.00) (1.00 to 2.00) GDS5: presence of depressive symptoms 18 (12%) 16 (33%) 0.002 Visual acuity Normal vision (≥ 6/18) 118 (87%) 55 (80%) 0.055 Slight vision reduction (6/60) 16 (12%) 11 (16%) Moderate vision reduction (3/60) 0 (0%) 3 (4.3%) Severe vision impairment (< 3/60) 2 (1.5%) 0 (0%) Best ear hearing Better than average 1 (0.7%) 0 (0%) < 0.001 Normal hearing 73 (53%) 10 (15%) Minimal hearing loss 33 (24%) 15 (23%) Low hearing loss 17 (12%) 17 (26%) Moderate hearing loss 10 (7.2%) 15 (23%) Moderate-severe hearing loss 4 (2.9%) 7 (11%) Severe hearing loss 0 (0%) 2 (3.0%) Worst ear hearing Normal hearing 53 (38%) 6 (9.1%) < 0.001 Minimal hearing loss 28 (20%) 13 (20%) Low hearing loss 32 (23%) 12 (18%) Moderate hearing loss 12 (8.7%) 18 (27%) Moderate-severe hearing loss 9 (6.5%) 12 (18%) Severe hearing loss 4 (2.9%) 5 (7.6%) For continuous variables valid cases, median and interquartile rank. For categorical variables valid cases and valid column percent older adults at high level of autonomy, and in a very In the cognitive domain, participants with abnormal early stage of the ageing process. results in the ICOPE Screening tool obtained a lower Several considerations about the findings in the five score than those with normal results in the screen- IC domains are worth discussing. The screening for the ing; even when such range of difference for the MEC cognitive screening achieved the highest sensitivity. has been shown to be clinically meaningful for people Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 8 of 11 Fig.2 Reference scores according to screening result without cognitive impairment [29], the average score of would be expected as its severity increases. Never- both groups was within the range of normality [30]. For theless, sensitivity was worse when we consider the mobility, both SPPB score and gait speed also showed worst ear. In relation to Gwet AC1, all non-sensory fair performance of diagnostic measures, as well as domains show moderate to good agreement with the clinically meaningful differences between those with reference standard methods, which may be explained screening normal and abnormals [31], with averages because some items of the ICOPE Screening tests are below the normal threshold in the group with altered based in constructs that are similarto the original ref- results in the screening. In the vitality domain, those erence standard method. To our knowledgthis is the with abnormal results in the screening obtained worse first study comparing the results of the ICOPE screen- results in the MNA, with average scores below the nor- ing with a reference test for each single dimension. A mal threshold. In the psychological domain, the GDS5 previous Chinese ICOPE pilot [11] compared results of showed worse results in those participants with a posi- gait speed, MMSE, and GDS30 score between persons tive screening, although differfences were not found in with decreased IC in at least one domain. In this case the median score (between the normal range in both those with all domains preserved found worse results groups). Regarding the sensory domain, no differences in MMSE and GDS30in persons with decreased IC and between groups were found in vision. Finally, sensitiv- no differences in gait speed. Nevertheless their analysis ity results for audition seemed to be counter-intuitive, have a risk of classification bias that may underestimate as a higher probability of detecting a hearing problem the effects of decreased IC. Few studies [11, 32, 33] have Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 9 of 11 published findings about the frequency of decreased Conclusions IC, but substantial differences in inclusion criteria pre- The WHO ICOPE Screening tool showed fair perfor- vents a straightforward comparison with them. mance indicators in healthy older community-dwelling Two limitations should be acknowledged for the population in initial stages of the ageing process in the study. First, there is a selection bias due to the healthy VIMCI study. Despite the relatively limited results in status of the study participants, with a sample not fully the performance of diagnostic measures in this popula- representative of the overall health status of older peo- tion, the ICOPE Screening tool highlighted as a simple, ple aged 70 and over due to participation criteria and inexpensive, and feasible tool, and may be suitable to face sampling methods. As a consequence, prevalence and the barriers of the implementation of the ICOPE strategy. all indicators relaying on it must be interpreted with Repeated assessments (i.e., every six months) in those caution and may hinder its generalization to general people without abnormalities in the ICOPE screening older population. Second, the IC sensory domain was tool may be a potential way to overcome the underesti- assessed by a reference method that may have lower mation of decreased IC in those participants with normal sensitivity and specificity than others considered as initial results in the screening. the “gold standard” [34] but the evidence about studies Nevertherless, further studies in different settings are which include this domain among the IC construct is required in order to assess the usefulness of the ICOPE still scarce [35]. screening tool and to establish proper recommendations. Four strengths of the study should be highlighted. First, the highest methodological quality in a prospec- Abbreviations tive design with study procedures according to