Guidance for person-centred assessment and pathways in primary care Second editionhandbookIntegrated care for older peopleGuidance for person-centred assessment and pathways in primary care Second editionhandbookIntegrated care for older peoplei

Guidance for person-centred assessment and pathways in primary care Second editionhandbookIntegrated care for older peopleIntegrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care, second edition

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Contents

Acknowledgements

Abbreviations and acronyms

Glossary

1

Integrated care for older people

2  Optimizing intrinsic capacity and functional ability

3

4

5

6

7

8

9

5

Four-step ICOPE pathway in primary care

Stakeholders and cross-cutting services for the

ICOPE care pathway in primary care

Care pathway to manage cognitive decline

Care pathway to improve mobility

Care pathway to manage malnutrition

Care pathway to manage vision impairment

Care pathway to manage hearing loss

iv

v

vi

1

11

15

41

53

63

73

85

95

10

Care pathway to manage depressive symptoms

105

10

11

Care pathway for social care and support

11

12

12

13

Care pathway to support carers

Care pathway to manage urinary incontinence

14

Implementation considerations for ICOPE

References

Bibliography

Annex: Example of a simplified care plan

115

125

133

143

149

152

154

iii

Acknowledgements

This handbook draws on the work of the many people around the
world dedicated to the care and support of older people. Yuka Sumi
and Rachel Albone in the Ageing and Health unit, Department of
Maternal, Newborn, Child and Adolescent Health and Ageing, World
Health Organization (WHO) led the preparation of this handbook,
under the leadership of Anshu Banerjee. Other colleagues in the unit
made invaluable contributions, including Matteo Cesari, Hyobum
Jang, Jotheeswaran Amuthavalli Thiyagarajan,  and YeJin Lee.

Many other WHO staff from regional offices and a range of technical
units contributed to this document: Andrew Briggs (WHO Regional
Office for South-East Asia), Shelly Chadha (Sensory Functions,
Disability and Rehabilitation), Neerja Chowdhary (Brain Health),
Carolina Der Mussa (Sensory Functions, Disability and Rehabilitation),
Shalini Desai (Essential Programme on Immunization), Laura Diaz
(Brain Health), Megan Doherty (Clinical Services and Systems),
Antony Duttine (Sensory Functions, Disability and Rehabilitation),
Samer Elfeky (WHO Regional Office for the Eastern Mediterranean),
Mai Eltigany (Noncommunicable Diseases), John Fogarty (Clinical
Services and Systems), Maria Nieves Garcia-Casal (Food and
Nutrition Action in Health Systems), Shoshanna Goldin (Health
Emergency Programme), Yuriko Harada (Oral Health Programme),
Thiago Herick De Sa (Demographic Change and Healthy Ageing),
Stefania Ilinca (WHO Regional Office for Europe), Mikiko Kanda (WHO
Regional Office for the Western Pacific), Catherine Kane (Health
workforce), Amrita Kansal (WHO Regional Office for South-East
Asia), Stuart Keel (Sensory Functions, Disability and Rehabilitation),
Pauline Kleinitz (Sensory Functions, Disability and Rehabilitation),
April Siwon Lee (WHO Regional Office for the Western Pacific), Silvio
Paolo Mariotti (Sensory Functions, Disability and Rehabilitation), Chris
Mikton (Demographic Change and Healthy Ageing), Patricia Morsch
(WHO Regional Office for the Americas), Andreas Mueller (Sensory
Functions, Disability and Rehabilitation), Triphonie Nkurunziza (WHO
Regional Office for Africa), Asiya Ismail Odugleh-Kolev (Quality of
Care), Alana Officer (Demographic Change and Healthy Ageing),
Roberta Ortiz (Noncommunicable Diseases), Alexandra Rauch
(Sensory Functions, Disability and Rehabilitation), Nicole Rendell
(Oral Health Programme), Katrin Seeher (Brain Health), Kylie Shae
(Health Products, Policy and Standards), Sangeeta Singh (WHO
Regional Office for Western Pacific), Shamsuzzoha Syed (Special
programme on Primary Health Care), Abena Tannor (Sensory
Functions, Disability and Rehabilitation), Emma Tebbutt (Health

Products, Policy and Standards), Benoit Varenne (Oral Health
Programme), Enrique Vega (WHO Regional Office for the Americas),
Inka Weissbecker (Brain Health), Kazuki Yamada (Demographic
Change and Healthy Ageing), Yongjie Yon (WHO Regional Office for
Europe),Mitasha Yu (Sensory Functions, Disability and Rehabilitation),
and  Patrick Zuber (Special programme on Primary Health Care).

The handbook also benefited from the valuable inputs of the
following experts in ageing and health and the care and support
of older people: Hanadi Alhamad (WHO Collaborating Centre for
Healthy Ageing and Dementia, Qatar University, Qatar), Márlon JR
Aliberti (University of São Paulo Medical School, Brazil), Hidenori
Arai (National Center for Geriatrics and Gerontology, Japan),
Prasert Assantachai (Mahidol University, Thailand), Liat Ayalon
(Bar Ilan University, Israel), Paola Barbarino (Alzheimer’s Disease
International, United Kingdom of Great Britain and Northern
Ireland[United Kingdom]), Jane Barratt (International Federation
on Ageing, Canada), Ivan Bautmans (Vrije Universiteit Brussel,
Belgium), John Beard (Columbia University, United States of
America [USA]), Fatemah Bendhafari (Ministry of Health, Kuwait),
Caroline Berbon (Toulouse University Hospital; WHO Collaborating
Centre for Frailty, Clinical and Geroscience Research, and Geriatric
Training, France), Heikea Bischoff-Ferrari (University of Zurich,
Switzerland), Marco Canevelli, (National Institute of Health,
Italy), Jagadish Chhetri (National Clinical Research Center for
Geriatric Disorders, China), Stephen Connor (Worldwide Hospice
and Palliative Care Alliance, United Kingdom), Eduardo Ferriolli
(University of São Paulo, Brazil), Roger Fielding (Tufts University,
USA), Leon Geffen (Samson Institute for Ageing Research, South
Africa), Celia Gregson (University of Bristol, United Kingdom),
Eva Heras Muxella (Andorran Healthcare System, Andorra), Lee
Hooper (University of East Anglia, United Kingdom), Yun-Hee Jeon
(University of Sydney, Australia), Javier Jerez (University of Vic -
Central University of Catalonia, Spain), Sebastiana Kalula (Albertina
& Walter Sisulu Institute of Ageing in Africa, South Africa), Ramesh
Kandel (Rapti Academy of Health Sciences, Nepal), Hongsoo
Kim (Seoul National University, Republic of Korea), Jan Kottner
(Charité-Universitätsmedizin Berlin, Germany), Christine Lafont
(IHU HealthAge, Toulouse University Hospital; WHO Collaborating
Centre for Frailty, Clinical and Geroscience Research, and Geriatric
Training, France), Caitlin Littleton (HelpAge International, United
Kingdom), Peter Lloyd-Sherlock (Northumbria University,

iv

United Kingdom), Carol Ma Hok Ka (Singapore University of
Social Sciences, Singapore), Shiromi Maduwage (Ministry of
Health, Sri Lanka), Finbarr Martin (King’s College London, United
Kingdom), Reshma Merchant (National University Health System,
Singapore), Jean-Pierre Michel (Geneva University Medical
School, Switzerland), Colin Milner (International Council on Active
Aging, Canada), Kenneth Edmund Mugayehwenkyi (Reach One
Touch One Ministries, Uganda), Cathy Murphy (University of
Southampton, United Kingdom), Claudio Pedone (Campus Bio
Medico University of Rome, Italy), Ian Philp (University of Kent,
United Kingdom), Jean-Yves Reginster (University of Liège; WHO
Collaborating Centre for Epidemiology of Musculoskeletal
Conditions and Ageing, Belgium), Leocadio Rodriguez Mañas
(Getafe University Hospital, Spain), Catherine Takeda (Toulouse
University Hospital; WHO Collaborating Centre for Frailty, Clinical
and Geroscience Research, and Geriatric Training, France), Hein
Thet Ssoe (AGE Myanmar, Myanmar), Vira Tum (HelpAge Cambodia,
Cambodia), Prakash Tyagi (Gramin Vikas Vigyan Samiti [GRAVIS],
India), Adrian Wagg (University of Alberta, Canada), Poppy Walton
(HelpAge International, United Kingdom), Sijiu Wang (Tsinghua
University, China), Camilla Williamson (HelpAge International,
United Kingdom), Jean Woo (Chinese University of Hong Kong,
SAR, China), Gordon Wood (Northwestern University Feinberg
School of Medicine, USA) and Anthony Woolf (Global Alliance for
Musculoskeletal Health, United Kingdom).

Inputs from the participants at the annual meeting of WHO Clinical
Consortium on Healthy Ageing (CCHA), December 2023, have also
been invaluable in the development of this handbook.

The WHO Department of Maternal, Newborn, Child and Adolescent
Health and Ageing acknowledges the financial support of the
Government of Japan, the Government of Germany and the
Kanagawa Prefectural Government in Japan.

Abbreviations and acronyms

ADL

activities of daily living

SDG

Sustainable Development Goal

BADL

basic activities of daily living

SPPB

short physical performance battery

BMI

CBT

body mass index

cognitive behavioural therapy

CCHA

Clinical Consortium on Healthy Ageing

CVD

dBA

cardiovascular disease

adjusted decibels

TAP

UHC

UI

UN

UTI

Training in Assistive Products (WHO)

universal health coverage

urinary incontinence

United Nations

urinary tract infection

dBHL

decibels hearing level

WHO

World Health Organization

FPG

fasting plasma glucose

IADL

instrumental activities of daily living

ICOPE

integrated care for older people approach

LBP

LTC

low back pain

long-term care

MUAC

mid-upper arm circumference

OSN

oral supplemental nutrition

PHC

primary health care

PTA

pure tone audiometry

v

Glossary

Ableism: A social prejudice that defines persons with disabilities by
their disabilities and characterizes them as being inferior to those who do
not have disabilities.

Age-friendly environment: Environment, such as home or
community, that fosters healthy ageing by building and maintaining
intrinsic capacity throughout the life course and by enabling greater
functional ability in someone with a given level of capacity.

Ageing in place: The ability to live in one’s own home and community
safely, independently and comfortably, regardless of age, income or
capacity. Ageing in (the right) place extends this concept to the ability to
live in the place that closest fits a person’s needs and preferences, which
may or may not be their own home.

Assistive products: Assistive products maintain or improve
functional ability and independence, and thereby promote well-being.
Assistive products can range from physical products such as wheelchairs,
spectacles, pill organizers, toilet chairs and hearing aids, to digital
solutions such as fall alarms, time management software and captioning.
Assistive technology is the umbrella term for assistive products and their
related systems and services.

Basic activities of daily living (BADL): The basic activities
necessary for daily life: bathing or showering, dressing, eating, getting in and
out of bed or chairs, using the toilet, and getting around inside the home.

Brain health: The state of brain functioning across cognitive, sensory,
social, emotional, behavioural and motor domains, allowing a person to
realize their full potential over the life course, irrespective of the presence
or absence of disorders.

Care coordinator: A health worker who ensures adequate
communication and coordination of decisions and information among
teams and services, facilitates navigation by an older person and carers
through various systems and ensures integrated care delivery. Case
managers frequently act as care coordinators. A care coordinator is often
chosen from the members of the multidisciplinary team.

Care worker: A health worker who provides direct personal care
services in the home, in health care and residential settings assisting
with routine tasks of daily life,  with the requisite training, remuneration,
supervision and regulation in place. Examples include formal caregivers,
social workers and nurses.

Carer: An individual such as a family member, partner, friend or
neighbour who delivers care within households or the community, who
commonly shares affective or social bonds with care recipients. They may
provide regular, occasional or routine care or be involved in organizing
care delivery by others. Carers are distinct from care workers, as they
are not employed by organizations entitled to coordinate and deliver
services. Their role is informal and unpaid.

Case manager: A health worker who supports, guides and
coordinates care for older people, families and carers. They serve as
the centre of communication, connecting individuals with members of a
multidisciplinary team and community stakeholders. A case manager is
usually chosen from the members of the multidisciplinary team.

Cognitive behavioural therapy (CBT): Psychological
treatment that combines cognitive components, aimed at thinking
differently (e.g. through identifying and challenging unrealistic negative
thoughts) and behavioural components, aimed at doing things differently
(e.g. by helping the person to do more rewarding activities).

Cognitive decline: A decline in one or more cognitive functions such
as attention, problem solving, learning ability and memory.

Cognitive function: Processes involved in the acquisition and
retention of knowledge (including language and social norms), manipulation
of information, reasoning and emotional regulation.

Cognitive stimulation therapy: A nonpharmacological
intervention that encompasses a variety of approaches including reality
orientation, validation, and/or reminiscence through group activities and
social interaction.

vi

Glossary

Cognitive training: An umbrella term referring to a group of non-
pharmacological interventions in which a range of techniques are applied
to engage thinking and cognition with various degrees of breadth and
specificity. It targets isolated cognitive functions (e.g. memory) with
individual, repetitive practice of standardized cognitive tasks.

Continuum of care: The spectrum of personal and population
health and social care needed during all stages of intrinsic capacity,
functional ability,  disease, injury or event throughout the life course,
including health promotion, prevention, treatment, rehabilitation,
palliative care and long-term care.

Community-based health care: Services delivered by a
range of health workers in the community, according to their training and
capacity – lay and professional, formal and informal, paid and unpaid – as
well as facility-based personnel who support and supervise them and
provide outreach services and campaigns.

Functional ability: The health-related attributes that enable people
to be and to do what they have reason to value; it is made up of the intrinsic
capacity of the individual, relevant environmental characteristics and the
interactions between the individual and these characteristics.

Community engagement: A process of developing and
maintaining relationships that enable stakeholders who share a
geographical location and/or thematic area of focus to work together to
address health-related issues and promote well-being to achieve positive
and sustainable health impact and outcomes.

Community health worker: Health workers who provide health
services including health education, in partnership with health workers in
health care facilities and referrals for a wide range of services, and provide
support and assistance to communities, families and individuals. They
provide preventive health measures and facilitate access to appropriate
health and social services by bridging gaps between providers of health,
social and community services and communities that may have difficulty
in accessing these services.  Community health workers are also  known as
village health worker, community health aide or promoter, health educator,
or some other term.

Community stakeholders: Individuals, families, groups or
organizations that have an interest or investment in a community and are
affected by or can affect the decisions, policies and operations within that
community. This includes but is not limited to civil society organizations
(e.g. nongovernmental organizations, community-based organizations,
faith-based organizations), private sector constituencies, older
people’s associations, groups or clubs, peer support groups, volunteers
and home-based carers, operating within an organized programme.
Community health workers are considered to be community stakeholders,
while also being included under the definition of health workers.

Geriatrics: Medical speciality focused on providing patient-centred
care to older people.

Health workers: All people primarily engaged in actions with the
primary intent of enhancing health (e.g. health and care workers, health
care professionals, health programme managers).

Healthy ageing: The process of developing and maintaining the
functional ability that enables well-being in older age.

ICOPE handbook: The tool to support health workers to provide
ICOPE in primary care, including the community.

Inappropriate medication(s): Inappropriate medication(s) are
present when one or more medicines are prescribed that are not or no
longer needed, either because: a) there is no evidence-based indication,
the indication has expired or the dose is unnecessarily high; b) one or
more medicines fail to achieve their therapeutic objectives; c) one, or the
combination of several medicines, cause or are at risk of causing adverse
drug reactions; and d) the patient is not willing or able to take one or more
medicines as intended.

Instrumental activities of daily living (IADL): Activities
that facilitate independent living: ability to use a telephone, shopping,
food preparation, housekeeping, laundry, transportation method, use of
medication, handling finances.

vii

Integrated care: Services managed and delivered in a way that
ensures people receive a continuum of care across health and social care,
through a person-centred approach. This includes health promotion,
prevention, diagnosis, treatment, rehabilitation and palliative care
and social care services including long-term care. Service delivery is
integrated across sectors, settings and sites across the life course.

Integrated care for older people approach (ICOPE):
The WHO approach to provide a continuum of integrated care that helps
to reorient health and social services towards a more person-centred
and coordinated care that supports optimizing intrinsic capacity and
functional ability for older people. The approach is referred to as "ICOPE".

Palliative care: An approach that improves the quality of life of
patients and their families who are facing problems associated with
life-threatening illness. It prevents and relieves suffering through the
early identification, correct assessment and treatment of pain and other
problems, whether physical, psychosocial or spiritual.

Person-centred care: An approach to care that consciously
adopts the perspectives of individuals, families and communities, and
sees them as participants in, as well as beneficiaries of, health care and
LTC systems that respond to their needs and preferences in humane and
holistic ways. Person-centred care is organized around the needs, values,
preferences and expectations of individuals rather than diseases.

Intrinsic capacity: The composite of all the physical and mental
capacities that an individual can draw on.

Loneliness: A subjective experience arising from a mismatch between
expected and the actual quality and quantity of connections.

Long-term care (LTC): The activities undertaken by others to
ensure that people with a significant ongoing loss of intrinsic capacity
can maintain a level of functional ability consistent with their basic rights,
fundamental freedoms and human dignity.

Multidisciplinary team: A group of health and care workers
from various organizations and professions (e.g. doctors, nurses,
physiotherapists, social workers) that work together to make decisions
regarding the care of an older person and their carers, and provide care in
a collaborative and coordinated manner.

Multimodal exercise: Exercise that is designed to develop balance,
aerobic capacity, muscle strength, flexibility and coordination with the
aim of maintaining and promoting intrinsic capacity (e.g. locomotor
capacity, cognition), reducing the risk of falls and preventing injuries
including fractures.

Physical activity: Any bodily movement produced by skeletal
muscles that requires energy expenditure – including activities
undertaken while working, playing, carrying out household chores,
travelling or engaging in recreational pursuits.

Physical exercise: Subcategory of physical activity that is planned,
structured, repetitive and aims to improve or maintain one or more
components of physical capacities.

Polypharmacy: The concurrent use of multiple medications often
defined as the routine use of five or more medications. This includes
over-the-counter, prescription and/or traditional and complementary
medicines used by a patient.

Primary care: A key process in the health system that supports first-
contact of care, often provided in primary care facilities, community
health centres, health posts, mobile clinics and through outreach
services. Primary care enables the continued provision of person-centred
integrated care within close proximity to people’s daily lives.

Primary health care (PHC): A whole-of-society approach to
effectively organize and strengthen national health systems to bring
services for health and well-being closer to communities. It has three
components: integrated health services to meet people’s health needs
throughout their lives; addressing the broader determinants of health
through multisectoral policy and action; and empowering individuals,
families and communities to take charge of their own health.

viii

Glossary

Psychoeducation: An intervention to provide information to people
with mental health conditions and their carers/family members about
the nature of the condition, including its likely causes, progression,
consequences, prognosis and treatment.

Social support: Psychological, physical and financial support
accessible to an individual through social ties to other individuals, groups
and the wider community, which can provide a buffer against adverse life
events, foster resilience and provide a positive resource for health.

Task sharing: An approach to optimize health workforce utilization,
particularly in the face of workforce shortages, wherein specific tasks
or roles are shared, where appropriate, to less specialized health
workers in order to make more efficient use of the available personnel.
It should be accompanied by appropriate measures in terms of
education, supervision, management support, licensing, regulation and
remuneration.

Universal health coverage (UHC): All people have access to
the full range of quality health services they need, when and where they
need them, without financial hardship. It covers the full continuum of
essential health services, from health promotion to prevention, treatment,
rehabilitation and palliative care across the life course.

Rehabilitation: Rehabilitation refers to a set of interventions
designed to optimize functioning and reduce disability in individuals with
health conditions in interaction with their environment. Rehabilitation
helps older people to be as independent as possible in everyday activities
and enables participation in education, work, recreation and meaningful
life roles.

Rehabilitation services: Delivery of interventions for rehabilitation
(see above definition) through a structured process of identifying needs,
defining goals, planning, delivering and monitoring care, usually over a
series of sessions.

Self-care: The ability of individuals, families and communities to
promote and maintain their own health, prevent disease and to cope with
illness – with or without the support of a health or care worker.

Self-management: The ability to use devices, medicines and
knowledge to undertake self-medication, self-treatment, self-examination
and self-injection.

Social care: Assistance and support to individuals and their families
with the basic and instrumental activities of daily living (personal care) to
promote quality of life and well-being.

Social isolation: Refers to the objective number of social
connections and interactions an individual experiences. A person may
be socially isolated if they have a small network of kin and non-kin
relationships and thus few or infrequent interactions with others.

Social protection: Social protection is a human right and is defined as
the set of policies and programmes designed to reduce and prevent poverty
and vulnerability throughout the life course. Social protection includes
benefits for children and families, maternity, unemployment, employment
injury, sickness, older age, disability, as well as health protection.

ix

x

1 Integrated care for

older people

Key points

 The key to supporting healthy ageing for all is optimizing
people’s intrinsic capacity and functional ability throughout the
life course.

 Care-dependency can be reduced, delayed or prevented
if the declines in intrinsic capacity are promptly identified,
assessed, diagnosed and managed including through creating
an enabling physical and social environment.

  The declines across the domains of intrinsic capacity are
interrelated and so require an integrated and person-centred
approach to assessment and management.

 Older people are key actors in their own health and should
be empowered to understand their health, make their
own decisions and set their own goals. Their meaningful
engagement, and that of their carers, is crucial.

 Health workers in primary care, including in the community,
can identify older people with loss(es) in intrinsic capacity and
provide evidence-based interventions by using this guidance
and adapting it to their context.

 Community stakeholders have an important role to play in
supporting the delivery of integrated care for older people,
and empowering them to engage with self-care and self-
management.

The 2015 World report on ageing and health defines the goal of
healthy ageing as "helping people to develop and maintain the
functional ability that enables well-being in older age". Functional
ability is defined as the “health-related attributes that enable people
to be and to do what they have reason to value”. Functional ability
consists of the intrinsic capacity of the individual, their environment
and the interactions between the two. Environments comprise all
the factors in the extrinsic world (home and home surroundings,
community and broader society) that form the context of an
individual’s life. Factors within these environments include the built
(physical) environment, people and their relationships, attitudes and
values, health and social policies, systems and services. Intrinsic
capacity is “the composite of all the physical and mental capacities
that an individual can draw on”(1).

This concept of healthy ageing inspires a new focus for health
care for older people – a focus on optimizing people’s intrinsic
capacity and functional ability as they age. As an older person’s
intrinsic capacity changes, so too will their needs and preferences
for health services and social care and support. The delivery of a
continuum of integrated care, following the trajectory of intrinsic
capacity and functional ability, is crucial in order to meet these
diverse needs and support optimal functional ability. A continuum
of care includes the full spectrum of care, from prevention and
promotion to treatment, rehabilitation and palliative care  and
responds to a person’s changing needs and intrinsic capacity, and
disease progression.

Older people with significant loss of intrinsic capacity not only
need health care, but also appropriate social care and support
to compensate for their loss. This support may be provided by
carers and can be facilitated by the use of assistive products to
create an enabling environment. Long-term care (LTC) includes
activities undertaken by others to support people with significant
loss of intrinsic capacity to maintain a level of functional ability
and sustain a dignified life, consistent with their basic rights and
fundamental freedoms. Long-term care can be provided in various
settings such as home, community and residential facilities. Much
of the day-to-day care needed by older people is provided by
carers, often family members, who also require support.

1

1

Integrated care for older people

1

1.1
Why do we need integrated
care for older people?

Older people make up a larger part of the world’s population than
ever before. In 2024, there were an estimated 1.18 billion people
aged 60 years or over in the world (14.5% of the global population).
This percentage will rise rapidly in the coming decades, particularly
in low- and middle-income countries. By 2050, there will be
2.1 billion people aged 60 and over, constituting 22% of the global
population (2), and people aged 65 and over will outnumber those
under 18 (3). This reflects the combined impact of rapidly falling
fertility rates and increasing life expectancy in much of the world,
often accompanying socioeconomic development.

Maintaining the health of older people is an investment in
human and social capital and supports the United Nations (UN)
Sustainable Development Goals (SDGs) and the right of all people
everywhere to the highest attainable standard of physical and
mental health. At the same time, caring for the growing older
population creates challenges for health and social care systems.
A fundamental change in public health approaches to population
ageing is needed.

Conventional approaches to health care for older people have
focused on individual diseases, often in isolation, putting the
diagnosis and management of these at the centre. Addressing these
diseases remains important, but focusing too much on them can
lead to difficulties when hearing, seeing, remembering, moving and
the other common losses in intrinsic capacity that can come with
ageing are overlooked.

A shift to an integrated continuum of care that is holistic and
focuses on intrinsic capacity and functional ability besides
diseases is required, based on a primary health care (PHC)
approach. They share a bidirectional relationship, with poorly
controlled diseases potentially precipitating the onset or

acceleration of declines in intrinsic capacity, and impairments
of intrinsic capacity potentially altering disease trajectories.
Attention throughout the health and social care system(s) to
the intrinsic capacity and functional ability of older people will
contribute broadly to the welfare of this large and growing part of
the population.