the GDS5 5 items Geriatric Depression Scale ICOPE guidelines, developed specifically to test the IC Intrinsic Capacity current hypothesis were followed, which differs from ICOPE Integrated Care for Older People IST Icope Screening Tool most analysis about ICOPE, mostly post-hoc analysis JGLS de Jong Gierveld Loneliness Scale and retrospective assessments. Second, the high qual- LSNS-R Lubben Social Network Scale–Revised ity of the information used, with a complete IC assess- MEC Mini Cognitive Examination MNA Mini Nutritional Assessment ment for the 5 domains with very little missing data. SPPB Short Physical Performance Battery Indeed, this is one of the few studies which include the VIMCI Validity of an Instrument to Measure Intrinsic Capacity sensory domain, measured by the appropriate instru- WHO World Health Organization ments to detect sensory issues in a validated, feasible, Acknowledgements and inexpensive way. This is extremely innovative, as The below persons contributed to data collection: Antonio Artuñedo information about the sensory, audition IC domain is González (Badalona Serveis Assistencials), Rocio Blanco Lapaz (Institut Català de la Salut Girona), Blanca Rosa Hernández Hernández (Badalona Serveis frequently missing, because it may not be accessible Assistencials), Ana Belén Fernández Sancho (Badalona Serveis Assistencials), in Primary Care health records, and if available is usu- Ivan Matey González (Badalona Serveis Assistencials), Maria Jesús González ally retrospectively collected. Third, one of the strong- (Fundació Sant Hospital), Pau Vilanova Gallart (Institut Català de la Salut Girona) est points of this paper is its novelty and originality, as to authors’ knowledge, no evidence is available about Authors’ contributions the performance of diagnostic measures of the ICOPE XR participated in the design of the study, the analysis and interpretation of the data and the writing of the article; SB and AS participated in the concep‑ Screening tool in their intended target population, tion and design of the study, the interpretation of the data and the review which make the findings valuable to advance forward of the article; DS participated in the writing and review of the article, SP, SF, in the implementation of the ICOPE strategy. Finally, NM, PF, MVR, RS, MVS, IM, MD, FR and AI participated in the acquisition of the data. The author(s) read and approved the final manuscript. the study showed the innovative experience of a larger systematic program aimed at identifying IC deficits and Funding implementing the WHO ICOPE approach as part of the The VIMCI study was carried out within the APTITUDE project, which is co- funded at 65% rate by the European Regional Development Fund (ERDF), decision-making process in clinical practice in a popu- through the INTERREG V-A Programme, Spain-France-Andorra (POCTEFA lation level. 2014–2020; grant EFA232/16), created by the European Union. The goal of the The detection of decreased IC in primary care is impor- project is to develop actions to prevent disability and dependence among older adults through the creation of a network of experts to promote care, tant because it has been associated to an increased risk of training, research and innovation in gerontology. death, incident disability and dependence (independently of health problems), up to a 5-year follow-up[6, 36, 37]. A Availability of data and materials The datasets analysed during the current study are not publicly available failure to recall 2 words or the day of the week has been because the informed consent stated that participants data will not be shared shown to increase the risk of incident dementia[38], and with any third party not related with the study. Data may be available from the a prolonged time performing the 5 times sit-to-stand test corresponding author on reasonable request after the approval of the Ethics Committee and the Data Protection Delegate of the Universitat Autònoma de is associated with disability[39]. Barcelona. Rojano i Luque et al. BMC Geriatrics (2023) 23:106 Page 10 of 11 Declarations 9. World Health Organization. Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary Ethics approval and consent to participate care. Geneva: World Health Organization; 2019. Report No.: WHO/FWC/ The study was conducted following the Good Clinical Practice guidelines, the ALC/19.1. ethical standards of the Helsinki Declaration (1964), and its further amend‑ 10. Leung AYM, Su JJ, Lee ESH, Fung JTS, Molassiotis A. Intrinsic capac‑ ments. Participants gave their informed consent before participation. The ity of older people in the community using WHO Integrated Care for reference Ethics Committee of each institution approved the study, namely: Older People (ICOPE) framework: A cross-sectional study. BMC Geriatr. Comitè d’Ètica en l’Experimentació Animal i Humana (CEEAH UAB) [Ref: 2022;22:304. 5328]; Comitè Ètic d’Investigació Clínica de l’IDIAP Jordi Gol [Ref: 20/194-P]; 11. Ma L, Chhetri JK, Zhang Y, Liu P, Chen Y, Li Y, et al. Integrated Care for Older CEIm—Hospital Universitari Arnau de Vilanova [Ref: CEIC-2394]; and Comitè People Screening Tool for Measuring Intrinsic Capacity: Preliminary Find‑ d’Ètica d’Investigació de la Fundació Unió Catalana Hospitals [Ref: 21/21]. Data ings From ICOPE Pilot in China. Front Med. 2020;7: 576079. were treated in compliance with the European Union General Data Protection 12. Aptitude [Internet]. 2022. 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