Health workers including care workers need guidance and training
to recognize and effectively manage declines in intrinsic capacity
and maintain functional ability, and to deliver care in an holistic
and integrated way that responds to the diverse health and care
needs of older people. As populations age, there is a pressing
need to develop comprehensive community-based approaches
that include interventions to prevent or delay declines in intrinsic
capacity, optimize functional ability by enabling the physical and
social environment, and to support the carers of older people.

1.2
What is the integrated care
for older people approach?

The integrated care for older people approach, referred to as
ICOPE, aims to facilitate the reorientation of health and social
services towards more person-centred and coordinated
care that supports the optimization of intrinsic capacity and
functional ability for older people. ICOPE is WHO’s approach to
support the delivery of integrated care for older people within
the context of a PHC-oriented health system.

A continuum of care requires the

implementation of integrated

services for older people and

their carers across all health and

social care settings, from older

people’s homes, primary care

clinics and hospitals to LTC facilities.

Communities have a particularly

important role to play to enable

“ageing in place”.

2

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Integrated care for older people

Box 1.1  Ageism

Ageism refers to the stereotypes (how we think), prejudice (how we feel) and
discrimination (how we act) directed towards people on the basis of their age.
Ageism exists in our institutions, our relationships (interpersonal) and ourselves (self-
directed). Ageism impacts negatively on older people’s health and well-being (4).

Ageism within health systems and services: At the system level, health strategies
often neglect older people or may include ageist policies, such as the denial of
treatment on the basis of age; care for older people and specific services that
address the most common issues faced in older age are often neglected; funding
is not prioritized; and facilities are not designed to be accessible for older people.
A lack of training and support and unchallenged cultural perceptions of ageing
can also lead to health workers having negative attitudes towards older people
or the ageing process, engaging in patronizing behaviour, failing to consult older
people about their preferences for care, and exclusion of older people from
clinical trials. Declines in intrinsic capacity are often overlooked by health workers,
who interpret them as “normal” signs of ageing, which is a form of ageism. The
attitudes of health workers and older people’s experiences within health care
settings can affect older people's health-seeking behaviour. The extent to which
health workers hold ageist attitudes towards older people, while perceived to
be high, is uncertain. A range of systemic and individual factors can influence
attitudes, including policies, education, resource shortages, gender, whether
the health worker chose to work specifically with older people, experience of
intergenerational contact and cultural background.

Self-directed ageism: Self-directed ageism refers to ageism turned against
oneself that has a negative impact on health. People internalize age-based biases
from their surrounding culture after being repeatedly exposed to those biases.
They may think that declines in intrinsic capacity are “normal” with increasing age
and cannot be prevented or changed and may feel there is nothing they can do to
improve their own health and well-being.

ICOPE offers an opportunity to tackle ageism by improving the competencies of
health workers in older people’s health and integrated care and by empowering
older people and carers. Community stakeholders can play a role through
raising awareness, including with older people themselves, about ageism and
older people’s right to health and care, the effectiveness of health promotion
and prevention in older age, and that it is possible to manage losses in intrinsic
capacity and to optimize functional ability.

ICOPE should be implemented in line with the following guiding
principles:

•  Older people have the right to the highest attainable

standard of physical and mental health.

•  Older people should have equal opportunity to access

services that address the determinants of healthy ageing,
and to be supported to adopt healthy behaviours, regardless
of their social or economic status, place of birth, residence,
age, gender or other social factors.

•  Older people should be included as key decision-makers in

their own care, respecting their autonomy.

•  Care should be provided equally to all, without

discrimination, particularly gender discrimination, ableism or
ageism (Box 1.1).

The WHO Integrated care for older people: guidelines on
community-level interventions to manage declines in intrinsic
capacity set out 13 evidence-based recommendations for health
workers to carry out person-centred integrated care for older
people in primary care including in the community. In order to put
these ICOPE recommendations into practice, WHO published the
Integrated care for older people handbook: guidance on person-
centred assessment and pathways in primary care in 2019 (5) to
address the lack of guidance and training for most health workers in
recognizing and effectively managing declines in intrinsic capacity
and functional ability and delivering holistic and integrated care. It
offered a care pathway, consisting of steps health workers should
take in the delivery of integrated care for older people and detailed
care pathways to manage declines in intrinsic capacity across six
domains – cognitive decline, limited mobility, malnutrition, vision
impairment, hearing loss, depressive symptoms – as well as to
support carers and enable social care and support.

3

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Integrated care for older people

1

1.3
ICOPE in primary health care

WHO defines PHC as a whole-of-society approach to health that
aims at ensuring the highest possible level of health and well-being
and their equitable distribution by focusing on people’s needs as
early as possible along the continuum from health promotion and
prevention to treatment, rehabilitation and palliative care, and as
close as feasible to people’s everyday environment.

As outlined in the Declaration of Astana, PHC includes three
inseparable and mutually influential components:

•

•

•

putting primary care and the essential public health functions
together at the core of integrated health services;

leveraging multisectoral policy and action; and

empowering people and communities as co-creators of
their health.

Primary care is at the heart of the services component of PHC that
supports first-contact, accessible, continuous, comprehensive
and coordinated care, often provided in primary care facilities
(polyclinics, walk-in clinics), homes, community health centres,
health posts, mobile clinics and through outreach services.  It is
characterized as the delivery of a full spectrum of integrated health
services, close to where people live, through a person-centred
approach. Primary care can also drive other components of the PHC
approach by engaging with the community and empowering older
people and their carers.

The original care pathway in the first ICOPE handbook (2019) was
designed  to support health workers in primary care to provide
person-centred integrated care within close proximity to an older
person’s daily life. The steps of the original care pathway can,
however, be applied in different settings and with older people with
varying levels of intrinsic capacity, including those with significant
losses (LTC needs). This handbook (second edition) therefore offers
an overarching care pathway comprised of four steps (Fig. 1.1, p. 5),
that should be seen within a broader PHC approach at the

population level, supporting the identification of older populations'
needs; planning, designing, organizing, managing and monitoring
of services. It can be adapted and expanded through the provision
of detailed guidance for each step, to enable its implementation in
different situations and settings (e.g. for older people in residential
LTC facilities).

Any adaptation and development of the overarching care
pathway should maintain a core focus on:

•

•

 an assessment of individual needs, preferences and goals;

 the development of a personalized care plan;

•  multidisciplinary team-based service delivery;

•

•

•

longitudinal care provision following the trajectory of
intrinsic capacity;

coordinated health and social services, driven towards the
single goal of maintaining intrinsic capacity and functional
ability; and

reorientation towards a PHC approach to meet the needs of
older people with services delivered through primary care
including in the community.

This overarching care pathway can inform multisectoral policy and
action, recognizing the important roles of sectors beyond health
such as housing, transport and social welfare, in line with the vision
of the UN Decade of Healthy Ageing (2021-2030) (Box 1.2, p. 6). The
overarching care pathway can be used alongside the ICOPE care
pathway in primary care to influence policy decision making with
regard to service provision for older people. This will contribute to
the strengthening of the PHC-oriented health systems required
to enable the delivery of a continuum of integrated care for older
people (Chapter 14). Implementation of ICOPE could also support
the achievement of better health outcomes, improved equity,
increased health security and better cost-efficiency; all closely
linked with PHC.

The detailed care pathways (Chapters 3-13), focus explicitly on the
implementation of integrated care for older people in primary care.

4

1

Integrated care for older people

Fig. 1.1
ICOPE care pathway

5

DEVELOP A PERSONALIZED CARE PLANIMPLEMENT & MONITORBBBAssess loss in intrinsic capacity Assess social and physical environmentsAssess for diseases and risk factorsIN-DEPTHASSESSMENTBASIC ASSESSMENT*ABC1234Identify and consolidate interventions, considering all resultsReassess According to the care plan After acute event or illnessWhen social role or living situation changes Basic assessment should always be conducted in full, particularly for loss of intrinsic capacity - see 3.1.1 for full instructions*Identify key family, relatives, friendsUnderstand the older person's life, values, priorities and socioeconomic context for loss of intrinsic capacityfor key factors in older people's health (social support, support for carers, urinary incontinence)provide health and lifestyle advice and promote self-careBefore the assessment:An integrated care plan, developed with the older personCoordinated implementation and follow up by a multidisciplinary team 1

Integrated care for older people

Box 1.2  ICOPE in context

The UN Decade of Healthy Ageing, 2021-2030 includes a focus on the role of
health systems in promoting healthy ageing by optimizing intrinsic capacity
and functional ability, initially outlined in the WHO Global Strategy and Action
Plan on Ageing and Health (2016–2020) (6). The vision of the UN Decade is a
world in which all people live long and healthy lives delivered through a global
multisectoral collaboration for concerted and catalytic action on healthy
ageing. It is focused on four action areas including the delivery of person-
centred, integrated care and primary health services responsive to older
people, and providing access to LTC for older people who need it. The ICOPE
technical resources for primary care as well as the Long-term care for older
people: package for universal health coverage (7) contribute to achieving
these commitments.

Universal health coverage (UHC) is the foundation for achieving the health
objectives of the SDGs and means that all people have access to the full range
of quality health services they need, when and where they need them, without
financial hardship (8). To achieve UHC, older people’s health needs must be
addressed through  a continuum of integrated care, delivered through health
services that are based on a PHC-oriented health system.

WHO has developed a suite of resources to optimize primary care service
delivery, including the UHC Service Planning, Delivery & Implementation
(SPDI) Platform and the UHC Compendium. The SPDI is an online resource
that supports countries to optimize and integrate service delivery, across the
full spectrum of care and across the life course. Countries are able to build a
package of health services using specific tools and resources, including the
ICOPE technical resources.

Achieving health for all is the goal of UHC. To achieve this, all people, including
all older people, need to have access to health services. Disability is not a natural
part of ageing, but prevalence of disability does increase with age, from 5.8% in
children and adolescents aged 0–14 years, to 34.4% among people aged > 60
years (9). The delivery of disability inclusive health services requires intersectoral
actions to support access for older people with disabilities, alongside all people
living with disabilities. The WHO Global report on health equity for people with
disabilities outlines 40 key actions for countries to take to strengthen their health
systems and reduce health inequities for people with disabilities.

1.4
Integrated care for older
people: guidance for person-
centred assessment and
pathways in primary care
(ICOPE handbook), second
edition

This second edition of the ICOPE handbook in primary care
incorporates learning from the implementation of integrated care
for older people in diverse contexts around the world and relevant
new or updated guidelines produced by WHO. The ICOPE handbook
(second edition) has been developed in collaboration with experts in
healthy ageing and the care of older people through WHO’s Clinical
Consortium on Healthy Ageing (CCHA) and with colleagues across a
range of technical units and regions in WHO.

 Inputs were sought through field experiences as well as meetings
of the CCHA, primarily the 2023 meeting, at which the update of
the care pathways was the major agenda item. Participants at this
meeting and other experts reviewed the revised care pathways and
guidance in this handbook throughout its development.  All those
involved in the development and review of the handbook were asked
to declare any conflicts of interest on the WHO form for declaration
of interests by WHO experts. No declared interests were considered
to be significant.

6

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Integrated care for older people

Key changes in the second edition of the handbook

1. Four-step care pathway
The ICOPE care pathway consists of four rather than five steps:
basic assessment and community level interventions; in-
depth assessment; developing a personalized care plan; and
implementing and monitoring. The crucial role of community
stakeholders and carers at all steps of the pathway has been
recognized. In response, community engagement and supporting
carers have been included as key elements across the four
steps of the pathway, with a key focus in Step 1, rather than being
addressed as a separate fifth step.

3. Community engagement
The ICOPE handbook (second edition) has an increased focus
on community engagement. It provides examples of what
community stakeholders can do at each step of the pathway,
including in the delivery of the expanded Step 1, facilitating
access to health and social care, providing direct support
in the community and empowering older people in their
health decision-making. Community stakeholders include
individuals, groups and organizations, such as nongovernmental
organizations, older people’s clubs, community-based
organizations, peer support groups, intergenerational groups
and volunteers, among others.

2. Expanded Step 1
To ensure the provision of key information, services and support, at
the first point of contact with an older person, as well as to enable
the delivery of care for older people within communities and by
community stakeholders in resource-limited contexts, Step 1 has
been expanded. Alongside a basic assessment (previously termed
"screening"), health and lifestyle advice and community-based
health care to address losses in intrinsic capacity can be provided.
The term "basic assessment" is used, rather than screening, to reflect
the move from a sole focus on potential losses in intrinsic capacity,
to also identify social support needs, carers’ needs for support
and presence of urinary incontinence – key factors impacting older
people’s health. The expansion of Step 1 to include provision of
services and support is particularly important in contexts where the
latter steps of the ICOPE pathway, including in-depth assessment,
are not feasible to deliver, or there may be a long delay between a
basic and an in-depth assessment.

4. Carers’ support needs
Recognizing the role of carers, most of whom are women and girls,
usually family members or friends, and the lack of support they often
face, greater attention is given to the support needs of carers. This
includes both information and training, and the need for support to
ensure carers’ own health and well-being. This issue was included
in the previous version of the handbook but has now been given
greater prominence with specific examples included in all chapters.
In the handbook, the term “carer” is used to refer to an individual,
such as a family member, friend or neighbour who provides informal
care to an older person.

5. Key factors in older people’s health
Additional factors important to older people’s health and
functional ability are included and/or given more emphasis.
This includes early identification of social support needs and
carers needs (where applicable) in the community, promotion
of vaccination as one of the most cost-effective public health
interventions, and inclusion of urinary incontinence (UI), for which
a new care pathway has been developed.

7

1

Integrated care for older people

Implementation in primary care

should be done within and by

existing services in a culturally

appropriate way.

1.5
How to use the ICOPE
handbook (second edition)

This handbook provides a global framework and guidance for the
implementation of ICOPE  that health workers can use to inform
the delivery of integrated care for older people in primary care in
their context. It aims to provide flexibility, to ensure feasibility of
implementation across different countries, contexts and resource
settings. To this end, prior to implementing ICOPE in primary care,
programme and system managers should conduct an assessment
of their readiness to deliver, to inform an adaptation of the
approach. This is important as the needs of older populations as
well as health and social care systems, service delivery structures
and capacities are different. Health workers can undertake similar
exercises to identify available resources in their own health care

settings.

 14.2

The detail of the specific care pathways (Chapters 5–13), in terms
of tools and instruments to be used and which evidence-based
interventions to be offered, where and by whom, is flexible and
should be considered as part of an adaptation process.

8

Examples of adaptation within the ICOPE handbook (second
edition) include:

•  Questions and tests in the ICOPE basic assessment and for

key factors are given as examples based on available evidence
and expert consultation and can be amended to ensure
relevance to the local context. For example, the social support
questions are intended to enable a broad understanding of
an older person’s social needs. The way questions are asked
and the wording used should be adjusted to ensure they are
relevant and appropriate culturally, religiously and societally,
and will be understood by older people.

•  Who does each step, where and how? Although this updated
pathway suggests Step 1 is implemented by community
stakeholders (
workers in a primary care facility.

 4.1.3), it can also be conducted by health

•

•

Instruments for use in the in-depth assessment are also
intended as examples, based on global validation and
recommendations. It is important that locally validated and
existing tools are used where they exist.

The interventions suggested for inclusion in personalized care
plans, are recommendations, based on available evidence.
A personalized care plan should be developed by a health
worker with input from the older person and carers, where
appropriate, and should respond to the person’s goals and
preferences. All interventions in the care plan must be feasible
to provide.

In some contexts, the capacity of health and social care systems
might affect the assessment of intrinsic capacity and need for
social care and support, as well as provision of interventions.
It is important to note that screening for diseases, such as
hypertension, suggested as part of a basic assessment,  is
unethical if referral pathways are not in place to enable access
to further assessment and treatment. The global guidance and
framework in this handbook may, therefore, be aspirational in
some settings, and can provide an aim to work towards.

1

Integrated care for older people

In all contexts and resource settings, there will be things that can
be done to support older people with losses in intrinsic capacity.
Through the expanded first step of the care pathway, this handbook
provides recommendations for what can be done in the community
immediately following a basic ICOPE assessment by community
health workers and other community stakeholders if an in-depth
assessment is not feasible or there will be a long delay. These actions
include health and lifestyle advice to prevent declines in intrinsic
capacity and functional ability and community-based health care to
address declines in intrinsic capacity.

The intention of including community-level interventions at the
time of a basic assessment is not to reduce the importance of the
in-depth assessment or the development and implementation of
a personalized care plan, which should always be the aim to enable
integrated person-centred care. Rather it is to demonstrate what
can be done as a starting point and in contexts where it may not
yet be possible to implement the full pathway. This information can
be found at the start of all chapters, following the care pathway
diagram, and is highlighted both on the pathway diagrams and
within the text by a coloured/shaded background.

1.6
Who is this handbook for?

The primary audience for this handbook is health workers in
primary care, which include doctors, nurses, community health
workers, pharmacists, nutritionists, social workers, care workers
and physiotherapists, among others. The language used is
purposefully simple to make the handbook accessible to as many
health workers as possible, with varying levels of training in older
people’s health and for whom English is not a first language.

Community stakeholders who provide services, advice and
support for older people can utilize the handbook to support
increased community engagement. The handbook should also
inform health workers whose specialized knowledge will be called
on, as needed, to assess and provide care for older people.

Additionally, authorities responsible for developing training and
curricula and providing accreditation in medicine, nursing, social
care and public health fields may draw on both the concepts
and the practical approaches described here. Other audiences
include health care managers and policy-makers, such as national,
regional and district programme managers in charge of planning
and organizing health care services, as well as agencies that fund
and/or carry out public health programmes, including age-friendly
cities and communities programmes.

9

1

Integrated care for older people

10

1.7
What does this handbook
oﬀer?

This handbook seeks to support health workers with
multidisciplinary backgrounds to identify and manage declines
in intrinsic capacity, based on recommended interventions
in the WHO Integrated care for older people: guidelines on
community-level interventions to manage declines in intrinsic
capacity and relevant WHO technical guidelines and guidance.
It facilitates the provision of integrated person-centred care in
primary care by addressing the health and social care needs of
older people.

This guidance describes how to:

•

•

•

•

•

•

•

Implement the step-by-step ICOPE care pathway in
primary care, including the provision of community-level
interventions.

Ensure engagement across stakeholders and sectors,
including with specialized services (Chapter 4).

Assess and manage loss of intrinsic capacity, with
consideration of associated diseases and environmental
factors (Chapters 5–10).

Assess need for and provide social care and support
(Chapter 11).

Assess need for and provide support for carers (Chapter 12).

Assess and manage urinary incontinence (Chapter 13).

Address key considerations in implementing ICOPE (Chapter 14).

M O R E   I N F O R M AT I O N

 UHC Compendium Health interventions for Universal

Health Coverage, Version 1.3. WHO; 2024 (https://www.

who.int/universal-health-coverage/compendium).

 UHC Service Planning, Delivery & Implementation (SPDI)

Platform. WHO; 2024 (https://www.who.int/universal-

health-coverage/compendium/related-tools).

 UN Decade of Healthy Ageing: plan of action, 2021–

2030. WHO; 2020 (https://www.who.int/publications/m/

item/decade-of-healthy-ageing-plan-of-action).

 Integrated care for older people: guidelines on

community-level interventions to manage declines

in intrinsic capacity. WHO; 2017 (https://iris.who.int/

handle/10665/258981).

 Implementing the primary health care approach:

a primer. WHO; 2024 (https://iris.who.int/

handle/10665/376777).

 Operational framework for primary health care:

transforming vision into action. WHO and UNICEF; 2020

(https://iris.who.int/handle/10665/337641).

2 Optimizing intrinsic capacity

and functional ability

Key points

 Intrinsic capacity tends to decline with increasing age; however,
a wide range of capacities around the average pattern,
highlights the importance of a person-centred continuum of
integrated care.

 Proactively identifying losses in intrinsic capacity in primary
care provides an opportunity to slow or reverse declines and
maintain intrinsic capacity and functional ability.

 Characteristics and behaviours that affect intrinsic capacity
can often be modified through the adoption of healthy
lifestyles and behaviours.

  Modifications to an older person’s physical and social
environment become increasingly important as intrinsic
capacity declines, in order to optimize functional ability.

 Community stakeholders can advocate for the creation of
environments in which older people are able to adopt healthy
behaviours, while also providing direct services and support.

This handbook supports maintaining functional ability by addressing
declines in intrinsic capacity, enabling social and physical
environments (including social care and support), providing support
for carers’ needs and assessing and managing urinary incontinence.

Key domains of intrinsic capacity

5

5

6

7

8

9

Cognition  |  Cognitive decline

Locomotor capacity  |  Limited mobility

Vitality  |  Malnutrition

Vision  |  Vision impairment

Hearing  |  Hearing loss

10

Psychological capacity  |  Depressive symptoms

Key factors in older people's health

10

11

Social care and support

11

12

Carer support

12

13

Urinary incontinence

11

2

Optimizing intrinsic capacity and functional ability

Fig. 2.1
Public health framework for healthy ageing: opportunities for public health
action across the life course

Source: World report on ageing and health. WHO; 2015.

12

2.1
How does intrinsic capacity
change over the life course?

Fig. 2.1 shows the typical pattern of intrinsic capacity and
functional ability across the second half of life. Intrinsic capacity
and functional ability decline with increasing age as a result of the
ageing process as well as underlying diseases. This pattern can
be divided into three common periods: a period of relatively high
and stable capacity; a period of declining capacity; and a period
of significant loss of capacity, characterized by dependence on
care. ICOPE primarily aims to address the needs of an older person
with declining capacity or with a significant loss of capacity, taking
into consideration aspects of LTC and age-friendly environments
of relevance to an individual’s goals and care needs. For those
with high and stable capacity, ICOPE provides an opportunity to
ensure health promotion and prevention.

There is a wide range of intrinsic capacity around the average
pattern evident both within and between countries. This is
reflected in persistent differences in life expectancies, which
range from 83 years and over in, for example, Australia, Italy, Japan,
the Republic of Korea, Sweden and Switzerland, to less than
58 years in the Central African Republic, Chad, Lesotho, Nigeria
and South Sudan (10).

Variation in intrinsic capacity is far greater across people in older
age than across younger groups. Such diversity is one of the
hallmarks of ageing, presenting both challenges and opportunities,
including for person-centred approaches. One individual may be
10 years older than another but may have a similar intrinsic capacity
and/or functional ability, while two older people of the same age
can show very different intrinsic capacity. This is why chronological
age is a poor marker of health status for older people.

2

Optimizing intrinsic capacity and functional ability

2.2
Intervening to optimize
intrinsic capacity and
functional ability

Identifying losses in intrinsic capacity provides an opportunity
to intervene to slow or reverse the declines and maintain intrinsic
capacity and functional ability (Fig. 2.1, p. 12). Health workers
in primary care, including community stakeholders, can detect
declines in intrinsic capacity.

Many of the characteristics and behaviours that can determine
or affect intrinsic capacity can be modified. For example, health
and lifestyle advice can be provided stressing the importance
of healthy diet, being physically active and avoiding a sedentary
lifestyle, staying socially connected, vaccination and when and
where to seek health services. These behaviours not only help
directly with the maintenance of intrinsic capacity, but also reduce
the risk of diseases that can contribute to losses in capacity.
ICOPE in primary care supports these healthy behaviours and
wider efforts towards optimizing intrinsic capacity and managing
risk factors in the second half of life.

Repeated assessments over time and regular follow up make it
possible to monitor any changes in intrinsic capacity while also
managing chronic diseases. Specific interventions to address
declines in intrinsic capacity as well as to provide social care
and support can be offered in a timely manner. Multicomponent
interventions that address different declines appear to be
effective because of the interaction between the intrinsic
capacity domains.

Community stakeholders can

play a role in holding governments

and local authorities to account

on efforts to address social

determinants of health and create

environments in which older

people are able to adopt healthy

behaviours, while also providing

services and support directly.

Modifications to an older person’s physical and social environment
become increasingly important as intrinsic capacity declines, in
order to optimize functional ability. Five domains of functional
ability (Box 2.1, p. 14) can all be supported by changes to an
older person’s home, home surroundings and other external
environments. For example, making changes at home to reduce
the risk of falls, or providing assistive products such as mobility
aids can support older people to be mobile, while providing
information on opportunities to engage with local community
events and groups can encourage continued social contribution,
as seen in examples provided by WHO’s Global Network for Age-
friendly Cities and Communities.

Carers also have an important role to play. They are often older
themselves and may have their own care and support needs. The
ICOPE care pathway includes an assessment of carers' needs and
the provision of training and support.

An integrated approach is necessary to the assessment and
management of declines in intrinsic capacity and functional ability
and the provision of a continuum of care that brings together health
and social care and support actors and services, including LTC.

13

Box 2.1  Domains of functional ability

•

•

•

•

•

To meet basic needs such as financial security, housing
and personal security, and access to health services.

To learn, grow and make decisions, including continuing
to learn and apply knowledge, engage in problem-solving,
maintain personal development, and have the ability to
make choices.

To be mobile, to keep doing things around the home,
accessing shops, services and facilities in the community,
and participating in social, economic and cultural
activities.

To build and maintain a broad range of relationships,
including with children and other family members, informal
social relationships with friends and neighbours, as well as
formal relationships with community health workers.

To contribute, which is closely associated with
engagement in social and cultural activities, such as
assisting friends and neighbours, mentoring peers and
younger people, volunteering, and caring for family
members and the community.

14

3

Four-step ICOPE pathway
in primary care

The four-step pathway in primary care includes basic assessment
and interventions in the community; in-depth assessment;
developing a personalized care plan; and implementing and
monitoring the plan. Primary care  is a key process in the health
system that supports first-contact care, often provided in primary
care facilities (e.g. walk-in clinics, polyclinics), homes, community
health centres, health posts, mobile clinics and through outreach
services. Primary care enables the continued provision of person-
centred integrated care within close proximity to people’s daily
lives. The steps of this ICOPE care pathway in primary care can be
implemented in any of these settings, and can often be delivered
with community stakeholders.

Person-centred care takes the perspective that older people are
individuals with unique needs and preferences within their specific
social contexts. Their care goes beyond managing their diseases
or health conditions to responding to their diverse needs, including
their need for LTC, embracing their choices and experiences. It also
addresses the impact older people’s health conditions and care
needs have on their family members and carers.

Key points

 Possible impairments in intrinsic capacity and social support
needs can be identified in the community.

 Community health workers and other trained community
stakeholders can provide tailored health and lifestyle advice
to older people while conducting a basic assessment, and
support them to undertake specific actions in response to
potential losses of intrinsic capacity and to prevent risk factors.

 Those identified with potential losses of intrinsic capacity
should be referred to primary care for in-depth assessment,
which will inform the development of a personalized care plan,
including referral to specialized care.

 The care plan may include multiple interventions, agreed
in discussion with the older person (and carers), to manage
impairments and prevent further declines of intrinsic capacity
and to optimize functional ability.

 The prioritization and sequencing of the interventions can be
guided by the urgency of an issue, the likelihood of success and
the wider impact of addressing the issue, and what the older
person feels is most important to them.

 Community stakeholders can play a role at each step of
the care pathway and should be meaningfully engaged and
appropriately supported to do so.

15

16

DEVELOP A PERSONALIZED CARE PLANAssess loss in intrinsic capacity Assess social and physical environmentsIMPLEMENT & MONITORDiscuss with the older person and carer(s) to:       Deﬁne the goal of care       Design an integrated care planConvene multidisciplinary team across health and social care, and other sectors, where neededCoordinate implementationEnsure regular follow up Reassess According to the care plan After acute event or illnessWhen social role or living situation changes 1Provide health and lifestyle advice and promote self care, including vaccinationIdentify need for social support and provide the supportConduct basic assessment regularlyRegardless of result:BBBIdentify and consolidate interventions, considering all resultsIdentify key family, relatives, friendsUnderstand the older person's life, values, priorities and socioeconomical  context Before the assessment:2Assess for diseases and risk factorsThe ICOPE care pathway in primary care34IN-DEPTHASSESSMENT(can be assessed in any order)PASSFAILBASIC ASSESSMENT* and initial interventionABCCommunity-based health care for intrinsic capacity lossReferral to primary care COMMUNITYPRIMARY CARETest for loss of intrinsic capacity1234*Basic assessment should always be conducted in full, see 3.1.1 for full  instructions3

The ICOPE care pathway in primary care

1

2

3

In-depth assessment

Develop a personalized care plan

Basic assessment and community-level
interventions

For all older people:

A.

Assess loss in intrinsic capacity

Conﬁrmation of the impairment of intrinsic capacity for

Conduct basic assessment for loss of intrinsic capacity

domain(s) that failed the screening test

(Table 3.1)

Provide health and lifestyle advice and promote self-care,

including vaccination and management of cardiovascular

disease (CVD) risk factors (3.1.3, 3.1.4)

Identify need for social support (home environment,

ﬁnancial security, loneliness and social participation) and

carer support and provide the support  (Table 3.2)

For older people who fail the screening for loss
of intrinsic capacity:

In addition to above, provide community-based health care

to address the speciﬁc losses in intrinsic capacity (3.1.5)

Refer to primary care

Community engagement

Community stakeholders including community health

workers facilitate care provision for older people, their

family and carers. Meaningful proactive community

engagement is important in the delivery of all steps of the

ICOPE pathway in primary care.

B.

Assess for diseases and risk factors

Assess need for:

Management of diseases and risk factors

Medication review

Vaccination

C.

Assess social and physical environment

Assess need for:

Environmental modiﬁcation

Assistive products

Social care and support, including risk of abuse and

need for personal care and assistance for daily life

(11.2, 11.4, 11.5)

Carers’ support needs (12.3)

Community icon

Health worker icon

This icon is used to denote actions that

This icon is used to show actions that should be

can be taken by community health

undertaken by a health worker primarily providing

workers and other trained community

care at a health facility, such as a doctor, nurse,

stakeholders

social worker or other health professional

Self-care and self-management

Community-based services and support

Multi-component interventions to manage and prevent

further declines in intrinsic capacity and functional ability

Management of diseases and risk factors

Vaccination

Medication review

Provision and maintenance of assistive products

Social care and support

10

11

Support for carers

11

12

4

Referral to specialized care (e.g. geriatric care, palliative

care, rehabilitation services)

4

Implement and monitor the
personalized care plan

Coordination of health and social care across settings,

including in the community

Coordination with specialized care

Regular and sustained follow up

Monitor adherence and discuss changes to the care plan

as necessary

Regular information sharing among health workers in a

multidisciplinary team including outcomes, barriers and

complications of interventions

17

       3.4       3.2       3.1       3.3       4.1.3
3

The ICOPE care pathway in primary care | Basic assesssment

There are four steps to consider when addressing older people’s
health and social care needs through an integrated care approach
in primary care (see p. 16). Throughout all steps, engaging older
people and the wider community, and ensuring support for carers
are critical. The four steps of the pathway will usually need to be
undertaken over time, in a series of discussions with the older
person, potentially involving multiple different health workers. In
most contexts, Step 1 can be implemented within the community
by community stakeholders (but may also be undertaken by
health workers at primary care facilities). The in-depth assessment
should be conducted by health workers at a primary care facility.
Given that both the in-depth assessment and the development
of a personalized care plan may require time and coordination
between different health workers, these steps will likely need to be
completed during scheduled meetings. Steps 3 and 4 require the
involvement of health workers including care workers, community
stakeholders and carers.

3.1
Basic assessment and
community-level interventions

ICOPE in primary care provides an opportunity to engage older
people, including those who may have limited access to health
services, with the objective of enhancing health and well-being, by
improving health literacy, promoting healthy lifestyles, providing
social support, when needed, and increasing health-seeking
behaviour. By offering a basic assessment, community health workers
and other community stakeholders can reach older people with
information and support and ensure an increased understanding of
any challenges they may be facing.

In the second edition of this handbook, the expanded Step 1 of the
ICOPE care pathway in primary care focuses on a basic assessment
with the possibility of delivering timely community-level interventions,
as appropriate:

•

The basic assessment is aimed at identifying:

–   Loss(es) in intrinsic capacity.

–    Key factors impacting older people’s health, such as

urinary incontinence (UI) (where feasible) and the need for
social support and carer support.

•

•

Provision of health and lifestyle advice, including in relation
to CVD risk factors.

Provision of community-based health care to address
loss(es) in intrinsic capacity including through supporting
adaptations to an older person’s environment.

•

 Referral to primary care for in-depth assessment (Step 2).

Expanding Step 1 aims to take maximum advantage of the first
contact with an older person for health promotion and prevention.
In addition to testing for the loss(es) of intrinsic capacity, Step 1
provides the opportunity to give specific information and support
and deliver community-based health care in contexts where the
implementation of all steps of the ICOPE pathway may not be
immediately possible or where an older person might choose not
to attend. As such, basic assessment and provision of health and
lifestyle advice should be provided to all older people (tailored
to respond to specific needs where possible). Older people
identified as having potential loss(es) of intrinsic capacity or
issues related to other key factors impacting their health should
be referred to primary care and social services and provided with
community-based health care where appropriate.

In the ICOPE basic assessment, simple questions and tests are
used to identify potential impairments across six domains of
intrinsic capacity (Table 3.1, p. 19), the need for social support and
carers’ support, and the presence of UI (Table 3.2, p. 27).

18

3

The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

Table 3.1
Basic assessment for loss of intrinsic capacity

Filter question
If YES, proceed for in-depth
assessment (Step 2)

.

Tests

Assess fully any domain
with a checked circle

Pass

5

Cognitive decline
(Cognition)

Do you have problems with
memory or orientation (such as
not knowing where you are or
what day it is)?

5

6

Limited mobility
(Locomotor capacity)

7

Undernutrition
(Vitality)

1.

2.

Remember three words (use nouns,
for example): ﬂower, door, rice.

Orientation in time and space: What
is the full date today? Where are you
now (home, clinic, etc.)?

3.

Recalls the three words?

Chair rise test
Rise from chair ﬁve times without
using arms. Did the person complete
ﬁve chair rises within 14 seconds?

1.

Weight loss
Have you unintentionally lost more than
3 kg over the last 3 months?

2.

Appetite loss
Have you experienced loss of appetite?

8

Vision impairment
(Vision)

Do you have any problems with
your eyes: difficulties in seeing far
or near*, eye pain or discomfort?

1.

External eye check

2.

Visual acuity test using WHO vision
screening chart*:

*with spectacles if normally worn

Do you have diabetes, or
hypertension, or are currently using
steroids or eye medications?

•  Distance vision (6/12 for each eye)

•  Near vision (N6 for both eyes)

9

Hearing loss
(Hearing)

Do you have a hearing problem?

Whisper test  or

For those using a hearing aid(s) add,
“even when using your hearing aid(s)”.

,

Screening audiometry or

Digits-triplet-in-noise test

10

Depressive symptoms
(Psychological capacity)

Over the past 2 weeks, have you been
bothered by either of the following:

•  Feeling down, depressed or hopeless?

•  Little interest or pleasure in doing things?

Wrong to either question
or does not know

Correct to both
questions

Cannot recall all three words

No

Yes

Yes

Fail

Fail

Fail

Yes

Yes

Yes

No to both
questions

Pass

Pass for both
distance and
near vision

Pass

No to both
questions

19
19

3.1.1
How to conduct a basic assessment
for loss of intrinsic capacity

A basic assessment  for loss of intrinsic capacity, which
usually takes 8–12 minutes (Table 3.1, p. 19), can be conducted
by trained community health workers, community volunteers,
nurse assistants, nurses, doctors and social workers or other
health workers.

It is strongly recommended to assess all domains of intrinsic
capacity at one time, not separately. For cognition, vision
and hearing, a filter question is suggested. If the older person’s
response is YES, they can be referred directly for an in-depth
assessment (Step 2) and no further basic assessment for these
domains is necessary. The basic assessment can be adapted to
the local health system and capacity of health workers.

3

20
20

• The person is unable to attempt the chair rise test; OR • Is unable to stand up ﬁve times within 14 seconds.Chair rise test• The person cannot answer one of the two questions   about orientation; OR• Cannot remember all three words.In-depth assessment is needed if:In-depth assessment is needed if:Simple memory and orientation test 1. Remembering three words: Ask the person to remember three words that you will say. Use simple, concrete nouns such as “ﬂower”, “door”, “rice”.2. Orientation in time and space: Then ask: “what is the full date today?” and “where are you now?” (home, clinic, etc.).3. Recalling three words: Now ask the person to repeat the three words that you mentioned.Filter question“Do you have problems with memory or orientation (such as not knowing where you are or what day it is)?”If the answer is YES, go directly to Step 2 – in-depth assessment.The person answers YES to either question.In-depth assessment is needed if:For improved safety, place a sturdy chair, ideally without armrests, next to a wall and demonstrate to the person how to do the test. If a person using a walking stick feels safe conducting the chair rise test with it, ask them to do so. Ask the person: “Do you think it would be safe for you to try to stand up and sit down from a chair ﬁve times as quickly as possible without using your arms, and without causing yourself pain or discomfort?” If the answer is YES, ask them to: • Sit in the middle of the chair.• Cross and keep their arms over their chest.• Stand up fully and sit down again.• Repeat ﬁve times as quickly as possible without stopping.Time the person taking the test in seconds. Ask the following two questions:• “Have you unintentionally lost more than 3 kg over the last 3 months?” (If body weight is unknown, ask: “have you noticed loose clothes, belts or wrist watches?”) • “Have you experienced loss of appetite?”If equipment is available, weigh the person and record their weight.Cognitive declineBasic assessmentLimited mobilityBasic assessmentUndernutritionBasic assessment555673

The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

2121

• The person is unable to attempt the chair rise test; OR • Is unable to stand up ﬁve times within 14 seconds.Chair rise test• The person cannot answer one of the two questions   about orientation; OR• Cannot remember all three words.In-depth assessment is needed if:In-depth assessment is needed if:Simple memory and orientation test 1. Remembering three words: Ask the person to remember three words that you will say. Use simple, concrete nouns such as “ﬂower”, “door”, “rice”.2. Orientation in time and space: Then ask: “what is the full date today?” and “where are you now?” (home, clinic, etc.).3. Recalling three words: Now ask the person to repeat the three words that you mentioned.Filter question“Do you have problems with memory or orientation (such as not knowing where you are or what day it is)?”If the answer is YES, go directly to Step 2 – in-depth assessment.The person answers YES to either question.In-depth assessment is needed if:For improved safety, place a sturdy chair, ideally without armrests, next to a wall and demonstrate to the person how to do the test. If a person using a walking stick feels safe conducting the chair rise test with it, ask them to do so. Ask the person: “Do you think it would be safe for you to try to stand up and sit down from a chair ﬁve times as quickly as possible without using your arms, and without causing yourself pain or discomfort?” If the answer is YES, ask them to: • Sit in the middle of the chair.• Cross and keep their arms over their chest.• Stand up fully and sit down again.• Repeat ﬁve times as quickly as possible without stopping.Time the person taking the test in seconds. Ask the following two questions:• “Have you unintentionally lost more than 3 kg over the last 3 months?” (If body weight is unknown, ask: “have you noticed loose clothes, belts or wrist watches?”) • “Have you experienced loss of appetite?”If equipment is available, weigh the person and record their weight.Cognitive declineBasic assessmentLimited mobilityBasic assessmentUndernutritionBasic assessment55567• The person is unable to attempt the chair rise test; OR • Is unable to stand up ﬁve times within 14 seconds.Chair rise test• The person cannot answer one of the two questions   about orientation; OR• Cannot remember all three words.In-depth assessment is needed if:In-depth assessment is needed if:Simple memory and orientation test 1. Remembering three words: Ask the person to remember three words that you will say. Use simple, concrete nouns such as “ﬂower”, “door”, “rice”.2. Orientation in time and space: Then ask: “what is the full date today?” and “where are you now?” (home, clinic, etc.).3. Recalling three words: Now ask the person to repeat the three words that you mentioned.Filter question“Do you have problems with memory or orientation (such as not knowing where you are or what day it is)?”If the answer is YES, go directly to Step 2 – in-depth assessment.The person answers YES to either question.In-depth assessment is needed if:For improved safety, place a sturdy chair, ideally without armrests, next to a wall and demonstrate to the person how to do the test. If a person using a walking stick feels safe conducting the chair rise test with it, ask them to do so. Ask the person: “Do you think it would be safe for you to try to stand up and sit down from a chair ﬁve times as quickly as possible without using your arms, and without causing yourself pain or discomfort?” If the answer is YES, ask them to: • Sit in the middle of the chair.• Cross and keep their arms over their chest.• Stand up fully and sit down again.• Repeat ﬁve times as quickly as possible without stopping.Time the person taking the test in seconds. Ask the following two questions:• “Have you unintentionally lost more than 3 kg over the last 3 months?” (If body weight is unknown, ask: “have you noticed loose clothes, belts or wrist watches?”) • “Have you experienced loss of appetite?”If equipment is available, weigh the person and record their weight.Cognitive declineBasic assessmentLimited mobilityBasic assessmentUndernutritionBasic assessment555673

The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

22

M O R E   I N F O R M AT I O N

 Vision and eye screening implementation
handbook. WHO; 2023 (https://iris.who.int/
handle/10665/375590).

  Training on reading spectacles. WHO; 2024
Training in Assistive Products (gate-tap.org).

Filter question“Do you have any problems with your eyes: diﬃculties in seeing far or near (with spectacles if normally worn), eye pain or discomfort?”“Do you have diabetes or hypertension, or are currently using steroids or eye medications?”If the answer is YES to either question, go directly to Step 2 – in-depth assessment. • A person listens to sets of three digits (e.g. 4−7−3)   presented with background noise.• The digits are spoken one at a time.• The person must repeat the digits they hear.• The result is recorded as either "pass" (correctly identify at   least 50% of the digit triplets) or "fail” (low score).Test near vision with the WHO vision screening chart• Test both eyes together (binocularly). • Hold the near chart at 40 cm from the person’s eyes.• A pass result of the near vision test is when both eyes see at least three of the Es (N6). • If near vision is worse than N6, check if the person is able to see N6 clearly with trial readymade reading spectacles.       Test distance vision with the WHO vision screening chart• Test each eye separately (monocularly), starting with the right eye ﬁrst, then the left eye.• Use an occlude (or a hand) to cover the eye not being tested.• Verify that the person is looking at the chart straight, without turning or twisting their head.• Ensure the chart is 3 m from the person’s eyes.• Start with the large Es (6/60). If at least two of the large Es (6/6) are seen, continue the test with the small Es (6/12).• Record the results for the right eye, and repeat the steps for the left eye.• A pass result of the distance vision test is when each eye sees at least three of the small Es (6/12).       Any of the following external eye abnormalities are observed: signiﬁcant crust or pus on eyelid margin, excessive watery or sticky discharge from the eyes, eye lashes turn inward, abnormal lid closure, abnormal red on the white part of the eye, abnormal haziness or red on the coloured part of the eye.In-depth assessment is needed if:1. External eye checkLook at the appearance of the external eye, eyelids and eyelashes, and observe how the eyelids open and close.2. Visual acuity testWhen testing visual acuity, the following points should be considered: • A well-lit testing space that allows a testing    distance of at least 3 m is required.• Demonstrate how to do the E test by  pointing with the ﬁngers in the direction that  the E is facing.• Test distance vision ﬁrst followed by near vision  (with spectacles if normally worn).• The WHOeyes app is available as a free mobile phone app for vision screening in all six UN languages and some additional languages (https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/whoeyes)• The person’s distance vision is worse than 6/12  in either eye; ORIn-depth assessment is needed if:• The person is unable to see N6 with the readymade   reading spectacles.The external eyeTop lidEyelashTear ductCornea(clear layer over the coloured part of the eye) Bottom lidConjuctivaPupilIrisVision impairmentBasic assessment888N6WHO NEAR VISION SCREENING CHART (40 cm test distance)612WHO DISTANCE VISION SCREENING CHART (3 metre test distance)cm

23

Filter question“Do you have any problems with your eyes: diﬃculties in seeing far or near (with spectacles if normally worn), eye pain or discomfort?”“Do you have diabetes or hypertension, or are currently using steroids or eye medications?”If the answer is YES to either question, go directly to Step 2 – in-depth assessment. • A person listens to sets of three digits (e.g. 4−7−3)   presented with background noise.• The digits are spoken one at a time.• The person must repeat the digits they hear.• The result is recorded as either "pass" (correctly identify at   least 50% of the digit triplets) or "fail” (low score).Test near vision with the WHO vision screening chart• Test both eyes together (binocularly). • Hold the near chart at 40 cm from the person’s eyes.• A pass result of the near vision test is when both eyes see at least three of the Es (N6). • If near vision is worse than N6, check if the person is able to see N6 clearly with trial readymade reading spectacles.       Test distance vision with the WHO vision screening chart• Test each eye separately (monocularly), starting with the right eye ﬁrst, then the left eye.• Use an occlude (or a hand) to cover the eye not being tested.• Verify that the person is looking at the chart straight, without turning or twisting their head.• Ensure the chart is 3 m from the person’s eyes.• Start with the large Es (6/60). If at least two of the large Es (6/6) are seen, continue the test with the small Es (6/12).• Record the results for the right eye, and repeat the steps for the left eye.• A pass result of the distance vision test is when each eye sees at least three of the small Es (6/12).       Any of the following external eye abnormalities are observed: signiﬁcant crust or pus on eyelid margin, excessive watery or sticky discharge from the eyes, eye lashes turn inward, abnormal lid closure, abnormal red on the white part of the eye, abnormal haziness or red on the coloured part of the eye.In-depth assessment is needed if:1. External eye checkLook at the appearance of the external eye, eyelids and eyelashes, and observe how the eyelids open and close.2. Visual acuity testWhen testing visual acuity, the following points should be considered: • A well-lit testing space that allows a testing    distance of at least 3 m is required.• Demonstrate how to do the E test by  pointing with the ﬁngers in the direction that  the E is facing.• Test distance vision ﬁrst followed by near vision  (with spectacles if normally worn).• The WHOeyes app is available as a free mobile phone app for vision screening in all six UN languages and some additional languages (https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/whoeyes)• The person’s distance vision is worse than 6/12  in either eye; ORIn-depth assessment is needed if:• The person is unable to see N6 with the readymade   reading spectacles.The external eyeTop lidEyelashTear ductCornea(clear layer over the coloured part of the eye) Bottom lidConjuctivaPupilIrisVision impairmentBasic assessment888N6WHO NEAR VISION SCREENING CHART (40 cm test distance)612WHO DISTANCE VISION SCREENING CHART (3 metre test distance)cm3

The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

M O R E   I N F O R M AT I O N

 Hearing screening: considerations for

implementation. WHO; 2021

(https://iris.who.int/handle/10665/344797).

24

Hearing lossBasic assessmentOne of three possible tests can be used for a basic assessment of hearing. Headphones are required except for the whisper voice test. It is important to ensure that levels of background noise are below 40 dBA (adjusted decibels). This can be ensured by testing with a sound level meter or with the use of a validated smartphone app (e.g. NIOSH Sound Level Meter). Both ears are tested together using an automated digits-in-noise test to determine how well the person can identify the digits despite the background noise.• A person listens to sets of three digits (e.g. 4−7−3)   presented with background noise.• The digits are spoken one at a time.• The person must repeat the digits they hear.• The result is recorded as either "pass" (correctly   identify at least 50% of the digit triplets) or "fail”   (low score).hearWHO is available as mobile phone app for free, in English, Chinese, Spanish, Russian, Dutch and French  (https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/hearwho)Detection of pure tones in both ears (each ear separately) at a ﬁxed dB level (35 dBHL [decibels hearing level]), at three frequencies (1 kHz, 2 kHz and 4 kHz). Results are recorded as "pass" (the test is passed) or "fail" (further evaluation is needed). 2. Screening audiometryThis is the simplest option but should only be used when other tests are unavailable. Tests 2 and 3 should be used where possible.Stand about an arm’s length away behind and to one side of the person.Ask the person to cover the ear that is NOT being tested by pressing one ﬁnger on the tragus (the small, pointed cartilage in front of the ear canal). Show how. Take a deep breath and exhale fully. Then whisper four common unrelated words (words should be familiar to the person, e.g. rice, ﬁsh, bicycle, garden, yellow, sky, dog). Speak the words one at a time, waiting for the person to repeat each word back to you. If the person repeats three or more words and you are sure that they can hear you clearly, then the person is likely to have normal hearing in this ear.Move to the other side of the person and test the other ear using diﬀerent words.Filter question“Do you have a hearing problem?” (for those using a hearing aid(s) add, “even when using your aid(s)”). If the answer is YES, go directly to Step 2 – in-depth assessment (diagnostic audiometry).  In-depth assessment is needed if:The person fails to repeat three or more of four words.In-depth assessment is needed if:The person fails to respond at 35 dBHL at one or more frequencies in either ear. In-depth assessment is needed if:The person fails to respond at 35 dBHL (presented as low score, e.g. hearWHO app score is below 50). Hearing test1. Whisper voice test3. Digits-triplet-in-noise test     9999
3

The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

After basic assessment for loss of
intrinsic capacity

Explain the results and the importance of regular reassessment.

For all older people:

•

•

Identify needs for support and provide the support.

 3.1.2

Provide health and lifestyle advice.

 3.1.3

•  Where possible, measure blood pressure  to identify

hypertension and enable management of CVD risk factors and
refer where necessary.

 3.1.4

For an older person identified as having potential loss(es) in
intrinsic capacity:

•

•

Refer to primary care for in-depth assessment (Step 2),
if losses are not already being addressed.

Provide community-based health care for loss of intrinsic
capacity if appropriate.

25

Hearing lossBasic assessmentOne of three possible tests can be used for a basic assessment of hearing. Headphones are required except for the whisper voice test. It is important to ensure that levels of background noise are below 40 dBA (adjusted decibels). This can be ensured by testing with a sound level meter or with the use of a validated smartphone app (e.g. NIOSH Sound Level Meter). Both ears are tested together using an automated digits-in-noise test to determine how well the person can identify the digits despite the background noise.• A person listens to sets of three digits (e.g. 4−7−3)   presented with background noise.• The digits are spoken one at a time.• The person must repeat the digits they hear.• The result is recorded as either "pass" (correctly   identify at least 50% of the digit triplets) or "fail”   (low score).hearWHO is available as mobile phone app for free, in English, Chinese, Spanish, Russian, Dutch and French  (https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/hearwho)Detection of pure tones in both ears (each ear separately) at a ﬁxed dB level (35 dBHL [decibels hearing level]), at three frequencies (1 kHz, 2 kHz and 4 kHz). Results are recorded as "pass" (the test is passed) or "fail" (further evaluation is needed). 2. Screening audiometryThis is the simplest option but should only be used when other tests are unavailable. Tests 2 and 3 should be used where possible.Stand about an arm’s length away behind and to one side of the person.Ask the person to cover the ear that is NOT being tested by pressing one ﬁnger on the tragus (the small, pointed cartilage in front of the ear canal). Show how. Take a deep breath and exhale fully. Then whisper four common unrelated words (words should be familiar to the person, e.g. rice, ﬁsh, bicycle, garden, yellow, sky, dog). Speak the words one at a time, waiting for the person to repeat each word back to you. If the person repeats three or more words and you are sure that they can hear you clearly, then the person is likely to have normal hearing in this ear.Move to the other side of the person and test the other ear using diﬀerent words.Filter question“Do you have a hearing problem?” (for those using a hearing aid(s) add, “even when using your aid(s)”). If the answer is YES, go directly to Step 2 – in-depth assessment (diagnostic audiometry).  In-depth assessment is needed if:The person fails to repeat three or more of four words.In-depth assessment is needed if:The person fails to respond at 35 dBHL at one or more frequencies in either ear. In-depth assessment is needed if:The person fails to respond at 35 dBHL (presented as low score, e.g. hearWHO app score is below 50). Hearing test1. Whisper voice test3. Digits-triplet-in-noise test     9999More information: Hearing screening consideration for implementation https://www.who.int/publications/i/item/9789240032767  Depressive symptomsBasic assessmentThe person answers YES to either question.In-depth assessment is needed if:Ask the following two questions:“Over the past 2 weeks, have you been bothered by either:• Feeling down, depressed or hopeless?• Little interest or pleasure in doing things?”After basic assessment for loss of intrinsic capacityExplain the results and the importance of regular reassessment.For all older people•Identify needs for support (3.1.3) and provide the support•Provide health and lifestyle advice (see Section 3.1.4)•Where possible, measure blood pressure and refer (see Section 3.1.4).For an older person with potential loss(es) in intrinsic capacity                              •Refer to primary care for in-depth assessment (Step 2), if losses are not being addressed.•Provide community-based health care for losses if appropriate. 10Providing care, particularly for an older person with significant
losses in intrinsic capacity, can be physically and psychologically
demanding, and it can affect the carer’s own health and well-
being. It is important that the needs of carers are identified
during a basic assessment or in-depth assessment as relevant,
and support for carers is included in the development and
implementation of a personalized care plan. Table 3.2 (p. 27)
includes questions that should be asked to carers.10
11
11   12

Urinary incontinence: Urinary incontinence is a common condition
affecting millions of older people, particularly older women (11)
impairing their quality of life and well-being (12). Given high levels of
under reporting of UI, likely due to the stigma felt by those affected,
and the resultant lack of access to care, it is recommended that
questions on UI are asked to older people during a basic assessment
in the community or in-depth assessment at a primary care facility
when assessing relevant intrinsic capacity domains (e.g. cognitive
decline, mobility loss, depressive symptoms). It is recognized that
there are potential challenges of conducting sensitive discussions
with older people in the range of environments ICOPE basic
assessment takes place.

13

12

3

The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

3.1.2
Key factors impacting older people’s health

After conducting a basic assessment for loss of intrinsic capacity,
a second element of basic assessment can be used to identify
other key factors impacting older people’s health, including social
support needs, support for carers and UI. Urinary incontinence is
treated separately from the domains of intrinsic capacity because it
is a disease (geriatric syndrome), not intrinsic capacity, but it affects
and is affected by losses of intrinsic capacity.

Social support and support for carers: Understanding the social
support needs of older people and their carers to enable the
inclusion of appropriate interventions within a personalized care
plan, and the delivery of these interventions, is crucial in the provision
of integrated care. In recognition of the importance of these issues
and their potential lack of prioritization, this handbook brings earlier
attention to social support and support for carers, by including
questions on these topics earlier in the ICOPE care pathway.

Addressing social determinants of health, such as socioeconomic
status, social connectivity and housing is key to improving health
outcomes for older people and optimizing functional ability. It is
recommended that all older people are asked about their social
support needs, irrespective of their intrinsic capacity. These
questions can be asked by the person who has conducted the basic
assessment, either directly after a negative ICOPE basic assessment
(i.e. no potential losses are identified) OR in cases where potential
losses have been identified but an in-depth assessment is not
(immediately) possible. Alternatively they can also be asked during
the in-depth assessment at a primary care facility, as part of the
broader assessment of the social and physical environments.

Given social and cultural diversity, the wording of the social and carer
support questions in Table 3.2 (p. 27), should  be adjusted to ensure
they are relevant and appropriate in the context in which they are being
asked. It is important to ensure that any adjustment or adaptation to
these questions does not lead to the use of discriminatory language,
including ageist words or terminology.

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The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

Table 3.2
Basic assessment of key factors impacting older people’s health

10

11

Social care and support

Questions/assessment

Home environment
Do you have problems with your home, for example, house
condition, location, safety?

Financial situation
Do you often have insuﬃcient funds to pay for your food, housing
and health care costs?

Social isolation and loneliness
Do you often feel lonely?

Social engagement and participation
Do you have diﬃculty in pursuing leisure interests and other
activities that are important to you?

11

12

Carer support
(Ask the carer of the older person
in private)

Do you feel you have whatever support you need in your role as a carer?

Do you feel conﬁdent in your ability to provide care and support?

Assess if there is negative impact of the carer role (physically, mentally,
ﬁnancially, socially).

12

13

Urinary incontinence

Do you have any problems with bladder control, such as accidental
leakage of urine?

Further assessment/
supplementary questions
should be considered

Re-ask regularly

Yes

Yes

Yes

Yes

No

No

Yes

Yes

No

No

No

No

Yes

Yes

No

No

Note: The wording of social support questions, shown as examples, can be adjusted to ensure the questions are relevant and appropriate in the local context.

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The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

Community-level interventions

Older people found to have potential impairment of intrinsic
capacity through a basic assessment should be referred for
an in-depth assessment at a primary care facility (Step 2)
wherever possible. The community health worker or other trained
stakeholder who conducted the basic assessment may facilitate
access to services for this further assessment. Older people
should be encouraged to have regular basic assessments (e.g.
at least once a year), except for vision and hearing (e.g. every
1–2 years), and/or following an acute event or illness, and if their
social role or situation changes (a change in residence, the death
of a partner). Periodic basic assessment enables the early
detection of declines in intrinsic capacity and supports prompt
intervention. Older people should also be encouraged to set
their own goals to stay healthy.

In addition to this referral to health and relevant social services,
other community-level interventions can be provided during
contact with an older person for a basic assessment, to ensure
the best possible advice and support are provided at this first
point of contact.

Community health workers and other trained community
stakeholders can provide various types of tailored support
and care: health promotion, through the provision of health
and lifestyle advice, screening for CVD risk factors such as
hypertension, and community-based health care that addresses
specific losses in intrinsic capacity and other factors impacting
older people’s health.

3.1.3
Promoting healthy lifestyles

All older people can benefit from health and lifestyle advice,
irrespective of their level of intrinsic capacity if they are able to
understand and apply this advice to change their behaviour. Advice
should be provided along with information to promote self-care
and when and where to seek health care. Older people should
also be asked about any existing diseases or conditions and self-
management should be supported.

It is important to note that people learn and respond to information
in different ways. Learning tends to happen through a combination
of six main routes: through community conversations; the arts;
printed materials; conventional mass media; digital media; and
communication and interaction with health workers (13). Community
health workers and other community stakeholders should therefore
consider different ways to provide information and advice to older
people. This could include one-to-one conversations, group
discussions and awareness-raising campaigns using different
communication materials. Community groups, such as older
people’s clubs, could be engaged to organize events for older
people, for example, peer discussions and local drama productions
with health and lifestyle messages.

Other factors to consider when providing health and lifestyle advice
include who to engage and what information to provide. People rarely
make decisions about their health and related behaviours in isolation,
and are likely to be influenced by others, including family and
community members, and religious leaders. In some cases decisions
will be taken communally. It is therefore important to reach and
engage a wider group across an older person’s community. Advice is
also more likely to be understood and followed if it is accompanied by
information on how to do it. For example, giving information on what
constitutes a healthy diet, alongside advice on where to buy healthy
foods and how to prepare them.

Health and lifestyle advice provided to older people as part of
Step 1 of the ICOPE care pathway in primary care should include
both general information to support health and well-being and
more specific actions related to the domains of intrinsic capacity.
Where possible, advice should be targeted and tailored for the
individual older person and their specific needs.

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The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

Healthy lifestyle advice for older people

1.  Taking regular physical activity

 6.1

3. Hydration

 7.1

•  All physical activity is beneficial and every move counts.

•

•

•

•

 It is good to start low, go slow and gradually increase
physical activity.

 There are different options available, including walking,
cycling, household tasks, gardening, dancing and sport, with
a focus on activities that are enjoyable to the older person.

It is important to avoid sedentary behaviour.

 Perceptions of physical activity can change towards
positive acceptance and engagement, including in
relation to cultural context and attitudes towards women’s
participation.

2. Eating a healthy diet

 7.1

•  Older people should eat plenty of protein.

•

•

•

•

•

 It can be helpful to make eating a social activity by eating
with other people.

 Suggest healthy foods available and affordable locally –
what they are and where to get them.

 Older people should eat at least 400 g (five portions)
of vegetables and fruits per day and less than 5 g or one
teaspoon of salt.

 Wholegrains, vegetables, fruits and pulses (as
carbohydrates), and nuts, seeds, beans, olives and fish (as
healthy fats), are important.

 It is ok to eat smaller amounts more often if large meals
are difficult.

•  A high-fibre diet can prevent constipation.

•

 Drink at least 6–8 cups (1.6–2.0 L) per day (unless restrictions
have been suggested on medical grounds), and a larger
amount in particularly hot weather.

•  Reduce caffeine intake, particularly in the case of UI.

4. Oral health

 7.1

•

 Brush teeth two times per day with fluoride-containing
toothpaste (1000–1500 ppm).

5.  Social connection and participation in the

community

 11.1

•  Spend time with friends and family.

•

 Be socially active and engage with the community in a way
that is enjoyable and meaningful.

6.  Preventing and managing diseases and

CVD risk factors

 3.1.4

•

•

•

•

 Adhere to treatment, including medication to control
diseases.

 Avoid the use of over-the-counter medication and
supplements, without the advice of health worker(s).

 Manage weight to prevent obesity, including limiting fats and
free sugars.

 Ensure good hygiene and sanitation practices (drinking
safe water, food hygiene, hand washing).

… continued

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The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

•

 Avoid or reduce alcohol and psychoactive substances:

10. Optimizing brain health

 5.1

–   Harmful use of alcohol impacts physical, mental, social,

•  Undertake regular cognitive stimulation activities including reading,

psychological and cognitive health

playing games, learning something new and playing music.

–   Seek support to be able to avoid alcohol use.

•  Tobacco cessation:

11. Promoting eye/vision health

 8.1

–  Discourage non-smokers from starting to smoke.

•  Regular eye and vision check-ups.

–   Highlight the risks associated with tobacco use, including

•  Follow advice on how and when to use spectacles.

an increased risk of cancer, respiratory conditions,
dementia, CVD, oral diseases and UI.

–   Give information on where to seek support to stop

tobacco use.

•

 Be aware of risk factors for vision impairment (diabetes and
hypertension).

7. Vaccination

•  Limit exposure to ultraviolet lights by wearing sunglasses

and hats.

•  Take regular breaks from near work activities (use of electronic

media, reading, sewing).

12. Promoting ear/hearing health

 9.1

•  Regular hearing check-ups.

•

•

 Routine vaccination in line with local vaccine regulations (14).

•  Seek advice if you suspect hearing loss.

It is important to keep a record of vaccinations received.

•  Clean the outer part of the ear with a soft cloth.

8. Promoting mental health

 10.1

•  Stress reduction when needed.

•  Follow advice on how to use hearing aids.

•  Don't put things inside the ears.

•  Don't swim or wash in dirty water.

•  Take regular breaks from caregiving (for carers).

•  Don't listen to loud sounds or music and use earplugs in

•  Do the activities you (used to) enjoy.

noisy places.

9. Good-quality regular sleep

•

 Maintain a healthy sleeping routine, including going to bed
and waking at a consistent time.

Further information on specific health and lifestyle advice in relation
to the domains of intrinsic capacity can be found in the relevant
chapters of this handbook.

•  Get an adequate number of hours of sleep per day.

M O R E   I N F O R M AT I O N

 WHO health topics: alcohol, tobacco. WHO;
2024 (https://www.who.int/health-topics/alcohol;

https://www.who.int/health-topics/tobacco).

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The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

Community health workers

could consider asking

the following, or similar

questions:

•  Have you smoked or used

any other tobacco product

in the past 12 months?

•  How many portions of fruit

and vegetables do you eat

each day?

•  Do you ever drink alcohol?

•

In the past week, on how

many days have you been

physically active for a total

of 30 minutes or more? For

example: walking, cycling,

cleaning, gardening,

climbing stairs, dancing or
playing sport?

Box 3.1  Screening for hypertension

Alongside the provision of information and support for behaviour
change, community health workers may also be able to screen
for hypertension. Blood pressure can be measured in the
community, if community health workers or other stakeholders
have the appropriate training and equipment and are able to refer
the person to primary care for further assessment and treatment.
Screening for hypertension if referral pathways are not in
place and treatment is not accessible is unethical.

Measuring blood pressure is the only way to diagnose
hypertension, as most people with raised blood pressure
do not have symptoms. For accurate blood pressure
measurement:

•

•

Use the appropriate cuff size.

Ask the person to sit with their back supported, legs
uncrossed, with an empty bladder, relaxed for 5 minutes,
not talking.

•

Take at least two readings and use the second reading.

In general, hypertension is diagnosed on two visits on
different days: if the systolic blood pressure readings are ≥
140 mmHg and/or the diastolic blood pressure readings are
≥ 90 mmHg. If hypertension is diagnosed, the person should
be referred to primary care for further assessment and
treatment including for other metabolic risk factors (diabetes
and cholesterol). They should be given information on the
risks associated with hypertension and the importance of
attending for further assessment.

M O R E   I N F O R M AT I O N

 HEARTS: technical package for cardiovascular
disease management in primary health care:
healthy lifestyle counselling. WHO; 2018
(https://iris.who.int/handle/10665/260422).

31

3.1.4  Screening and prevention of risk factors for cardiovascular diseases Cardiovascular diseases (CVD) are a group of disorders of the heart and blood vessels such as coronary heart disease and cerebrovascular disease (e.g. heart attack, stroke). In 2021, they were the leading cause of death globally (15), with high prevalence in older people (16). The risks for CVD include behavioural factors, such as tobacco use, an unhealthy diet, harmful use of alcohol and inadequate physical activity; and metabolic factors, including high blood pressure (hypertension), high blood cholesterol and high blood sugar (diabetes).Given the high prevalence of CVD among older people, and high rates of undiagnosed hypertension (17) in some contexts, Step 1 of the ICOPE care pathway provides an important opportunity to raise awareness among older people, and where possible, identify the risk factors (Box 3.1). Health workers can provide individual advice and counselling to older people for whom behavioural risk factors are identified, with the aim of encouraging behavioural change. Counselling for healthy lifestyles in relation to CVD involves guiding and supporting an older person toward making changes in certain behaviours to reduce the risk of CVD and other conditions (diabetes, lung disease and cancer) as well as declines in intrinsic capacity such as cognitive decline and vision impairment. A brief counselling intervention between a community health worker and an older person (and carers, where appropriate), during a basic assessment can identify potential problems, provide information and motivate and assist the older person to change their behaviour. The 5As tool (Ask, Advise, Assess, Assist, Arrange) can be used to identify risk factors and support behaviour change.
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The ICOPE care pathway in primary care | Basic assesssment and community-level interventions

3.1.5
Community-based health care to address losses
in intrinsic capacity

When a basic ICOPE assessment identifies potential loss of
intrinsic capacity, community-based health care can be provided
by community health workers with the support of other community
stakeholders, and in partnership with health workers in health care
facilities, in some contexts. These interventions are important
in settings where an in-depth assessment at a primary care
facility may not be possible, where organizing or accessing a full
assessment may take time, or where it is thought the older person
may choose not to attend. Feasible interventions to deliver across
contexts and resource settings include (see the relevant chapter
for detailed information):

•  Cognitive stimulation, physical exercise and advice for family

members and carers for cognitive decline.

 5.2

•

Physical exercise programmes for limited mobility with
consideration of safety concerns.

 6.2

•

Balanced diet including high protein foods for undernutrition.

 7.2

•

Provision of reading  spectacles and screening for
hypertension for vision impairment.

 8.2

•  Communications advice for hearing loss.

 9.2

•

•

•

Stress management including relaxation techniques for
depressive symptoms and pain.

 10.2, 6.5.2

Provision of advice and information about available
community services and activities for social participation and
support.

 11.1

Provision of advice and information about available
community services to support carers.

 12.2

•

Bladder training to manage UI.

 13.2

If in doubt about whether or how an intervention can be safely
provided, refer to an appropriate health care worker with
knowledge.

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The ICOPE care pathway in primary care | In-depth assessment

If during this assessment, another

older person, for example, a

spouse, is identified within the

family, their need for integrated

care should also be considered and

a basic ICOPE assessment offered,

as appropriate.

3.2
Undertake an in-depth
assessment at a primary care
facility

An in-depth assessment of health and social care needs at a primary
care facility is critical to be able to provide appropriate services
and support. An initial step is to gain a better understanding of the
older person’s life by taking a medical history, including current
medications, and by asking about their values and priorities
for their life including health and its management, their social
context, and identifying key family members, other relatives and
friends.

An in-depth assessment is likely to require a trained health
worker(s) such as a nurse or doctor undertaking scheduled visits
or appointments. There are three key elements to an in-depth
assessment; investigating and confirming impairment of intrinsic
capacity; evaluating underlying diseases and risk factors; and
assessing the person’s social and physical environment. These
three elements can be undertaken in any order (unless otherwise
stated). Based on the findings of all three elements, potential
interventions should be identified. Each specific care pathway
provides information on what to consider in the assessment and
for interventions, which should inform a single consolidated
personalized care plan.

3.2.1
Assess loss in intrinsic capacity

A potential impairment of intrinsic capacity needs to be confirmed
by applying the tools/tests, that are locally available and validated.
Examples of tools and tests are presented in each care pathway
(Chapters 5-10).

3.2.2
Assess for associated diseases and risk factors

As people age, the likelihood of having diseases, such as CVD,
hypertension, diabetes, cancer, chronic obstructive pulmonary
disease, osteoarthritis, osteoporosis, cataracts and dementia,
as well as multimorbidity (the coexistence of two or more chronic
conditions) increases.

While some risk factors, such as arthritis, can present with
symptoms, others, like hypertension and diabetes, may remain
asymptomatic for years. Therefore, ensuring their early detection
in primary care is crucial. WHO provides a range of guidance to
address early detection and management of noncommunicable
diseases, including risk-based CVD management and dementia.
Blood pressure measurements should be conducted for all adults
during routine visits to primary care facilities, including at the first
presentation, and, if normal, periodically thereafter. A person with
elevated blood pressure readings requires immediate follow-
up as per the established protocol. For diabetes detection, it
is recommended to test individuals presenting with symptoms
using fasting plasma glucose (FPG) or random plasma glucose.
Additionally, asymptomatic adults aged 40 and above with a body
mass index (BMI) greater than 25 should be tested using FPG.

People’s immune systems also tend to weaken over time, putting
older people at higher risk for certain infectious diseases. An
older persons’ vaccination status should be monitored to reduce
vaccine-preventable diseases.

Some diagnoses including multimorbidity or polypharmacy (
may require specific diagnostic tests, equipment and specialized
skills that are not always available in primary care. Depending on
the setting, referral to secondary- or tertiary-level specialized
services may be needed.

 4.2.4)

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The ICOPE care pathway in primary care | In-depth assessment

3.2.3
Assess social and physical environments

An in-depth assessment of the social and physical (built) environments
at home, in the community and broader society and the identification
of any needs for social care and support are both required.

Social environments include living conditions, financial security,
loneliness (relationships), access to community activities and public
services, freedom from abuse, among others. If needs for support
are identified, services should be provided to enable older people to
do the things that are important to them. An older person might need
social support regardless of their level of intrinsic capacity.

It is also important to consider the potential care and support
needs of family and other carers involved in the care and support
of an older person. Family carers, particularly those living with the
person they care for, may feel there are constant demands. They
are unlikely to have received any training and may well not have
any support. This can lead to burnout, which has impacts for the
carer’s mental and physical health and for the quality of care they
are able to provide. Need for respite care should be considered.

The pathway in Chapter 12 presents a set of questions for
assessing and managing carers’ needs. In addition, each care
pathway notes specific support carers might need in relation to
intrinsic capacity domains and conditions.
11

12

An older person’s need for assistive products used on or directly
by the body (e.g. hearing aids, walking sticks, wheelchairs) can be
assessed by health workers with training.
 4.2.2  An assessment
of the physical environment at home and home surroundings,
undertaken through asking questions to the older person or
through home visits, where possible, can help inform necessary
environmental modifications, including identifying any need for
assistive products, risk of falls, and how to make the environment a
safer and more accessible place to live.

 4.2.5

If an older person has a significant loss in intrinsic capacity, social
care (personal care and assistance with daily activities) might be
needed. Social care needs can be identified by asking an older
person whether they can perform various daily tasks without the
help of others, and should consider needs and preferences for care
at home, within the community and in institutions, and who could
provide that care. This can inform specific needs for LTC services
(where available) and their inclusion in a personalized care plan.

The pathway in Chapter 11 presents a set of questions for assessing
and addressing social care and support needs in general. In
addition, each care pathway notes possible social care and
support needs specific to the intrinsic capacity domain and
conditions.10

11

M O R E   I N F O R M AT I O N

 Guideline for the pharmacological treatment of
hypertension in adults. WHO; 2021
(https://iris.who.int/handle/10665/344424).

 HEARTS: technical package for cardiovascular
disease management in primary health care:
evidence-based treatment protocols. WHO; 2018
(https://iris.who.int/handle/10665/260421).

 HEARTS: technical package for cardiovascular
disease management in primary health care:
risk-based CVD management. WHO; 2020
(https://iris.who.int/handle/10665/333221).

 WHO package of essential noncommunicable
(PEN) disease interventions for primary care. WHO;
2020 (https://iris.who.int/handle/10665/334186).

 WHO clinical treatment guideline for tobacco
cessation in adults. WHO; 2024
(https://iris.who.int/handle/10665/377825).

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The ICOPE care pathway in primary care | Develop a personalized care plan

3.3
Develop a personalized
care plan

Personalized care planning is a humanistic approach that moves
away from the traditional disease-oriented methods and instead
focuses on older people’s needs, values and preferences.
The process recognizes the person’s skills and strengths, their
experiences, the things that matter most to them, and their
social context. A personalized care plan guides all aspects of
health and social care and support and is essential in ensuring the
integration of these services and how the older person accesses
them. The results of an in-depth assessment across the domains
of intrinsic capacity and any identified potential interventions,
as outlined in Chapters 5–13, should be brought together into a
consolidated personalized care plan, taking the following points
into consideration:

•

•

Interventions should be agreed based on the older person’s
goals, loss of intrinsic capacity, diseases and risk factors and
opportunities to promote an enabling environment.

A personalized care plan should include interventions
delivered within primary care, with referrals to specialized
care where needed. It should also include social services,
and be adapted to the settings in which the services will be
provided (home, community, institution), as appropriate.

•

Sustained, regular follow up with reassessment is essential
for the effective delivery of integrated care.

•  Community-based services should be included, and can be

delivered by community stakeholders.

3.3.1
Define and set the person-centred goal(s)

The starting point for developing a personalized care plan should
be the older person’s goals, identified through discussion with
a health worker, ideally a doctor or nurse, led by a case manager
or care coordinator. A doctor or nurse can fulfil the role of case
manager/care coordinator. Health workers must involve the older
person (and their carer(s), where appropriate) in decision-making
about their own care, and respect their needs, values, preferences
and priorities. Taking this approach can mark a transformational
shift in the way health workers relate to older people.

For a multidisciplinary team  (Box 3.2) supporting an older person,
a unifying goal of optimizing intrinsic capacity and functional
ability can be helpful to ensure the integration of care and ability

Box 3.2  Multidisciplinary team

A multidisciplinary team brings together the people involved
in an older person’s care to provide a broad range of services
through a coordinated and integrated approach. The
composition of a multidisciplinary team in primary care will
vary by setting, but may include doctors, nurses, community
health workers, social care workers, therapists (physiotherapy,
occupational, speech and language, psychological), carers,
care workers, pharmacists and volunteers. Depending on
the capacity of health and social care systems, a core team
comprising a small number of health workers most directly
involved in the provision of care could be established, with
others brought into discussions as and when possible.

How members of multidisciplinary teams work together,
as a team, is crucial. There are things that can help facilitate
effective ways of working, including: having an identified care
coordinator or case manager who facilitates the work of the
team; joint meetings to share insights and concerns; shared
record keeping; and inclusion of a diversity of professions and
disciplines, which reflect the needs of the person receiving
integrated care.

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The ICOPE care pathway in primary care | Develop a personalized care plan

to monitor progress. An older person’s goals, which should be at
the centre of the plan, can go beyond reducing the direct impact
of diseases, to also address aspects that enable them to do what
they value most, such as to age independently and safely in place, to
maintain their personal development, to be included and to contribute
to their communities while retaining their autonomy and health.

A personalized care plan can be developed with any older person,
including those with significant multiple losses of intrinsic capacity
which may be irreversible and those facing the end of life. A
discussion between a health worker and an older person should
consider any concerns the older person might have in relation to
death and dying and determine any medical treatment or care the
older person would not want. For an older person, facing a serious
illness with a limited prognosis, special consideration is needed to
identify a person-centred goal within the context of the expected
disease trajectory.

A personalized care plan should include timebound goals. In
addition to goals for the mid- to long term, it is recommended
to include short-term goals to leverage more immediate
improvements or benefits, with a view to keeping older people
motivated and engaged.

36
36

How to set person-centred goal(s)

An example of how a health worker can undertake a person-
centred goal-setting exercise with an older person, their family
members and carers, where appropriate, is provided below. The
plan should be based on the results of an in-depth assessment
and the interventions that could be provided in response. The
approach should be adapted to the local context.

Identify goals, by discussing:

•

•

•

•

The things that matter most to the older person in all parts of their life.

Some specific goals the older person has in their life.

Some specific goals they have for their health.

Three goals they would like to focus on in the short term (e.g. next
3 months) and longer term (e.g. 6–12 months).

Set goals – these can be adapted to the older person’s needs and
their own definition of problems by discussing:

•  What specifically about goal one, two or three they would like to

work on over the short and longer term.

•  What they are currently doing about the goal(s).

•  What would be an ideal yet possible target for them in achieving

the goal(s).

Prioritize goals – agreement on prioritized goals of care between
an older person and a health worker will demonstrate improved
outcomes. Prioritization can be informed by discussing:

•  Which of the goals they are most willing to work on in the short
and longer term – either by themselves or with support from a
health worker or care coordinator.

Source: Javadi et al; 2018. Adapted from original by Health Tapestry
(http://healthtapestry.ca).

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The ICOPE care pathway in primary care | Develop a personalized care plan

For example, muscle strength

training is the key intervention

to prevent and manage loss

of mobility, while at the same

time, indirectly protecting

against depressive symptoms

and cognitive decline and

helping to prevent falls.

3.3.2
Developing an integrated personalized
care plan

Developing an integrated personalized care plan that addresses
all domains of intrinsic capacity for which losses have been
identified, is important because some losses share some
underlying physiological and behavioural determinants. As a result,
interventions have benefits across domains.

For some people with significant loss of intrinsic capacity across
several domains, an in-depth assessment may suggest that their
impairments are unlikely to reverse. This may be, for example, in
the presence of disability due to injuries or diseases (e.g. stroke)
or progressive illness such as dementia or Parkinson's disease.
The personalized care plan will need to take into account the
likely trajectory as well as follow-up planning, which might need
to continue lifelong. The balance among modification of intrinsic
capacity and treatment of diseases, palliative care and provision of
social care and support, including carer’s support, would change
over time.

Three main steps can be followed in the development of a
personalized care plan:

1.  Review findings and discuss opportunities to improve intrinsic

capacity, functional ability, health and well-being:

During a discussion to set goals, the results of the in-depth
assessment and suggested interventions for different loss(es)
of intrinsic capacity should be reviewed. Prioritization of
interventions for inclusion in a care plan can be guided by the
urgency of an issue from a clinical perspective; the likelihood
of success of the intervention; the wider impact addressing a
specific issue might have, including how addressing one loss
may impact the ability to address another; the predictable
burden of interventions; and take into consideration what the
older person feels is most important to them.

In order to determine potential interventions, health workers
will need comprehensive knowledge of available services and
resources across both health and social sectors.

2.  Agree on interventions

This agreement should have concurrence from the older
person, based on informed consent and be in line with their
goals, needs, preferences and priorities; include components
of self-care and self-management; accommodate physical
and social environments; and include carer support, where
needs are identified. Each potential intervention should be
discussed one by one with the older person. The examples
of potential components of a personalized care plan are
found in Box 3.3 (p. 38).

In many cases, the proposed interventions will require inputs
from health workers across sectors and disciplines. Ideally,
one case manager or care coordinator should coordinate a
multidisciplinary team (Box 3.2, p. 35) that will be involved in
the assessment, development, implementation and monitoring
of a care plan. A partnership between the older person, their
carers and the multidisciplinary team is important to sustain the
older person’s well-being where they live.

3.  Finalize and share the care plan

The health worker identified as the case manager or care
coordinator should document in the care plan the agreed
interventions and share the plan with the older person,
their family members and carers (as appropriate) and the
multidisciplinary team involved in their care, with the older
person’s consent. If interventions in the care plan require
referral, the older person should be given guidance about how
to make appointments and how health workers can support the
process. An example care plan can be found in the Annex.

37
37

3

The ICOPE care pathway in primary care | Develop a personalized care plan

Box 3.3  Potential components of a personalized care plan

•  Goal(s) informed by the priorities and preferences of the

•  Where applicable, the management of any advanced

older person.

•

Self-care and self-management to promote health and
well-being

•  Community-based services and support. Social

prescribing provides a means to connect older people to a
range of non-clinical services in the community to improve
health and well-being (Box 11.1, p. 124).

•

•

•

•

A package of multicomponent interventions to prevent
and manage losses in intrinsic capacity. Most care
plans will include interventions to improve nutrition and
encourage multimodal exercise.

The management of underlying diseases, geriatric
syndromes (e.g. falls, UI) and risk factors, including for
CVD.

Periodic vaccination, including COVID-19 and annual
influenza as well as other vaccines, depending on the
schedule of vaccination by country.

A medication review to identify inappropriate
medications, and issues regarding access, adherence
and practicalities for medication.

 4.2.4

chronic conditions and life-threatening illness, including
through palliative care, to ensure that older people can
continue to live lives of meaning and dignity and that their
rights are protected.

 4.2.3

Social care and support, including environmental
adaptations, such as home adaptation and the provision
and maintenance of assistive products; social support
with the help of family members, friends and community
and other services; personal care and assistance with daily
activities, that can be delivered at home, in the community
and institutions (day centres, care homes and other LTC
facilities).

Support for carers, based on a discussion with the carer(s).
This could include advice on how to provide particular
types of care and support, tips for self-care, opportunities
for respite, psychosocial support, access to financial
support, and support with grief and bereavement.

Referral to specialized care, including rehabilitation
services, palliative care and geriatric care, where needed
and available, through local referral mechanisms.

An agreed follow-up date to ensure any changes or further
losses are identified and care can be modified accordingly.

•

•

•

•

38
38

The follow-up process includes, but is not limited to:

•

•

•

•

•
•

Ensuring successful implementation of each step and
intervention of the care plan.
Proactive enquiry to identify possible side-effects or
unanticipated consequences of the intervention.
Repeating the basic and/or in-depth assessment and
documenting any changes.
Summarizing outcomes, barriers and complications of
implementing the interventions.
Identifying changes and new needs.
Adapting the care plan as required.

3

The ICOPE care pathway in primary care | Implement and monitor the personalized care plan

4

3.4
Implement and monitor the
personalized care plan

Monitoring the implementation

of the care plan and regular

reassessment with the older

person are vital for achieving

agreed goals.

Collaboration and coordination between members of a
multidisciplinary team drawn from different levels and types of
health and social care services, and guided by a care coordinator
or case manager, are essential for implementing the interventions
agreed in a personalized care plan. Such an approach promotes
early detection of complications, including any adverse effects
of interventions and enables identification of any challenges
related to acute events and illnesses, and changes in social roles
or living situation. It also allows for losses in new or additional
domains of intrinsic capacity to be identified. Regular monitoring
helps avoid unnecessary emergencies and saves costs by
enabling early action. Regular follow up also enables frequent
contact between the older person and their health workers,
supporting the maintenance of a successful relationship.

The frequency of follow up is informed by the intensity of the
care required, types of interventions being provided and the
person’s social context, and should be determined by the care
coordinator or case manager and agreed with the older person.
The care coordinator or case manager can provide reminders
of all appointments, including those scheduled to conduct a
reassessment. Follow up with older people can be provided in
different ways, including in-person meetings and by phone or
video call. The most appropriate mechanism for each individual
should be determined by the health worker and agreed with the
older person (and carer where appropriate).

39
39

33

The ICOPE care pathway in primary care | Implement and monitor the personalized care plan

3.5
Communication skills

Across all steps of the ICOPE care pathway in primary care,
effective communication by health workers and community
stakeholders is key to ensuring the successful delivery of a
person-centred continuum of integrated care.

Health workers conducting an in-depth assessment and
developing a care plan will need to take their time to properly
engage with the older person in order to build trust. To enable this
to happen, an appropriate environment is needed that is conducive
to the older person feeling able to be open about any challenges
they may have and their preferences, choices and goals.

There are a number of points health workers and community
stakeholders should bear in mind when communicating with an
older person. Most are useful for conversations with everyone but
should be borne in mind particularly in relation to ageism within
the health system, and its impacts.

•  When first meeting an older person, make sure to use the
proper culturally appropriate form of address and avoid
using familiar terms (e.g. “dear”). After building a rapport, ask
the person how they would like to be addressed.

•

Be respectful and avoid ageist attitudes and words or
phrases. You should not take anything for granted or make
assumptions about an older person, including on their
capacities for communication without testing them (e.g.
hearing, cognition) (Box 1.1, p. 3).

•  Consider the setting, and the need to balance privacy and
the older person’s autonomy with inputs from their carer(s)
where necessary or helpful. Only when deemed necessary
due to specific loss of intrinsic capacity, such as cognitive
decline, and in line with legal frameworks, should a carer or
other person be asked to speak on behalf of an older person.

•  Consider the setting from the perspective of the person’s
mobility, ensuring that it is fully accessible (e.g.for a
wheelchair).

•

Sit at a suitable distance from the person and with an open
posture.

•  Consider any potential sensitivities regarding gender and,

where appropriate and possible, offer a health worker of the
same gender to meet with the older person.

•

Before starting, let the older person know how long you
would like to talk to them for and check they are happy to go
ahead. Consider taking breaks if necessary.

•  When asking questions try not to rush, avoid interrupting

and distractions, maintain eye contact and show empathy.
Use open questions where appropriate, that encourage
the person to share their experiences, feelings and
perspectives.

•

•

Adapt communication approach and language to ensure
understanding. For some older people this might mean sticking
to one topic at a time, avoiding giving too much information at
once, using short, simple words and sentences, speaking slowly
and clearly and avoiding jargon.

Practise active listening by occasionally summarizing what
the older person says, reflecting a particular point back and
clarifying by putting the person’s feelings into words.

•  When communicating with an older person with hearing loss,

adopt appropriate communication strategies.

 9.2.1

•  When communicating with an older person with vision

impairment, ensure adequate lighting, check if the person
has brought and uses spectacles, make sure all instructions
and materials are clear and typed in large font, and consider
recording instructions, using diagrams, aids or devices.

 8.6

•  Make sure recommendations are clear and understood by

the older person (and carer, where appropriate). Provide
clearly written notes about recommendations, prescriptions,
future schedules and referrals.

•

Be mindful of and observe for any warning signs of abuse or
neglect.

 11.4

As well as being mindful of the

way they talk and listen to older

people, health workers should

be aware of nonverbal forms of

communication, including body

language and the importance of

observing the behaviour of both

the older person and any carers
or relatives present.

40

4

Stakeholders and cross-cutting
services for the ICOPE care pathway
in primary care

Implementation of the ICOPE care pathway in primary care requires
the engagement of a range of stakeholders and collaboration and
coordination across sectors and services. A number of factors,
focused on who should be involved, what services will be needed
and how they could be delivered should be considered when
planning to implement ICOPE. These factors will be determined
by the local context, (
mechanism of primary care, the availability of specialist services,
and the presence and capacity of community stakeholders.  In
some instances, health workers in primary care, may need to
make referrals to specialists at other levels of the health system
(secondary, tertiary) or social system, where this expertise, or
service does not exist within primary care.

 14.2) including the structure and

Key points

 Successful implementation of the ICOPE care pathway in
primary care requires the engagement of a range of different
stakeholders across the health and social care sectors and the
community.

 Older people’s meaningful engagement and empowering carers
are key enablers across all steps of the ICOPE care pathway.

 Community stakeholders should be meaningfully engaged and
appropriately supported in the delivery of integrated care for
older people.

 Where referral to specialized care is needed, coordination and
collaboration among health workers is important.

 Cross-cutting services and support in response to losses across
multiple domains of intrinsic capacity should be provided in a
holistic and integrated way.

41

4

ICOPE care pathway in primary care: stakeholders and cross-cutting services

4.1
Engagement of stakeholders

4.1.1
Meaningful engagement of older people

Older people’s proactive engagement with and support for ICOPE
and integrated care more broadly is fundamental to its success
and can contribute to an increased sense of empowerment
and self-fulfilment. This engagement can take two forms: older
people’s engagement with their own health and well-being
through the ICOPE care pathway; and broader engagement
to support healthy ageing within their communities, including
through older people’s clubs and associations. Age-friendly cities
and communities help ensure the meaningful engagement of older
people. Examples of the role older people’s clubs or associations
can play in the delivery of integrated care are provided.

 4.1.3

A key first step to achieve this engagement is prioritizing co-
design in services, improving services based on older people’s
feedback and shared decision-making as key principles when
adapting all steps of the care pathway to local context. Efforts
should be made to raise awareness among older people through
locally appropriate and available channels highlighting the
opportunity ICOPE provides for older people to be centrally
involved in their own care and to state their own preferences and
goals.
care and self-management to empower older people (Box 4.1).
Information campaigns, if well designed, can also help to raise
awareness of ageism, including self-directed ageism (Box 1.1, p. 3)
and abuse of older people.

 3.3.1  Care plans should include components of self-

 11.4

42

Box 4.1  Self-care and self-management
for older people

Support for self-care and self-management involves
providing older people and their carer(s) with the information,
skills and tools they need to promote their health and well-
being, reduce risk factors, manage their diseases, prevent
complications, maximize their intrinsic capacity and maintain
their functional ability.

This does not imply that older people will be expected to “go
it alone” or that unreasonable or excessive demands will be
placed on them. Instead, it recognizes their autonomy and
ability to direct their own care, in consultation and partnership
with health workers, their families and other carers. All older
people should be provided with health and lifestyle advice,
irrespective of their levels of intrinsic capacity.

 3.1.3

The WHO mobile health for ageing (mAgeing) initiative can
complement health workers’ routine care by supporting self-
care and self-management. By delivering health information,
advice and reminders through mobile phones, it encourages
healthy behaviours and helps older people to improve and
maintain their intrinsic capacity.

M O R E   I N F O R M AT I O N

 Be healthy, be mobile: a handbook on how to

implement mAgeing. WHO; 2018

(https://iris.who.int/handle/10665/274576).

 Voice and meaningful engagement in the

UN Decade of Healthy Ageing: a discussion paper.

Decade of Healthy Ageing Platform; 2023

(https://www.decadeofhealthyageing.org/find-

knowledge/resources/publications/detail/voice-

and-meaningful-engagement-in-the-un-decade-

of-healthy-ageing-a-discussion-paper).

4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

4.1.2
Empowering and supporting carers

Carers, mostly women and girls, play a fundamental role in caring
for older people and supporting their adherence to a personalized
care plan and should be empowered in this role. The demands
of caregiving and carers’ need for support is acknowledged, in
particular regarding the provision of training and advice for carers
to ensure they are able to provide the best quality care possible;
and ensuring adequate support to protect carers’ own health and
well-being. The main areas of support carers will likely benefit from
are access to respite care, psychological support, financial support
and support for their own health and well-being.
particularly important if a carer is an older person, in which case they
should also be offered a basic ICOPE assessment.

   This is

12

11

4.1.3
Engaging community stakeholders

The health care system owes a responsibility to work appropriately
with and support its partners, particularly community organizations,
volunteers and carers. While community stakeholders often act
as a bridge between older people and health workers and can
fill some gaps in formal service provision, they should not be
expected to provide services that are the responsibility of health
and social care systems.

The rights and well-being of individual community members who
engage, whether as carers or in a paid, unpaid or voluntary role,
should not be infringed upon, or negatively impacted by their
engagement. Their health and well-being should be protected.
Box 4.2 (p. 44) provides self-care advice for community health
workers and other community stakeholders.

Depending on their capacity, community stakeholders may be able
to support each step of the ICOPE care pathway in primary care
(Chapters 5–13). Examples of possible engagement include:

WHO defines community

engagement as “a process of

developing relationships that

enable stakeholders to work

together to address health-related

issues and achieve positive health
impact and outcomes” (18).

Around the world, community stakeholders play a central role
in the care of older people as highlighted by many ICOPE pilot
projects (19).

Step 1: Basic assessment and
community-level interventions

The role of community stakeholders depends on the local
context – the types of organizations and infrastructures that
exist and their areas of focus and capacities, including human
resources. They can raise awareness of older people’s rights
and entitlements, support the views, experiences and opinions
of older people and their carers to be heard in programme and
service delivery planning processes. They can also advocate
for necessary changes to systems and services, including
rapid changes in response to evolving needs. Community
stakeholders can support the establishment and organization of
mechanisms for older people and other community stakeholder’s
engagement. They have a role in holding service providers and
others to account, including through a direct role in monitoring
and evaluation. If community stakeholders, including community
health workers,  are involved in the direct provision of services and
support for older people, they should be appropriately trained,
supported, supervised and monitored.

Community venues or spaces (e.g. town halls, social care centres,
post offices, religious and community meeting spaces) can
be used to organize events for basic ICOPE assessments and
awareness raising on healthy ageing, for example, to combat
ageism and break down stereotypes around “normal ageing”
and increase knowledge and understanding of health in older
age, rights and entitlements. Community stakeholders can
encourage older people’s attendance. Health workers can work
with community organizations to offer outreach basic assessments
through older people’s clubs or associations and by organizing
home visits, at which older people eligible for a basic assessment
can be identified. During a basic assessment, community health
workers and other trained community stakeholders can provide
various types of tailored advice, support and community-based
health care.

 3.1.3

43

4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

Box 4.2  How to practice self-care for
community stakeholders

Dos

•

•

•

•

•

Set boundaries between your personal life and work.

Try to make a routine and organize your daily activities
to balance work, family and free time.

Take time to eat, drink water, sleep, rest, reflect and
relax.

Build healthy habits, like exercising regularly and
avoiding alcohol, tobacco and other harmful
substances.

Be aware of your emotions and try to recognize
situations that may affect your feelings.

•

Talk to family and friends and ask for support.

•  Connect with colleagues and find ways to help each

other at work.

•

Reach out to a health worker  if you need help.

Don’ts

•  Don’t force yourself to do things that make you feel bad.

•  Don’t routinely exceed your working hours.

•  Don’t think you’re alone and don´t need help.

•  Don’t feel that talking about being unhappy is a sign of

weakness.

Source: mhGAP community toolkit: Mental Health Gap Action Programme
(mhGAP). WHO; 2019.

Step 2: In-depth assessment

While in-depth assessments should be conducted by health
workers at a primary care facility, community stakeholders can play
a role in ensuring access through organizing or providing transport
for older people, as well as supporting health workers to assess an
older person’s social and physical environment. They could also
follow up with older people after a basic assessment to ensure they
understand their results, and where relevant, the importance of
having an in-depth assessment and follow up.

Step 3: Personalized care plan

Care plans should include social care and support, which may be
provided by community stakeholders. It may therefore be useful
to engage with them during the development of a care plan to
understand their services. Community stakeholders can also
support a broader mapping exercise, detailing what services and
support are available locally, whether delivered by community-
based organizations, local government authorities or local
businesses and for-profit actors. This information can then be
provided to health workers, care coordinators or case managers, to
inform the development of personalized care plans.

4

Step 4: Implementation and monitoring

There are multiple ways in which community stakeholders can
support this step of the pathway:

•  Organizing and managing social care and support, such as day
centres, home-based care services, lunch clubs to encourage
social dining, meal/food delivery services and services
providing support with household tasks.

44

4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

•  Organizing group exercise activities and social events
to support participation and tackle social isolation and
loneliness, for example, through supporting older people to
use digital technology to stay connected with family, friends
and the community.

•

•

•

•

•

Running events and information campaigns to support
self-care and self-management, both for older people and
their carers.

Supporting access to health care facilities and services,
through deliveries of medications, providing transport and
offering regular venues and times for outreach services,
including health camps and vaccination events.

Establishing and facilitating support groups, including peer
support for older people and carers, and groups focused on
specific issues, to support psychosocial well-being.

Liaising with local businesses and facilities to raise awareness
around specific issues, for example, providing shops, cafes,
market and kiosk venders with tips about how best to interact
with someone with cognitive decline or asking local facilities to
make their toilets available to older people.

Building up a resource bank of information and advice on
how to access other services and support, such as financial
support, local meal deliveries, home repair, cleaning or
gardening services. These types of support can be particularly
important for carers, who may struggle to find the time for
these activities. Accessing such services can help to reduce
the demands on carers’ time and their subsequent stress, and
enable them to give a greater focus to the person they are
caring for while also taking breaks for themselves.

•  Monitoring the implementation of ICOPE and holding service
providers (both non-profit and for-profit) and policy-makers
to account for commitments they have made to the delivery of
integrated care for older people.

4.1.4
Collaboration and coordination among
multidisciplinary health workers

Collaboration and coordination between health and social care
workers drawn from different levels and types of health and social
care are essential for the successful delivery of integrated care
for older people.
 3.4  Although health workers at primary care
facilities can provide many services and specialized services
might be available at primary care in some contexts, collaboration
is key to ensuring referral pathways are in place that can enable
timely access to specialized services, including for the provision
of acute care, and to the social sector.

This coordination and collaboration can be guided by a care
coordinator or case manager and should be supported by
a multidisciplinary team (Box 3.2, p. 35). Specialist health
professionals may be required, in cases where more specialized
knowledge and skills are needed than can be provided by trained
health workers in primary care. This includes, but is not limited
to, ophthalmologists, audiologists, psychologists, dentists, and
health professionals for geriatric care (Box 4.3), rehabilitation
services and palliative care.

Box 4.3  Geriatric care

Specialists in geriatric care play an important role, where
available, in the delivery of integrated care for older
people, including during acute episodes and in the
management of long-term conditions. Geriatric care is
provided by geriatricians, supported by geriatric nurses
and other health professionals. Geriatricians, specialized
doctors in the care of older people, have expertise to
assess and manage older people’s health needs and their
social consequences, including geriatric syndromes
such as falls, UI, pressure ulcers and delirium, and in the
management of polypharmacy. Geriatricians and geriatric
nurses work with older people to enable autonomy and
should be a key part of a multidisciplinary team and can
support other team members.

45

4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

4.2
Integration across services
and sectors

Alongside coordination and collaboration between different
stakeholders involved in the delivery of the ICOPE care pathway
and integrated care more broadly, integration across services and
sectors is fundamental. For example, losses across a number of
domains of intrinsic capacity increase an older person’s risk of falls.
Therefore falls prevention services and support should address all
losses and risk factors an older person has. The following services
and support are likely to be required in response to multiple losses

and conditions.

4.2.1
Rehabilitation services

Rehabilitation is a set of interventions designed to optimize
functioning (“functioning” is an umbrella term used in the
rehabilitation sector for body functions, body structures, activities
and participation), alleviate pain and reduce disability. It is effective
in shortening recovery time, preventing complications related to
acute and chronic conditions, and improving intrinsic capacity
and functional ability. Interventions for rehabilitation comprise
therapeutic techniques and procedures, exercises and training
(e.g. muscle-strengthening exercises, cognitive training, breathing
exercises, training for activities of daily living [ADL], social skills or
communication skills), provision and training in the use of assistive
products, and environmental modifications. Interventions for
rehabilitation also address self-management skills, including
provision of education and advice on health conditions or self-
directed exercises, and carer and family training on care-related
techniques and tasks.

Rehabilitation services are typically provided by a range of health
professionals including rehabilitation nurses and medical doctors,
psychologists, occupational therapists and physiotherapists.
However, health workers at primary care facilities can also be trained
to provide a limited set of rehabilitation interventions. It is important
to empower a person receiving rehabilitation services by educating
and advising, motivating and coaching, and providing support. Safety
considerations should always be applied to address any problems
that may arise during the provision of rehabilitation interventions.

Interventions for rehabilitation may be required as a result of loss(es)
of intrinsic capacity, in relation to diseases and risk factors and to
support an older person’s social and physical environments. WHO’s
Package of interventions for rehabilitation outlines the interventions
for rehabilitation with information on workforce needs, assistive
products, equipment and consumables. Examples across the
domains of intrinsic capacity include:

•  Cognitive decline: Rehabilitation interventions aim to improve

specific cognitive function and help individuals compensate
for cognitive decline. There are a number of interventions
that can be used to stimulate memory with assistive products
including memory aids and pill organizers. Cognitive
stimulation therapy, cognitive behavioural therapy (CBT)
and cognitive training, are often provided by psychologists
or occupational therapists as part of rehabilitation services,
depending on the capacity of health care.

5

•

Limited mobility: Rehabilitation interventions comprise
guided exercises and training but also include advice on how to
start and continue personalized exercise independently, which
fits into the person’s daily routine, and should check progress
on/against the interventions being provided. The interventions
can target joint and muscle function, muscle strength and
associated pain and swelling with musculoskeletal conditions
such as osteoarthritis, osteoporosis and sarcopenia. They can
also include a nutrition intervention as an essential component
for people with limited mobility.5

6

Different health and social care

services need to be brought

together and provided in a

way that responds to an older

person’s holistic needs, rather

than addressing specific

losses of intrinsic capacity or

conditions, one by one.

46

4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

•  Undernutrition due to difficulties with swallowing (dysphagia):
Rehabilitation interventions include the instruction and training in
different techniques and exercises such as postural techniques,
supraglottic swallowing, expiratory muscle-strengthening
exercises to improve food sucking, chewing, manipulating food
in the mouth, salivation and swallowing; and advice on modification
of food consistency. These techniques are practised repetitively
and, if feasible, performed self-directed.

7

•  Vision impairment: Rehabilitation interventions include
the provision of optical and non-optical and electronic
assistive products, advice to optimize the living environment,
orientation and mobility training and vision skills training, and
psychological support.

8

•  Hearing loss: Interventions for rehabilitation include provision

and training in the use of hearing devices and assistive
products, and speech and language therapy to enhance
perceptive skills and develop communication and linguistic
abilities. Interventions also include training in the use of sign
language and other means of sensory substitution, such
as speech reading, use of print on palm or Tadoma, signed
communication. These interventions are often provided by
audiologists and speech and language therapists.

9

M O R E   I N F O R M AT I O N

 WHO’s Package of interventions for rehabilitation.
WHO; 2023 (https://iris.who.int/handle/10665/370502).

  Module 2: Musculoskeletal conditions
(https://iris.who.int/handle/10665/370503).

 Module 3: Neurological conditions
(https://iris.who.int/handle/10665/370504).

 Module 6: Sensory conditions.
(https://iris.who.int/handle/10665/370508).

 Training in assistive products (TAP). TAP; 2024
(https://www.gate-tap.org/).

4.2.2
Assistive products

Assistive products (also known as assistive devices or aids) include
walkers, eating and drinking aids, spectacles, pill organizers,
incontinence products, devices that support memory and
hearing aids. They can support maintenance or improvement
of an individual’s functional ability and hence independence
by addressing losses in intrinsic capacity, associated diseases
and necessary adaptations to an older person’s environment.
They can also be used to prevent secondary complications, e.g.
diabetic footwear or pressure relief mattresses, and can lessen the
demands on carers.

Appropriate assistive products should be discussed by trained
health workers to determine what is needed. Stigmatizing
attitudes towards assistive products, linked to ableism, should be
considered and may need to be overcome to ensure older people’s
use of such products. At the same time, unnecessary use may lead
to reliance, which could reduce independence.

The following service provision steps are necessary to ensure the
appropriate use of assistive products:

1.  Selecting the best product for a person’s needs.

2.  Fitting the product to suit the person.

3.  Teaching the person (and carers) how to use and take care of

their product.

4.  Ongoing monitoring to review whether the person’s needs

have changed, and carry out any maintenance and repair.

Assistive products can be provided by the health sector and/or the
social sector by personnel with the appropriate competency. For
example, a hearing aid is likely to be provided by a health worker;
while the social care sector may be responsible for the placement
and management of audio loops. Wheelchairs, canes and walking
frames will usually be provided by the health system and grab rails
and bars within a person’s home may be organized and installed

47

4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

Advance care planning should be part of usual practice. Discussion
and documentation of a health care proxy decision-maker and
a person’s preferences about future care are important. These
discussions should include information about preferred location of
care and place of death (e.g. home, LTC residential facility), choices
related to medical treatments including transfer to hospital and
high intensity care which may be potentially life-sustaining but
impose a significant burden and potential suffering, important
spiritual practices and practical matters surrounding death.

In older people expected to experience significant declines,
particularly in their cognitive capacity or ability to communicate,
discussing and making decisions about end-of-life care early, is
essential. These conversations should be conducted in a sensitive
manner, bearing in mind individual and cultural perceptions and
attitudes towards death and dying and understanding of what
palliative care is and the benefits it provides.

M O R E   I N F O R M AT I O N

 Palliative care: symptom management and end-
of-life care. WHO; 2004 (https://iris.who.int/
handle/10665/68535).

 WHO guidelines for the pharmacological and
radiotherapeutic management of cancer pain in adults
and adolescents. WHO; 2018 (https://iris.who.int/
handle/10665/279700).

 Integrating palliative care and symptom relief into
primary health care. WHO; 2018 (https://iris.who.int/

handle/10665/274559).

by social services. The types of products provided by different
sectors will depend on national systems. It is important that both
an older person and their carer(s) are provided with information
about assistive products, where to access them specific to their
location, their use and maintenance.

Some simple assistive products can be provided by health workers
in primary care with some additional training. This can reduce the
need for multiple appointments at different specialist services.
WHO’s Training in Assistive Products (TAP) is available to support
training of health workers in identification and provision of a range
of simple assistive products. It is an online resource with training
modules organized by six streams including vision, hearing,
cognition, communication, mobility and self-care (personal care).

Examples of assistive products for different domains of intrinsic
capacity are included in the social and physical environments
sections of Chapters 5–13.

4.2.3
Palliative care

Palliative care is an approach that improves the quality of life of
patients and their families who are facing problems associated with
life-threatening illness and helps them to live as independently and
actively as possible. It prevents and relieves suffering through the
early identification, correct assessment and treatment of pain and
other problems, whether physical, psychosocial or spiritual. It also
includes services to help families cope with emotional, social or
spiritual distress during the patient’s illness and during bereavement.

Palliative care should be provided by a multidisciplinary team in
primary care including in older people’s homes, according to their
needs and preferences and delivered using an integrated approach
alongside any symptom relieving or curative treatments being
offered. All health workers should have basic palliative care skills to
manage symptoms, prescribe essential palliative care medicines
(including morphine and other opioids), and incorporate palliative
care into a personalized care plan. Where available, specialized
palliative care, can help manage complex pain and other symptoms,
and address multidimensional suffering.

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4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

4.2.4
Inappropriate medication(s) and polypharmacy

Older people with multiple diseases may be more likely to present
changes of pharmacokinetics and pharmacodynamics. Together with
physiological ageing of the metabolic/catabolic pathways impacting
organ systems, including renal and hepatic functions, there is an
increased risk of adverse drug reactions. It is essential to ensure that
the medications are appropriate for the individual to gain the most
benefits with least harm.

Inappropriate medication(s) are present when medicine is
prescribed that is not or no longer needed, either because:

•

there is no evidence-based indication, the indication has
expired, or the dose is unnecessarily high;

•  medicine(s) fail to achieve their therapeutic objectives;

A medication review is a structured evaluation of a patient’s
medicines with the aim of optimizing their use and improving
health outcomes. Because inappropriate medications and
polypharmacy can contribute to losses across multiple domains
of intrinsic capacity, in-depth assessment should include a review
of medicines. Risks can be reduced by eliminating unnecessary,
ineffective medicines as well as medicines that share an active
ingredient, and replacing with alternatives if the continuation of a
medicine is necessary (Box 4.4, p. 50).

Community stakeholders can play a role in addressing
inappropriate medications and improving adherence to
treatments. Community health workers can work with local
pharmacists to ensure access to medications for older people
in line with local regulations. They can also support older people
to take medication correctly and to provide community-level
education and awareness-raising campaigns on the safe use of
medication, including for pain.

•

•

one, or the combination, of several medicines cause or are at
risk of causing adverse drug reactions; and

the patient is not willing or able to take medicine(s) as
intended.

M O R E   I N F O R M AT I O N

Polypharmacy is commonly described as the daily use of five or
more medicines, which include over-the-counter, prescription
and/or traditional and complementary medicines. This use of
multiple drugs can be associated with adverse drug reactions and
increases the risk of negative health consequences, resulting in
potentially avoidable losses in intrinsic capacity and acute hospital
admissions.

Older people receiving fragmented care or who have been
hospitalized recently (care transition) and those with multimorbidity
are at greater risk of polypharmacy or inappropriate medications,
highlighting the importance of integrated person-centred care.

 Medication safety in polypharmacy: technical report.

WHO; 2019 (https://iris.who.int/handle/10665/325454).

4.2.5
Falls prevention

Declines in any domain of intrinsic capacity can increase the risk
of falls. The physical environment and the way a task or activity
is performed can also be factors. It is therefore important to
consider interventions that address both intrinsic capacity and
environmental factors in efforts to reduce risks and prevent falls.
With training, health workers can assess the risk of falls. If a home
visit is not possible, they can give general instructions to the older
person and/or a carer on how to identify home hazards and create
a safer home environment.

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4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

Box 4.4  How to prescribe appropriately and reduce medication errors

•  Obtain a complete medication history including over-the-counter medicines and traditional,
complementary and herbal medicines, and medicines that have been stopped due to lack of
efficacy or side-effects.

•  Consider whether the medicines may negatively affect intrinsic capacity.

Avoid prescribing before a diagnosis is made except in severe acute pain.

•

•

•

Try non-pharmacologic treatment first, where appropriate.

at night).

Review medications regularly, including after any major health event or hospital discharge (care
transition) and before prescribing a new medicine.

•  Monitor any adverse effects, drug interactions and toxicity of medicines.

A full assessment of the risk of falls includes:

•

Taking a history of falls, including details of the activities being
carried out.

•

An assessment of:

–    Intrinsic capacity: mobility that includes muscle and joint
function, gait, balance and flexibility; vision; cognition.

–   Cardiovascular and neurological status.
–    Urinary urgency incontinence, or nocturia (waking to urinate

–    Foot problems including deformities of feet and peripheral
neuropathy due to underlying diseases such as diabetes
and arthritis.
–    Fear of falling.

•

•

•

•

•

Try to use one medicine to treat two or more conditions (e.g. antidepressants to improve mood and
manage sleep disorder) and identify opportunities to reduce medicines.

•

An assessment of the physical environment in the home and
home surroundings to find possible hazards.

Provide a pill card and make pill organizers available.

Educate the older person and carer about each medicine including symptoms of potential side-
effects and when to alert health workers and the importance of checking expiry dates.

If new symptoms occur, check whether they could be the result of adverse drug reaction.

Use pictures or visual aids to explain if an older person has literacy issues or other difficulties with
reading and be aware of any hearing loss that might affect communication and understanding.

•

Review of medications such as psychotropic medicines.

Some people will need further assessment and management
for conditions such as syncope (blackouts), epilepsy and
neurological disorders such as Parkinson’s disease. A full
assessment and management of a person’s risk of falls requires
specialized knowledge.

Note: If in doubt about whether a medication can be safely stopped, refer to an appropriate health care worker with
knowledge (e.g. pharmacist, geriatrician).

The risk of falls can be reduced by:

This might include reducing clutter, removing loose rugs and slippery

floor surfaces or coverings, smoothing out bumps in floors and steps,

moving furniture and other hard objects to create a wide, unblocked

usual walking path, improving lighting and access to the toilet, especially

at night, adding handrails to stairs and grab bars in the bathroom. A ramp

to the main doorway will make it easier for people who use wheelchairs
and others with difficulty climbing steps.

•

•

•

Improving the older person’s balance and coordination
through multimodal exercise such as Tai chi.

Identifying the need for home modifications and adapting
their physical environment. A person’s specific losses of
intrinsic capacity will guide what environmental adaptations
are most important.

Identifying the need for assistive products such as spectacles
for vision impairment and suitable footwear, and referral
for assessment and prescription. Older people should be
encouraged to wear enclosed sturdy shoes around the house,
rather than slip-on footwear.

50

4 ICOPE care pathway in primary care: stakeholders and cross-cutting services

•  Medication review to identify inappropriate medications and

withdrawal of unnecessary or harmful medicines.

•

For those with vision impairment specific changes can be
made to the home and in a person’s usual areas of movement
to make daily tasks and leisure activities safer and easier and
 8.6.2
to reduce the risk of falls.

–    Improve lighting: good lighting is particularly important
for near vision. Install lights in hallways, stairs, cupboards
and small, dark spaces to provide direct light. Light is
best coming from the side of the person (without creating
shadow).

–    Reduce glare: brighter light is usually better. But glare from

the sun or bright lights can bother some people.

–    Create contrast: good contrast within and between objects
makes them easier to see, find or avoid. Use high contrast
marking on the edges of steps (particularly for those with
vision in only one eye), coloured plates so that food stands
out in contrast, use a black pen for writing, colour the
handles of household and kitchen tools to make them more
visible and safer (e.g. wrapping a knife handle with brightly
coloured adhesive tape or painting it).

Health workers can offer advice on things to be aware of related to
housing and age-friendly initiatives.

Community stakeholders may be able to support efforts
towards age-friendly environments inside and outside the home,
including through age-friendly home programmes or initiatives
to map and audit the local area. This could take the form of
auditing green spaces, access to benches and public toilets and
local services and facilities. Mapping problem areas, including
where overgrown bushes and grass encroach on walkways,
fallen obstacles such as trees and rocks block walkways,
and holes in paths, can provide information that community
stakeholders, including older people’s clubs or associations, can
use to advocate for local authorities to make repairs and ensure
upkeep. Relevant community stakeholders may also be able to
work with local authorities to undertake this work if appropriate
training, support and compensation are provided.

M O R E   I N F O R M AT I O N

 Step safely: strategies for preventing and

managing falls across the life-course. WHO; 2012

(https://iris.who.int/handle/10665/340962).

 Integrated care for older people (ICOPE)

implementation pilot programme: Findings from

the 'ready' phase. WHO; 2022

(https://iris.who.int/handle/10665/353553).

 Global Database of Age-friendly Practices. WHO;

2024 (https://extranet.who.int/agefriendlyworld/

age-friendly-practices/).

 WHO Global Network for Age-friendly Cities and

Communities. WHO; 2024 (https://extranet.who.

int/agefriendlyworld/who-network/).

51

52

Cognition

5 Care pathway to manage

cognitive decline

Cognitive decline presents differently in each person, and it may
include increased forgetfulness, loss of attention, language
difficulties, changes in judgement and reduced ability to solve
problems. It is associated with conditions including hearing loss,
and noncommunicable diseases such as depression, hypertension,
diabetes and Alzheimer disease and other dementias. Other factors
for increased risk of cognitive decline include lack of physical
exercise, social isolation and a low level of education.

Cognitive decline is commonly accompanied by changes in mood,
emotional control, behaviour or motivation and it becomes of
greatest concern when it starts to interfere with a person’s ability to
function effectively in their environment (dementia). It has physical,
psychological, social and economic impacts, not only for the person
with cognitive decline, but also for their carers, families and society at
large. Cognitive decline and dementia are not part of normal ageing
and many people will not experience cognitive decline or dementia in
older age. The estimated prevalence of dementia in people over 60
years old in 2019 varied by region from 2.9% in South East Asia to 6.5%
in Europe. The global prevalence rises rapidly with age, from 1.1% in
people aged 60-64 to 35.9% in those aged 90 and over (20).

Key points

 Health workers in the community can conduct a basic
assessment for cognitive decline using a set of questions.

 Promoting a healthy lifestyle, including physical exercise,
cognitive stimulation and social engagement, can optimize
brain health, including for those with cognitive decline.

 Carers of people with cognitive decline or dementia need
advice on how to best provide appropriate care as well as
support for their own health and well-being.

 For a person with dementia, a more specific, targeted or tailored
approach is needed.

 Community stakeholders can raise awareness of cognitive
decline, stressing that people with cognitive decline or
dementia should not face stigma or discrimination and their
rights and dignity should be protected. They can support
people with cognitive decline to remain socially connected.

53

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Cognition

Care pathway to manage
cognitive decline

54

•Social care (maintaining daily routines) and support needs•Need for assistive products (e.g. memory aids) •Carers' support needsReassessConsolidate interventions, considering results of A, B and CAssesssocial and physical environments3Consider potential interventions2Consider potential interventions6.15.45.1 FAILPASS•Delirium•Inappropriate medication(s)•Cerebrovascular diseases •Cardiovascular diseases•Urinary incontinenceAssessfor diseases and risk factorsACProvide health and lifestyle advice to reduce the risk of cognitive decline Provide health and lifestyle advice, including strategies to reduce risk of cognitive decline Conduct basic assessment regularly  Regardless of result:5.1Physical exerciseProvide:•   Cognitive stimulation therapy•   Cognitive training •   Cognitive behavioural therapyIf cognitive decline affects autonomy and independence, see mhGAP intervention guide (dementia)        https://iris.who.int/handle/10665/250239If cognitive decline LIKELYIf cognitive decline UNLIKELYAssess cognition1BDEVELOPa care planIMPLEMENT& MONITORASSESS(BASIC)ASSESS(IN-DEPTH)A, B and CFirst, identify and treat potentialcauses (see B     )5.2Physical exercise, cognitive stimulation, and  advice for family members and carersRefer to primary care3.15

Cognition

Need for specialized knowledge
and training

•     Management of people with multiple diseases or

Table 5.1  Example of brief cognitive assessment tools for use in primary care

T O O L / T E S T

Mini-Cog

https://mini-cog.com/download-the-mi-

ni-cog-instrument/

A D VA N TAG E

D I S A D VA N TA G E

Brief; minimal language,
educational and racial bias; can
be an alternative screening tool

Use of different word lists may
affect scoring

T I M E

2–4 min

delirium, and with social contexts, including being

Montreal cognitive assessment (MoCA)

socially isolated, that require a more comprehensive

https://mocacognition.com/paper/

Can identify mild cognitive
impairment; available in
multiple languages

Educational and cultural bias; limited
published data; and training and
cost implications (e.g. copyright)

10–15 min

approach

•  Management of behaviours and psychological

symptoms associated with dementia, such as walking

about, apathy (appearing uninterested), agitation,

aggression, delusions, and hallucinations

•  Provision of cognitive behavioural therapy (5.4.3)

1

Assess cognition        5.3

In-depth assessment of cognitive capacity should
use a locally validated tool. Table 5.1 provides a list of
options for assessing cognition in primary care
facilities.

What is dementia?

Dementia is a chronic and progressive syndrome due

to changes in the brain. While Alzheimer disease is the

most common form, dementia can be caused by a

variety of diseases and injuries to the brain. Dementia

results in decline in cognitive functioning, and

interferes with memories and skills needed to carry
out everyday activities such as washing, dressing,

eating and personal hygiene as well as managing

ﬁnances and personal affairs and household chores.

Other common symptoms include deterioration in

emotional control, social behaviour and motivation .

Mini mental state examination (MMSE)

Widely used and studied

https://www.parinc.com/products/pkey/237

Subject to age and cultural bias;
ceiling effects; and training and
cost implications (e.g. copyright)

General practitioner assessment of
cognition (GPCOG)

http://gpcog.com.au/index/downloads

Minimal cultural and
educational bias; available
in multiple languages

May be challenging to get
an informant’s report

7–10 min

5–6 min

Rowland Universal Dementia
Assessment Scale (RUDAS)

Minimal language, educational,
and socio-cultural bias

Limited published data

10 min

https://www.dementia.org.au/professionals/
assessment-and-diagnosis-dementia/rowland-
universal-dementia-assessment-scale-rudas

2
B

Interventions for diseases and risk factors

       5.5

Delirium

Identify cause (severe dehydration, infection, medication,
electrolyte metabolic abnormalities) and treat (5.5.1)

Inappropriate medication(s)

Review medication and withdraw or prescribe alternatives (5.5.2)

Cerebrovascular and
cardiovascular diseases

Urinary incontinence

Management of diseases and reduce risk factors (5.5.3, 5.5.4)

See UI care pathway

13

3
C

Interventions for social and physical environment

       5.6

Social care and support needs

Enable social participation and ability to maintain daily routines (5.6.1)

Provide personal care and support with activities of daily living (11.6)

Identify and manage risk of falls at home and home surroundings (4.2.5)

Need for assistive products

Provide guidance on memory aids (notes, reminders and calendars) (5.6.2)

Carer's support needs

Provide advice (5.2.3) and training on how to support an older person
with cognitive decline and support for the carers’ well-being (12.4)

55

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56

5.1
Health and lifestyle
advice to reduce the
risk of cognitive decline

Community health workers and community stakeholders can
give older people and their carers advice on health and lifestyle
behaviours and strategies to reduce the risk of cognitive decline,

alongside more general advice.
for people with cognitive decline, for whom prevention of further
loss may be possible. Specific targeted advice may also be useful for
people with cognitive decline.

 3.1.3  This advice remains relevant

For all older people, the importance of:

•  Managing risk factors for CVD.

•  Doing cognitive training through repetitive practice to improve

memory.

•  Doing regular cognitive stimulation activities, undertaken

alone, including reading, playing games, learning something
new and playing music.

•

Being socially active and engaging with the community
(e.g. interacting with children and grandchildren, practising
hobbies, listening to and discussing news and current affairs).

•  Managing hearing loss and depression.

9   10

For older people with (potential) cognitive decline, the
importance of:

•

Understanding the nature of their condition, available
treatment options and support.

The information can be provided through one-to-one
conversations, group meetings and discussions and awareness-
raising campaigns. These broader campaigns are important in
challenging often widely held misconceptions around cognitive
decline. Communities need to be educated to understand that
cognitive decline is not a “normal part of ageing” and to tackle
harmful cultural beliefs around cognitive decline as “punishment”
or “witchcraft” and the stigmatization and abuse that can happen
as a result. Stigma and discrimination heighten the already
significant psychological, social, emotional and financial impacts
that dementia has on individuals, their carers, families and
communities.

5.2
Community-based
health care to address
cognitive decline

If an older person is identified with potential cognitive decline
through a basic ICOPE assessment, and an in-depth assessment
is not immediately available, community health workers and
community stakeholders can provide support with physical
exercise, cognitive stimulation and advice for family members.

5.2.1
Physical exercise

Being physically active may reduce the risk of (further) cognitive
decline. A variety of physical exercises, including aerobic exercise
with moderate intensity as well as balance and muscle strengthening
exercises such as Tai chi, have positive effects on cognitive function
and everyday function (21)(22)(23). Community stakeholders can
support older people to undertake physical exercise (three to four
times per week for 30–45 minutes for more than 12 weeks) through
setting up and running exercise programmes and making these
programmes accessible and affordable.

 6.1

5

Cognition

•

•

Learn about and understand the nature of the condition
of the person they are caring for, and available treatment
options and support.

Importance of taking care of their own health and
well-being.
11

12

M O R E   I N F O R M AT I O N

 Risk reduction of cognitive decline and

dementia: WHO guidelines. WHO; 2019

(https://iris.who.int/handle/10665/312180).

 Field test version: mhGAP community toolkit: Mental

Health Gap Action Programme (mhGAP). WHO; 2019

(https://iris.who.int/handle/10665/328742).

 Towards a dementia inclusive society: WHO toolkit

for dementia-friendly initiatives. WHO; 2021

(https://iris.who.int/handle/10665/343780).

5.2.2
Cognitive stimulation

With training community health workers and other community
stakeholders can support an older person through cognitive
stimulation. Depending on the setting and the capacity of the
community stakeholders, individual or group sessions can be
organized in a more or less formal way, such as organizing a line
dancing group, chess club or language class. Groups are efficient
if the members of the group share a common purpose.

5.2.3
Advice to family members and carers

Providing practical advice for daily life to family members and
carers might be helpful in supporting them to care for an older
person with cognitive decline.

•

•

•

•

Support an older person with writing down appointments,
setting reminders and having a calendar on the fridge or wall
with these appointments and an order of tasks throughout the
day.

Support the social care needs of an older person with
cognitive decline, including through developing plans
for ADL.

Provide orienting information, such as the date, current
community events, identity of visitors, weather, news of family
members.

Encourage and arrange contact and activities with friends and
family members at home and in the community.

•  Make and keep the home safe to reduce the risk of falls and

injury.

 4.2.5

•

•

Post signs in the home to help the person find their way about
(e.g. for the toilet, bedroom, door to outside).

Arrange for and join in social activities (as appropriate to the
person’s capacities).

9   10

57

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Cognition

58

5.3
Assess cognition

Cognition is a process associated with thinking, that includes
reasoning, remembering, judgement, problem-solving and
planning. An important step, before any diagnostic tests for
).
cognition, is to identify and treat any reversible causes (

 5.5

Almost all standard cognitive assessments used for the basic
assessment or diagnosis of cognitive decline assume a minimal
amount of education (Table 5.1, p. 55). If a person has low levels
of education, or they are illiterate, cognitive assessment can be
limited (24) (25). Other sociocultural factors, such as language to
be used and socioeconomic status, can also affect the efficacy
of an assessment. These factors should be considered and
where necessary interview and clinical judgement should be
used instead. For these individuals, enrolling in an adult literacy
programme (if available) is highly recommended, as it promotes
brain health.

The care pathway outlines two different paths based on the results
of an in-depth cognitive assessment. Those assessed to have
normal cognition should still be assessed for diseases and risk
factors and social and physical environments.

A person with cognitive decline, should also be assessed for
difficulty with ADL or instrumental activities of daily living (IADL).
Their basic assessment results for other linked domains of intrinsic
capacity, such as limited mobility, hearing loss and depressive
symptoms should also be verified and an in-depth assessment
conducted as necessary.5
important for integrating interventions related to other losses in
intrinsic capacity and social care and support needs as part of a
personalized care plan.10

This information is

6   9   10

11

5.4
Manage cognitive
decline

Interventions to manage cognitive decline should always be
provided as part of a comprehensive personalized care plan
addressing the underlying diseases (e.g. CVD), symptoms such
as delirium and risk factors, along with interventions that address
other domains of intrinsic capacity.

For a person with dementia, a more specific, targeted or tailored
approach is appropriate. Referral to those with specialized
knowledge might be needed in cases with multiple associated
diseases or delirium and with behavioural and psychological
symptoms such as walking about, apathy, agitation, aggression,
delusions and hallucinations.

In addition to physical exercise and cognitive stimulation,
which can be provided in the community, there are multiple
other ways to manage cognitive decline. Cognitive stimulation
therapy, cognitive training, CBT, and referral to rehabilitation
services (
 4.2.1), should be considered in alignment with
the WHO Mental Health Gap Action Programme (mhGAP)
guideline for mental, neurological and substance use disorders.
These interventions are often provided by psychologists or
occupational therapists, but can be delivered by a trained health
worker at a primary care facility with supervision. Local protocols
should be applied for referral to specialists.

Prescription of anti-dementia medicines for cognitive decline
without diagnosis of dementia is not recommended. Health
workers need to be trained and supervised to ensure competence
in diagnosis and monitoring for the prescription of anti-dementia
medicines.

5

Cognition

5.4.1
Cognitive stimulation therapy

5.4.3
Cognitive behavioural therapy

Cognitive stimulation therapy encompasses a variety of approaches
including reality orientation, validation, and/or reminiscence.
The standard group approach emphasizes social interaction by
stimulating multiple cognitive functions simultaneously and involves
up to 14 themed sessions of about 45 minutes each, held twice
a week. Typically, a session might start with some non-cognitive
warm-up activity and then move to a variety of cognitive tasks,
including reality orientation (for example, a board displaying such
information as place, date and time), led by a facilitator. Sessions
focus on different themes, for example, childhood, use of money,
word games, cooking or music. These activities generally avoid
factual recall but instead focus on questions such as: “What do
these (words or objects) have in common?”

5.4.2
Cognitive training

Cognitive training refers to a range of techniques that are applied
to engage thinking and cognition with various degrees of breadth
and specificity. It targets isolated cognitive functions (e.g. memory)
with individual, repetitive practice of standardized cognitive tasks.
For example, placing five everyday items (e.g. cup, pen, key) on a
table, studying them for a minute, covering them with a cloth and
then trying to recall the items. To progress the exercise, a greater
number of items can be used and the time between covering the
items and recall can be extended. The goals include improving
or maintaining cognitive processes or addressing the impact of
impairment in cognitive processes on associated functional ability
in daily life.

It is important to encourage family members and carers to regularly
provide older people with information such as day, date, weather,
time and names of people, which helps them to remain oriented in
time and place.

Cognitive behavioural therapy (CBT) is an umbrella term covering
a wide range of psychological approaches that aim to improve
affective function. CBT focuses on the process of thought rather than
content to help people accept their thoughts. CBT can have positive
effects on everyday functioning and quality of life, and reduction of
depressive symptoms as a comorbid condition.

 10.4.2

M O R E   I N F O R M AT I O N

 Optimizing brain health across the life

course: WHO position paper. WHO; 2022

(https://iris.who.int/handle/10665/361251).

 mhGAP guideline for mental, neurological and

substance use disorders, [3rd ed.]. WHO; 2023

(https://iris.who.int/handle/10665/374250).

 mhGAP intervention guide for mental,

neurological and substance use disorders in non-

specialized health settings, version 2.0. WHO; 2016

(https://iris.who.int/handle/10665/250239).

Providing materials such as

newspapers, radio and TV

programmes, family albums and

household items can promote

communication, orient an

older person to current events,

stimulate memories and enable

the person to share and value

their experiences.

59

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Cognition

60

5.5
Assess and manage
associated diseases
and risk factors

An assessment of diseases and risk factors for cognitive decline
should start by identifying and treating possible causes (
Common reversible conditions and risk factors that can
cause cognitive decline include delirium, medication(s) and
cerebrovascular diseases. In some cases, treatment of these
conditions results in improvement in cognition. If cognitive decline
persists, further assessment will be required.

).

Uncovering a reversible cause of cognitive decline involves a full
diagnostic work-up, sometimes including blood tests. It may be
necessary to explore several different potential explanations of
symptoms to arrive at an accurate approach for a care plan.

5.5.1
Delirium

Delirium is acute, fluctuant loss of the ability to direct, shift, sustain
and focus attention. People also become confused about where
they are and what the time is. Delirium develops over a short
period of time and tends to come and go during the course of a
day. It can be accompanied by other disturbances of perception,
memory, thinking, emotions and concentration. For a person with
significant cognitive decline, including dementia, any sudden
change in circumstances such as moving home or a bereavement
may precipitate a worsening of confusion or delirium. In most
people, the common precipitating factors are illness particularly
infection, dehydration, new medication, metabolic abnormalities
(such as hypoglycaemia, hyponatraemia, hypothyroidism, vitamin
deficiency), injury, substance intoxication or substance withdrawal.

5.5.2
Inappropriate medication(s)

Two or more medicines may interact and cause adverse side-
effects.
 4.2.4  The potential harm of these medicines can also
outweigh their benefits for some people. These include, but are
not limited to: opioids, antidepressants, psychotropic medicines,
dihydropyridines, antihistamines and anti-muscarinics (26).

5.5.3
Cerebrovascular disease

Vascular disease in the brain is closely associated with cognitive
decline. If the patient has a history of stroke or transient ischaemic
event, then prevention of further events is the primary approach to
stop further declines in cognition.

5.5.4
Cardiovascular diseases and risk factors

Cardiovascular diseases and risk factors, such as hypertension,
diabetes and high cholesterol, are modifiable factors for cognitive
decline. The risk of developing CVD can be reduced by adopting
a healthy lifestyle. Early diagnosis and treatment of CVDs are
essential to prevent complications. Screening for hypertension
can be integrated in the community by measuring blood pressure,
 3.1.5, 3.2.2   The early detection
followed by a prompt referral.
of diabetes at a primary care facility is encouraged by testing those
who are symptomatic, overweight or obese. For those with CVD,
support should be provided to ensure adherence to treatment,
including medication.

5.5.5
Urinary incontinence
12

13

Urinary incontinence is common in people with cognitive decline
and should be assessed for and managed as appropriate.

5

Cognition

Community stakeholders

can help create age-friendly

and dementia-inclusive

environments, from outdoor

spaces to public services

(e.g. libraries, cafés) and

businesses.

5.6
Assess and manage
social and physical
environments

5.6.1
Social care and support 10

11

With training and support from health workers, family members
and carers can develop plans for ADL that maximize independent
activity, enhance functional ability, help to adapt and develop
skills, and minimize the need for support.

For those with dementia, specific measures may be needed to
support daily activities while keeping the person safe. These
measures should be commensurate with the person’s abilities,
changing as their condition progresses. For example, someone
with more advanced symptoms of dementia should avoid driving,
avoid the use of gas for cooking, cook with someone else present
and carry a note with them with their name and address in case
they get lost.

Carers can also inform friends and neighbours about the person’s
dementia, in case they get disoriented and are found in the
community. In some contexts, tele-assistance services may be
available that include emergency buttons and other devices
to help older people with dementia stay safe at home and in
community settings, while also providing reassurance for carers.

5.6.2
Assistive products including memory aids

Assistive products including memory aids (notes, reminders and
calendars) can help a person with cognitive decline to remember
important things and to continue to live with some independence.
It can be helpful to place notes and other reminders around the
home, for example, a list or pictures near the door to remind the
person what they should take with them when leaving the house.
Labelling cupboards so the person can identify where to find
things, and labelling items specifying their use, could also help. If a
smartphone is available, alerts, apps and calendar functions can be
useful memory aids. Using pill boxes or organizers can assist with
remembering to take medications as prescribed.

Note reminders can include:

household chores

•
•  medications and when to take them
•
•
•

shopping lists
phone numbers of close friends, family, emergency services
how to perform important tasks.

5.6.3
Optimize the physical environment to reduce
the risk of falls

An assessment of and modifications to the physical environment
can be useful in reducing the risk of falls.

 4.2.5

61

5.6.4
Support for carers
11

12

Caring for an older person with cognitive decline, including
dementia, can be overwhelming. As cognitive decline progresses,
the person may become forgetful and increasingly need help with
daily tasks. They may not recognize relatives or friends and may
experience changes in their behaviour that can be distressing and
difficult for their carers to manage. These demands can put carers’
health and well-being at risk.

It is important that carers receive support for their well-being
and information and training to support their ability to provide care.

This can focus on the importance of maintaining a daily routine,
identifying and modifying environmental falls risk factors, detailed
recording of falls incidents (
 4.2.5), how to use assistive products,
what to do in response to challenging behaviour and how to respond
when/if the person they are caring for does not remember them.

M O R E   I N F O R M AT I O N

 WHO iSupport for dementia: training and support

manual for carers of people with dementia. WHO;

2019 (https://iris.who.int/handle/10665/324794).

5

Cognition

62

Locomotor capacity

6 Care pathway to improve

mobility

Musculoskeletal health refers to the performance of the locomotor
system, comprising muscles, bones, joints, nerves and connective
tissues. Locomotor capacity is defined as the status of a person’s
musculoskeletal system, encompassing endurance, balance,
muscle strength, function and power, and joint function, and how
these change over time (27). Mobility is the interaction of locomotor
capacity and a person’s environment. Mobility is a critical
determining factor for maintaining autonomy and independence.

Nutritional status is closely associated with locomotor capacity.
Pain also impacts mobility, balance and coordination, which may
increase the risk of falls. There are effective strategies to improve
and maintain locomotor capacity and mobility in older age.

Key points

 Health workers in the community can conduct a basic
assessment for limited mobility with a simple test.

 A multimodal exercise programme, tailored to individual
capacities, preferences and needs, is the most important
approach to improve or maintain locomotor capacity, alongside
nutritional interventions.

 Health workers should assess pain and include pain
management interventions in a personalized care plan.

 Assistive products can enable older people to maintain mobility
despite reduced locomotor capacity.

 Environmental adaptations to the home and home surroundings
can support the functional ability of older people with limited
mobility.

 Community-based organizations and older people themselves
can support adherence to physical activity including exercise,
through establishing their own activities and peer support.

63

6

Locomotor capacity

Care pathway to improve
mobility

64

ReassessMultimodal exercise A multimodal exercise programme for people with limited mobility combines diﬀerent types of exercise with emphasis on the core muscle groups of back, thigh, abdomen and lower bodyIF NORMAL MOBILITY (SPPB score 10–12 points)IF LIMITED MOBILITY(SPPB score 0–9 points)(A, B and C can be assessed in any order)Provide support for self-care and self-managementProvide multimodal exercise with close supervisionConsider increasing protein intake      7.2Provide health and  lifestyle advice  to promote physical activity and prevent falls A1C•Risk of falls  in home and home surroundings •Need for mobility assistive products•Social care and support needs including with ADLs •Carers' support needs (training on transfer)2B•Inappropriate medication(s) •Pain•Musculoskeletal conditions (e.g. osteoarthritis, osteoporosis and sarcopenia) •Urinary IncontinenceExample: Short Physical Performance Battery (SPPB)       6.1Provide health and lifestyle advice including advice to promote physical activity  Conduct basic assessment regularly  Regardless of result:AssessmobilityASSESS(BASIC)3.1ASSESS(IN-DEPTH)A, B and CFAILPASSAssess social and physical environmentsAssessfor diseases and risk factorsConsolidate interventions, considering results of A, B and C3Consider potential interventionsConsider potential interventions       6.1,DEVELOPa care planIMPLEMENT& MONITOR       6.2Refer to primary carePhysical exercise programmes for limited mobility       6.4.2 4.2.56

Locomotor  capacity

65

2Short Physical Performance Battery (SPPB)SPPB measures timed performance on three tasks, each scored out of four, for a total score from 0 (worst) to 12 (best).Describe each test and ask if the person feels able to do it. If not, score accordingly and move to the next step. 1.   Balance: Stand for 10 seconds with feet in each of the three positions. Use the sum of the three scores.  If any not attempted, end balance tests.2.  Gait speed: time to walk 4 m  <  4.82 seconds  4 points 4.82–6.20 seconds 3 points 6.21–8.70 seconds 2 points >  8.70 seconds 1 point Unable to complete  0 points 3.  Chair rise: time to rise from a chair ﬁve times         <  11.19 seconds  4 points 11.2–13.69 seconds 3 points 13.7–16.69 seconds 2 points 16.7–59.90 seconds 1 point > 60 seconds or unable to complete 0 points1Final SPPB score = sum of scores for the three tests above. Inappropriate medication(s)PainMusculoskeletal conditions   Urinary incontinenceReview medication and withdraw or prescribe alternatives (6.5.1)Pain management including through physical exercise and psychological interventions (6.5.2)Management of diseases (6.5.3) See UI care pathway       6.5       6.3       6.6       6.5.2• Rehabilitation for those with signiﬁcant loss of intrinsic capacity and multimorbidity (4.2.1)• Management of chronic pain that limits activity (6.5.2)• Management of pain and multidimensional suffering, associated with life-threatening  illness (4.2.3)• Tailored exercise informed by an assessment of safety risks (Box 6.1) • Provision and maintenance of mobility assistive products (6.6.2)Need for specialized knowledge and trainingAssess mobilitySide-by-side stand:Held for 10 seconds 1 pointNot held for 10 seconds 0 pointsNot attempted 0 pointsSemi-tandem standHeld for 10 seconds 1 pointNot held for 10 seconds 0 pointsNot attempted 0 pointsTandem standHeld for 10 seconds  2 pointsHeld for 3 to < 10 seconds   1 pointHeld for < 3 seconds 0 pointsNot attempted 0 pointsIf any of the above are not attempted, end balance testsPain is a unique and unpleasant sensory and emotional experience that can limit activities and make daily life diﬃcult. It may cause discomfort, limit movement, aﬀect sleep and social participation. It is aﬀected by a person’s physical, psychological, social, cultural and spiritual circumstances. Pain can also impact mood, motivation, overall well-being and depressive symptoms. It can be acute but is often chronic (longer than 3 months) in older people. Severe pain associated with movement can limit or prevent physical exercise. Addressing pain includes a comprehensive pain assessment, understanding of the person’s goals for pain management and use of non-pharmacological and pharmacological approaches to achieve optimal pain control.Interventions for diseases and risk factorsRisk of falls Need for assistive productsSocial care and support needs Carers' support needs3Optimize physical environments at home and home surroundings (4.2.5)Provide mobility assistive products and advise on use and maintenance (6.6.2)Provide personal care and support with activities of daily living (11.6)Support access to health care and getting medications  (6.6.3)Provide training on positioning and transfer of an older person with mobility loss (12.4)Interventions for social and physical environmentHow pain aﬀects mobility136

Locomotor  capacity

Physical activity is important
for carers too, supporting their

physical and mental health

and their resilience. This may

become more important if

an older person’s locomotor

capacity declines and carers

have to take on more physically

demanding tasks, supporting

with moving, transfer and lifting.

66

6.1
Health and lifestyle
advice to promote
physical activity

Everyone should undertake regular physical activity. The benefits
are well established, including for older people and those with pain.
The benefits include helping to prevent and control CVD risk factors;
reducing depressive symptoms and anxiety, and enhancing cognitive
function; promoting and maintaining locomotor capacity and preventing
falls; and  improving bone health thus preventing osteoporosis (28).

Community health workers and other community stakeholders can
provide advice on physical activity to all older people, including
those with potential loss of mobility. This advice can be provided
alongside the more general health and lifestyle advice.
Advice on physical activity should take into consideration the
person’s intrinsic capacity and social and physical environment,
and cultural perceptions and acceptability of physical activity in
their context. Advice should also include the fact that activity that is
too intense, including physical work, may not be beneficial.

 3.1.3

For all older people and carers:

Each week:

•  Get at least 150 minutes of moderate intensity aerobic physical
activity or at least 75 minutes of vigorous intensity aerobic
physical activity, or an equivalent combination of both.

•

Aim for 300 minutes of moderate intensity activity or
150 minutes of vigorous intensity activity for substantial health
benefits.

•

Exercise at least 10 minutes at a time.

•  Do muscle-strengthening activities that involve all major

muscle groups 2 days or more.

•

Perform physical activity that enhances balance on 3 days or
more.

•  Do multimodal physical activity combining both balance and

strength training on 3 days or more.

•

If you cannot exercise as much as recommended, be as
physically active as you can.

Moderate intensity activity: heart is beating faster than usual, and
you are breaking a sweat. Carrying on a conversation is difficult but
not impossible.

Vigorous intensity activity: heart is beating very fast, and you are
breathing hard. Carrying on a conversation is almost impossible
and you are likely sweating profusely.

•

•

•

•

•

All older people can benefit from physical activity, regardless
of their level of mobility.

For older people with (potential) limited mobility, to
prevent falls:

Every move counts. Any amount of physical activity is better
than none. Older people can start slowly, doing small amounts
of physical activity and gradually increase frequency and
intensity. Try walking, cycling, jogging, swimming, everyday
household tasks, gardening, dancing and sport.

Too much sedentary behaviour is unhealthy. Getting moving
and replacing sedentary time with physical activity of any
intensity provides health benefits.

Physical activity should be adjusted to a person’s ability.

A healthy diet is also important.

 7.1

•  Certain activities can help prevent falls, including balance activities

like yoga.

•

•

Adapt the home environment using lighting, contrast and the use of
colours, installation of handrails and grab bars.

Practising good foot care and hygiene and wearing appropriate
footwear.

6

Locomotor  capacity

M O R E   I N F O R M AT I O N

 Physical activity. WHO; 2024
(https://www.who.int/initiatives/behealthy/
physical-activity).

 Promoting physical activity for older people:
a toolkit for action. WHO; 2023
(https://iris.who.int/handle/10665/373332).

 WHO guidelines on physical activity and
sedentary behaviour: at a glance. WHO; 2020
(https://iris.who.int/handle/10665/337001).

6.2
Community-based
health care to address
limited mobility

6.2.1
Physical exercise

If an older person is identified as potentially having limited mobility
through a basic ICOPE assessment, and an in-depth assessment
is not immediately available, community health workers and other
community stakeholders can provide more specific advice and
facilitate access to community-level opportunities for physical
exercise. This can include organized exercise classes, and more
informal groups and activities. Community stakeholders, including
older people’s groups, can set up physical exercise activities,
such as brisk walking groups, regular Tai chi classes in a local park,
or yoga classes in a community hall, organizing trained people to
guide these exercises. This will provide opportunities for social
engagement and peer support, which may encourage older people
to stick with their physical exercise.

If in doubt about the safety of exercise, refer to an appropriate

health care worker with knowledge (Box 6.1, p. 69).

Intergenerational activities could also be offered where
appropriate and desirable for older people. Community
stakeholders might be able to work with local authorities and
other service providers (e.g. religious gatherings, gyms) to secure
dedicated time for older people’s exercise and to improve the
physical environment through age-friendly cities and communities
programmes.

67

6

Locomotor  capacity

More information on the SPPB, what

it involves and how it is scored can

be found on p.65

68

6.3
Assess mobility

6.4
Manage limited mobility

Mobility can be assessed more fully by using a physical
performance test. The short physical performance battery (SPPB)
(29) is one of the most commonly used and widely recommended
tools. It has superior measurement properties and is useful across a
range of capacities. The SPPB comprises a balance test, a walking
speed test and a chair rise test with scores added together to
determine a person’s physical performance, including locomotor
capacity. If a person uses assistive product(s), alternative or
modified tests, conducted with or without the product(s), can be
considered.

This care pathway outlines two different paths based on the total
score. Those assessed to have normal locomotor capacity should
still be assessed for diseases and risk factors and social and
physical environments.

The basic assessment results for other linked domains of intrinsic
capacity, such as undernutrition should be verified and an
assessment conducted as necessary.

7

Urinary incontinence should be assessed for and managed as
appropriate.

13

12

Interventions to manage limited mobility should always be
provided as part of a comprehensive personalized care plan,
including underlying diseases (e.g. musculoskeletal conditions) and
factors contributing to limited mobility, such as pain or joint issues,
along with interventions for other domains of intrinsic capacity.

In addition to promoting physical activity, including exercise
provided in the community, there are multiple other ways to
manage limited mobility. Multimodal exercise programmes,
increased protein intake and referral to rehabilitation services
should be considered.

6.4.1
Support for self-care and self-management

Support for self-care and self-management of physical activity
increases adherence and benefits, and helps to address pain.
People whose SPPB scores are in the range of 10–12 (considered
as normal mobility) can exercise on their own at home and in the
community, as can those with a lower score if advice, support and
close follow up are provided.

6.4.2
Multimodal exercise

For those with limited mobility, a multimodal exercise programme
should be tailored to suit individual capacity, needs and preferences
and provided with supervision to ensure the safety of exercise
(Box 6.1, p. 69). The use of safe and familiar equipment and careful
warming up and cooling down should be prioritized to prevent
injury. Consideration should be given to cultural perceptions and
gender-specific factors, including in relation to the acceptability
of exercise. Multimodal exercise can also help reduce the risk of
falls.

 4.2.5

6

Locomotor  capacity

Where pain limits mobility, pacing exercise in manageable chunks of

time and slowly increasing physical tasks helps to build the body’s

resilience and manage pain. Pain management should be considered

and provided as appropriate alongside physical exercise. For people

with significant loss of locomotor capacity, exercise training in bed

or seated on a chair can be a starting point. For people with cognitive

decline or dementia, a simple and less structured exercise programme

may be more suitable.

Box 6.1 Safety of exercise

Before giving advice on exercise or planning an exercise programme, ask about
health conditions that would affect the type and intensity of the activity. If the person
answers yes to any of the following questions, a health professional should develop a
tailored exercise programme.

•  Have you experienced chest pain or palpitations in the last month?

•  Have you had a heart attack within the last 6 months?

•  Have you fainted or lost consciousness?

•  Have you fallen in the past 12 months?

•  Have you broken a bone in the last month?

•  Do you get out of breath doing ordinary daily activities at home, such as getting

dressed?

•  When you walk, do you need to use objects to support yourself, for example, holding

on to furniture or leaning on another person?

•  Do you have a joint or muscle disease that limits exercise?

•  Has a health worker advised you to limit exercise?

If an older person has chronic conditions or significant loss of
intrinsic capacity or pain limits mobility, health professionals should
be consulted for advice on the type and amount of physical exercise.

A multimodal exercise programme for people with limited mobility
should be designed with the local context in mind, considering
the exercise facilities and equipment available. There are multiple
ways people can exercise and specific types of training can be
adapted. A gym and/or specialist equipment are not necessary. A
programme for older people with limited mobility should include:

•  Strength/resistance training, which requires muscles to work

under load, using weights, resistance bands or body weight
exercises such as squats, lunges and sit-to-stand exercises;
other examples are heavy gardening and climbing stairs. If
exercise weights are not available a household item can be
used, for example, tins of food or bags of beans or rice.

•  Aerobic/cardiovascular training, such as fast walking, cycling

or dancing that increases heart rate until the person is slightly
out of breath but can maintain a conversation; it is important to
warm up and cool down after aerobic exercise by doing light
stretches and walking at a gentler pace.

•  Balance training, which challenges balance and coordination,

including static and dynamic exercises; can progress to
different surfaces and with eyes open and shut; examples
are standing on one leg at a time and walking heel-to-toe in a
straight line.

•

Flexibility training, which improves the extensibility of soft
tissues, such as muscle, and the range of joint movement;
examples are stretching, yoga, Tai chi and Pilates exercises.

The Vivifrail project offers a practical guide to developing a
tailored exercise programme, based on locomotor capacity and
risk of falls (30).

Nutritional interventions, including the provision of dietary advice
such as increased protein intake, can enhance the benefits of an
exercise programme.

7

69

6

Locomotor  capacity

Numeric rating scale for pain

0 = no hurt

2 = hurts little bit

4 = hurts little more

6 = hurts even more

8 = hurts whole lot

10 = hurts worst imaginable

70

6.5
Assess and manage
associated diseases
and risk factors

6.5.1
Inappropriate medication(s)

Some medicines can impair or interfere with locomotor capacity yet
are sometimes still prescribed. The potential harm of these medicines
can outweigh their benefits for some people (31). These include, but
are not limited to, medicine that affects the central nervous system
including those with anticholinergic effects (e.g. benzodiazepines,
 4.2.4
opioids, antidepressants).

6.5.2
Pain

Pain can make an older person’s daily life difficult. It is important that
pain is assessed and managed.

Assess pain
It is helpful to rate the severity of pain as part of a person-centred
assessment, both to help with designing an exercise programme
and for managing pain. Early identification of pain (severity
and cause) should be performed proactively to facilitate the
management of loss of locomotor capacity and depressive
symptoms. There are several pain scales such as numeric rating
scale and the Brief Pain Inventory (32). The numeric rating scale
is an 11-point scale for patient self-reporting of pain. The person
should be asked to rate the severity of their pain, when the pain
is experienced (morning, during sleeping at night, during or after
exercise), and duration of the pain.

Manage pain
The goal of pain management (33) is to relieve pain to a level that
allows for an acceptable quality of life. Where pain is a significant
barrier to movement and activity, a health professional with
specialized knowledge of pain management should develop pain
management interventions, including medications with close
monitoring, for integration into a consolidated personalized care
plan, that may also include referral to rehabilitation services  or
palliative care.

 4.2.1, 4.2.3

Community stakeholders, including older people’s groups, could
also provide advice and support for older people living with pain,
including through establishing peer support groups.

Interventions for pain might include:

•

self-management, including staying physically active,
applying heat and cold, changing posture and reducing
inactive posture, managing stress, including through
relaxation techniques, sleeping well and modifying thinking
to focus more on positive thoughts;

•

physical exercises;

•  manual therapy such as massage, joint manipulation and joint

mobilization;

•

•

•

psychological therapy including CBT;

 10.4

acupuncture;

assistive products to aid mobility; and

•  medication such as nonsteroidal anti-inflammatory medicines,
which should be used with extreme caution, due to substantially
increased risk of gastrointestinal adverse events and renal
impairment. Where absolutely necessary, prescription requires
careful attention to medical history, medication review, close
follow up and the shortest duration of treatment possible.

Pain related to serious illnesses
Pain is one of the most frequent, serious symptoms experienced
by patients with serious illnesses. Palliative care should be
provided, including for those with life-threatening or chronic
and/or progressive diseases (e.g. dementia, chronic obstructive
pulmonary disease, cardiac failure) to prevent and relieve suffering

6

Locomotor  capacity

The benefit of pain relief must

be balanced against the risk of

adverse effects and overdose

that may result in respiratory

depression. Regular monitoring

is important to reduce the

risks associated with opioids,

promoting early identification

of potential adverse effects.

through the early identification, correct assessment and treatment
of pain and other issues. Pain relief might be required at all stages of
a disease, not only at the end of life. Such patients must be reviewed
regularly, as they may require increasing doses of analgesia with
progression of their disease.

 4.2.3

Pain related to musculoskeletal conditions
Musculoskeletal conditions that impair locomotor capacity often
involve chronic pain. A specific biological cause of persistent
pain is not always found. Holistic assessment and personalized
care from a biopsychosocial perspective, therefore, addresses
multiple factors that may be associated with pain – physical
factors such as muscle strength, range of movement and
endurance, psychological well-being such as coping with pain
and social factors.

Chronic low back pain
Chronic/recurrent low back pain (LBP) (longer than 3 months) is
commonly experienced by older people in addition to pain from
other musculoskeletal conditions. Chronic LBP results in high levels
of disability and a pronounced impact on quality of life. Since health
workers may identify underlying disease or structural lesions (e.g.
arthritis, old fracture) among older people, their clinical judgement
and a comprehensive approach is critical to diagnose chronic
primary LBP. The WHO guideline for non-surgical management of
chronic primary low back pain in adults in primary and community
care settings recommends 10 interventions related to education,
physical, psychological, medicines and multicomponent
interventions (Table 6.1).  Besides these interventions, mobility
assistive products should be considered.

6.5.3
Management of muscoskeletal conditions

Musculoskeletal conditions such as osteoarthritis, osteoporosis
and sarcopenia can impair locomotor capacity.

Osteoarthritis is a degenerative joint condition, which affects the
joint and surrounding tissues. It causes pain, swelling and stiffness,
can lead to significant losses in locomotor capacity, reduced
social participation and quality of life and increased psychological
distress. It is most common in the knees, hips, spine and hands.

Table 6.1
Recommended interventions for  chronic
primary low back pain in adults

Intervention class

Interventions

Education

•  Structured and standardized

education and/or advice

Physical
interventions

•  Structured exercise therapies or

programmes

•  Needing therapies
•  Spinal manipulative therapy
•  Massage
•  Mobility assistive products

Psychological
interventions

•  Operant therapy
•  Cognitive behavioural therapy

Medicines

•  Non-steroidal anti-inflammatory

drugs (NSAIDS)*

•  Topical cayenne pepper
(Capsicum frutescens)

Multicomponent
interventions

•  Multicomponent biopsychosocial care

*This recommendation does not include older people

M O R E   I N F O R M AT I O N

 WHO guideline for non-surgical management
of chronic primary low back pain in adults
in primary and community care settings. WHO;
2023 (https://iris.who.int/handle/10665/374726).

 Executive summary: WHO guideline for non-surgical
management of chronic primary low back pain in adults in
primary and community care settings. WHO; 2023
(https://iris.who.int/handle/10665/374531).

71

6

72

Osteoporosis is characterized by low bone mass and
structural deterioration of bone tissue, leading to an increased
susceptibility to fractures, especially of the hip, spine and wrist.
Osteoporosis is more common in women often being caused by
hormonal changes after the menopause. Smoking, alcohol, long-
term use of steroids, lack of calcium and vitamin D, and being
underweight are the main risk factors.

Sarcopenia is a progressive skeletal muscle condition involving
the loss of muscle mass and strength, which is associated
with increased adverse outcomes including falls, limitations in
performing ADL, social participation, loss of independence and
mortality.

 7.5.1

6.5.4
Urinary incontinence
12

13

There is evidence that demonstrates the link between UI and limited
mobility (34), which can negatively affect access to the toilet. If a
loss of locomotor capacity is identified, UI should be assessed and
managed as appropriate.

6.6
Assess and manage
social and physical
environments

6.6.1
Optimize the physical environment to
reduce the risk of falls

An assessment of and modifications to the physical environment
can be useful in reducing the risk of falls.

 4.2.5

6.6.2
Assistive products

Mobility assistive products can improve an older person’s
independence and safety and enable them to live at home for as long
as possible. Mobility assistive products include walking aids, portable
ramps, grab bars, transfer boards and wheelchairs.

 4.2.2

Assistive products can:

•  Help a person sit up, stand or walk.

•

•

•

•

Support a person to be more independent in their  basic ADLs.

Reduce the risk of fall whilst walking.

Provide people who cannot walk with a different way of
moving around.

Support a person to access their environment (home and home
surroundings), including access to health and social services.

6.6.3
Social care and support 10

11

An older person with limited mobility might need assistance with daily
tasks including washing, dressing, going to the toilet and getting out
of the house. Potential challenges with accessing health care and
getting medications (e.g. going to the pharmacy) linked to reduced
mobility may also need to be addressed, with carers and community
stakeholders exploring alternative ways to facilitate access.

6.6.4
Support for carers
11

12

Carers should be provided with training on how to assist someone
to move safely, while also protecting themselves from injury.

M O R E   I N F O R M AT I O N

 Mobility assistive products, walking aids, portable

ramps. TAP (https://www.gate-tap.org/).

Vitality

7 Care pathway to manage

malnutrition

WHO uses the term vitality to describe the physiological factors
that contribute to an individual’s intrinsic capacity. These may
include energy balance and metabolism, neuromuscular function,
and immune and stress response functions of the body (35). Body
composition changes occur with ageing with fat mass replacing
muscle mass and inadequate nutrition also contributes to the
loss of muscle mass and strength (sarcopenia). Nutritional status,
including hydration, one of the key factors for vitality, significantly
affects an older person’s health, functional ability and quality
of life. Impairment of oral function may affect chewing and
swallowing ability and therefore nutrition. This handbook addresses
malnutrition, focusing on undernutrition.

Key points

 Health workers in the community can easily make an initial
assessment of nutritional status. A full assessment requires
specialized knowledge and usually blood tests.

 A high protein diet through locally available protein rich foods is
important for older people.

 Not drinking enough causes dehydration. Older people should
be encouraged and supported to drink well.

 A balanced diet in adequate amounts usually provides
the necessary vitamins and minerals for older people, but
deficiencies in vitamins D and B12 are common.

 Overweight and obesity are major risk factors for
noncommunicable diseases and should be prevented and
managed through diet and exercise.

 Making eating a social activity, by eating together at home or
within community groups, can encourage older people to eat
more healthily and avoid isolation.

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Care pathway to manage
malnutrition

74

FAILPASSProvide health and lifestyle advice, including advice on good nutrition, hydration and locally available foodsPromote oral health (Box 7.1)Conduct basic assessment regularly  Regardless of result:7.17.4.17.4.2ASSESS(BASIC)3.1ReassessCIF NORMAL (or low risk of undernutrition)IF AT RISK OF UNDERNUTRITIONProvide personalized diet adviceRecord and adapt eating patternsMonitor weight closelyConsider multimodal exerciseConsider oral supplemental nutrition* if unable to improve food intakeIF MALNOURISHEDProvide personalized diet adviceProvide oral supplemental nutrition* with increased protein intake (400–600 kcal/day) (Box 7.2)Monitor dietary intake and weight closely23Provide advice on hydration and locally available foodsPromote oral health (Box 7.1)ASSESS(IN-DEPTH)A, B and C(A, B and C can be assessed in any order)       6.4.2A1Assessnutritional statusAssesssocial and physical environmentsAssessfor diseases and risk factorsB•Sarcopenia•Gastrointestinal conditions•Oral diseases and issues with chewing or swallowingConsider potential interventions•Social eating habits•Social care and support needs(access, preparation and provision of food and drinks)•Need for assistive products(eating and drinking aids, dentures)•Carers' support needsConsider potential interventionsConsolidate interventions, considering results of A, B and CDEVELOPa care planIMPLEMENT& MONITOR7.1Refer to primary care7.2Balanced diet including high protein foods for undernutrition7

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 (36)

 (37)

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• Management of gastrointestinal symptoms (e.g. chronic vomiting, diarrhoea, abdominal pain) (7.5.2)• Management of malnutrition in the presence of diseases affecting metabolism (e.g. cancer, heart failure, respiratory diseases, renal dysfunction, liver dysfunction, diabetes) • Personalized nutritional counselling for those with malnutrition• Oral diseases and issues with chewing and swallowing (7.5.3)Social eating habitsSocial care and support needsNeed for assistive productsCarers' support needs3Encourage family and social dining in the community (7.6.1)Arrange assistance with access, preparation and provision of food and drinks (7.6.2)  Advise the appropriate positioning and assistance with feeding (11.6) Provide eating and drinking aids, and dentures (7.6.3) Provide advice on food preparation, feeding and drinking (12.4)1Mini nutritional assessment (MNA)https://www.sciencedirect.com/science/arti-cle/abs/pii/S0899900798001713  Malnutrition universal screening tool (MUST) https://www.bapen.org.uk/pdfs/must/must_full.pdfSeniors in the community risk evaluation for eating and nutrition questionnaire, version II (SCREEN II)https://olderadultnutritionscreening.com/screen-tools/Short nutritional assessment questionnaire 65+ (SNAQ65+)  https://clinicalnutrition.science/en/nrs/screen-ings/snaq-65−.html)Several tools are available to determine the risk of under-nutrition (normal nutritional status/low risk of malnutrition, medium risk of malnutrition, and malnourished/at high risk of malnutrition) without a blood test. For example:Need for specialized knowledge and training2SarcopeniaGastrointestinal conditionsOral diseases and issues with chewing or swallowingConsider rehabilitation to improve muscle function (7.5.1)Management of diseases (7.5.2)Management of oral diseases (7.5.3)Advice on consistency and texture of drink and food (chopped, minced, pureed) (7.5.3)What is dehydration?Dehydration, “an insufficient amount of water in the body” is a common condition in older people            . One in every four older people living in the community or in LTC facility has low-intake dehydration (dehydration due to drinking too little)            . It is important to encourage and support sufficient intake of water based on individual capacity and social context.Interventions for diseases and risk factorsInterventions for social and physical environment       7.5       7.6       7.3       7.3.2Assess nutritional status7

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Remember: It is important
that family members and other
carers as well as the older person
receive this advice, together with
information on where specific
affordable foods, with adequate
energy (e.g. carbohydrates,
protein) and micronutrients such
as vitamins and minerals, can be
purchased or sourced (shops,
markets) locally.

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7.1
Health and lifestyle
advice to promote good
nutrition and oral health

Our diets and the way we eat are influenced by our culture and, for
many people, eating is a social event. As such, communities and
families, including carers, can play a key role in supporting healthy
diets and promoting oral health.

 3.1.3

All older people can benefit from healthy diet advice, including
those at risk of or affected by undernutrition. When providing
advice on healthy diets, including hydration, it is important to note
that older people should follow any medical advice they have been
given, for example, the need to restrict certain foods or drinks due
to underlying diseases and conditions, including medication
(drug-food interaction).

For all older people, the importance of:

•

•

•

Food hygiene: keep hands and food preparation areas clean
and raw and cooked food separate, cook food thoroughly,
store food properly and use safe, clean water.

Eating enough: eat smaller amounts more often (5–6 times per
day) if having large meals is difficult.

Family-style meals and social dining can help, particularly for
older people living alone or who are socially isolated.

•  Carbohydrate intake should primarily come from wholegrains,

vegetables, fruits and pulses and fats from wholefoods, such as
nuts, seeds, beans, olives and fatty fish.

•  Hydration: drink at least 1.6–2 L (6–8 glasses or cups) per day,

regularly throughout the day. Drinks can include water, tea,
coffee, fruit juice, soft drinks and soups, Other fluids will come
from food. The amount of liquid should be increased during
particularly hot weather or in hot places.

•  Doing physical activity, which enables protein to be incorporated

into muscle and builds appetite, and helps to prevent and
manage overweight and obesity.

 6.1

•

•

•

•

Safe exposure to sunlight to allow the skin to manufacture
vitamin D. The vitamin D in food may not be enough for older
people to maintain optimal levels.

Promote oral health (Box 7.1, p. 77)

For older people who are overweight or obese, limit
energy intake from total fats and free sugars and increase
consumption of fruit and vegetables, legumes, wholegrains
and nuts.

For some older people, including those with UI and limited
mobility, it may be beneficial to avoid frequent trips to the toilet
during the night. In such cases, drinking could be reduced in
the evening.

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Box 7.1 Promote oral health

WHO defines oral health as the state of the mouth, teeth
and orofacial structures that enables individuals to perform
essential functions such as eating, breathing and speaking.
It encompasses psychosocial dimensions, such as self-
confidence, well-being and the ability to socialize and work
without pain, discomfort and embarrassment. Poor oral
hygiene is a risk factor for oral diseases, which negatively
affect nutrition intake. Oral diseases are also associated
with CVD risk factors, particularly diabetes mellites.
Community stakeholders can provide the following advice:

•

•

•

•

Brush teeth twice a day with fluoride toothpaste
(1000–1500 ppm) and safe water after breakfast and
before going to bed. For those with no teeth, brushing
gums and tongue with a soft toothbrush twice per day
to remove food debris and bacteria is advised.

Advise on denture hygiene, if applicable.

Limit free sugar intake.

Stop the use of all forms of tobacco including chewing
of areca nuts and betel quid.

For older people with (potential) undernutrition:

•

•

Advise on what and how much to eat. A person with diabetes, renal
or liver dysfunction should be advised to consult a health worker for
diet advice.

Encourage to keep a record of food and drink consumed on a chart
every day – both at meals and between meals. This can make it
easier to follow a good diet and stay hydrated.

In addition to organizing community meetings to provide nutrition
advice, community stakeholders can also support healthy nutrition
by encouraging eating as a social event, and organizing lunch clubs
and other regular community meetings with a meal provided. They
could work with local authorities and others to identify small areas
of land that could be used for community allotments or kitchen
gardens and older people and families who already grow food
could organize amongst themselves to exchange surpluses for
more dietary diversity.

M O R E   I N F O R M AT I O N

 Nutrition and food safety poster.
WHO; 2024 (https://www.who.int/teams/
nutrition-and-food-safety/multisectoral-actions-in-
food-systems/five-keys-to-safer-food-poster).

 Healthy diet. WHO; 2024 (https://www.who.int/
news-room/fact-sheets/detail/healthy-diet).

 Oral health training course for community health
workers in Africa. OpenWHO; 2024 (https://openwho.
org/courses/oral-health-community-AFRO).

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Foods rich in proteins (> 20 g per 100 g) include legumes such as nuts,
beans, lentils, peas and pluses, seeds, cereals, grains, cheese, meat
and fish. Community health workers can use a food composition
table to identify local foods with high protein and micronutrients
(https://www.fao.org/infoods/infoods/tables-and-databases/
faoinfoods-databases/en/). Although some dried pulses have a
protein content similar to animal protein sources, when cooked they
are not comparable. Given the diversity in availability of different
food groups and types and cultural practices and tastes, developing
a local food list can be helpful for older people to access locally
available foods high in protein.

7.2
Community-based
health care to address
undernutrition

7.2.1
High-protein diet

If an older person is identified as potentially experiencing undernutrition
through a basic ICOPE assessment, and in-depth assessment is not
immediately available, community health workers can support them
with guidance on a high-protein diet. Proteins are needed for cell and
tissue growth and they support muscle contraction and movement
and digestive and immune functions. A high-protein diet is important
for older people who are undernourished because the body’s ability to
absorb protein decreases with age.

For an older person with undernutrition, protein intake of
1.0–1.2 g per kg of body weight is recommended. A person
recovering from weight loss or an acute illness or injury may need up
to 1.5 g per kg of body weight. Guidance should also be provided
on safely increasing physical activity, as this enables protein to be
incorporated into muscle and builds appetite.

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7.3
Assess nutritional status

Nutritional status and risk of undernutrition should be
identified through an in-depth assessment using locally available
and validated tools.

Examples of tools  can be

found on p. 75

Most nutrition assessment tools (38) ask about:

food and fluid intake
recent weight loss

•
•
•  mobility
•
•  mental conditions
living situation.
•

recent psychological stress or acute disease

They also record:

•  weight
height
•
body mass index (BMI – kg/m2)
•
•  mid-upper arm circumference (MUAC) and calf circumference.

A deficiency in micronutrients; vitamins such as A, B12, D; and minerals
such as iron, folic acid and calcium can cause diseases and health
conditions such as anaemia and osteoporosis (39). A blood test can
identify specific vitamin and mineral deficiencies to inform nutritional
interventions. Specific oral nutrient supplements or injections can treat
these deficiencies.

This care pathway outlines three different paths based on the risk of
undernutrition. Those assessed to have normal nutritional status (low risk
of undernutrition) should still be assessed for diseases and risk factors
and social and physical environments.

The basic assessment  results for other linked domains of intrinsic
capacity, such as limited mobility and depressive symptoms, should also
be verified and an assessment conducted as necessary. 5

6   10

7.3.1
Body mass composition and ageing

Typically after around 60 years of age, muscle mass tends to
decrease. Both inadequate nutrition and inadequate physical
activity lead to loss of muscle mass and strength. Body weight
may decrease, or it may remain the same, masking these possible
harmful changes.

The use of BMI in older people has limitations, for example, loss of
height can be caused by vertebral collapse and change in posture.
An older person with undernutrition might have lost crucial lean
body tissue and still have a BMI in the accepted or even overweight
range, due to increased fat.

Anthropometric proxy indicators of malnutrition such as MUAC and
calf circumference are simple and convenient tools. The available
data suggest that a MUAC of 23.5–25.0 cm, on the non-dominant
arm can be used to identify the risk of undernutrition for adults in
the community (40) (41) (42).

A trained health worker could assess muscle strength and function
and undernutrition with a tool such as a hand dynamometer to
measure grip strength, if available. This tool measures how hard
a person can squeeze the tool with one hand. Low hand grip
strength indicates the need for exercise and a diet that includes
more protein.

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80

7.3.2
Dehydration

7.3.3
Obesity

Dehydration (43) is associated with adverse health outcomes such
as urinary tract infection (UTI), renal failure, constipation, delirium
and cognitive decline and has multiple causes and contributors,
including age-related reductions in the thirst sensation and fluid
reserves, uncontrolled diabetes and renal dysfunction. Cognitive
decline, swallowing difficulties, mobility loss, UI and difficulty
in feeding may also limit an older person’s intake of water. An
older person with UI may actively choose to limit their fluid intake,
thinking this will help manage their UI. Certain medicines, such as
diuretics and laxatives, can contribute to fluid losses, and older
people can also be particularly susceptible to fever, diarrhoea and
vomiting, which all cause dehydration.

Health workers can:

•

•

•

•

Look for symptoms of dehydration, such as dryness of the
mouth, lips and tongue, sunken eyes, constipation, less
frequent urination, tachycardia, headaches, weakness,
confusion and dizziness, although an older person may not
show typical clinical symptoms or signs (44).

Advise the older person (and carers) to keep track of fluid
consumption, including water, fruit juices and soups.

Set an individualized daily fluid intake goal. This should be at
least 1.6–2 L (6–8 glasses or cups) when no clinical conditions
are present that require a different approach and take into
account environmental factors, such as hot weather.

Encourage the older person (and carers) to keep a supply of
fluids they enjoy made the way they like to hand, and make
use of drinking aids (e.g. light containers, straws and spoons)
where needed.

•  Discuss and support the older person to manage UI to enable

them to drink well.
12

13

The prevalence of obesity among older people is rising worldwide
(45). Obesity is associated with multiple chronic diseases
including CVDs and cancer, as well as loss of locomotor capacity
and quality of life. For older people, the benefits of weight loss
need to be weighed against potential risks, such as loss of muscle
mass, which can exacerbate sarcopenia and increase the risk of
fractures. Promoting healthy lifestyles (nutrition, physical activity)
is critical to maintain muscle mass and bone density during any
caloric restriction.

 3.1.3

Health workers in primary care facilities should:

•

•

Assess the weight and height of older people regularly.

Provide counselling on healthy diet and lifestyle.

•  Monitor and manage CVD risk factors (

 3.1.4) and assess the
presence of comorbidities, including mental health conditions.

•  When a person is diagnosed with overweight or obesity:

–    Provide health services to manage obesity including dietary
intervention, physical exercise and medical measures where
indicated.

–    Assess for the presence of diabetes.

–    Refer to a specialist dietitian where available.

M O R E   I N F O R M AT I O N

 Obesity and overweight. WHO; 2024
(https://www.who.int/news-room/fact-sheets/
detail/obesity-and-overweight).

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7.4
Manage undernutrition

Nutritional interventions should always be provided as part
of a comprehensive personalized care plan addressing the
underlying diseases (e.g. gastrointestinal or oral diseases,
malignancy) and factors contributing to poor nutrition, along with
interventions that address other domains of intrinsic capacity.
These factors include sensory impairments (a decreased sense of
taste and smell), poor oral health such as chewing problems and
swallowing difficulties, social isolation, loneliness, low income and
long-term chronic conditions. Some medications can also interfere
with taste or smell or cause nausea and vomiting.

In addition to a high-protein diet, there are multiple other ways to
manage undernutrition such as nutritional counselling with weight
monitoring, multimodal exercise and OSN.

Box 7.2 Oral supplemental nutrition: key points

•  Food comes first. Unless the need for OSN is urgent, improvements in diet and more frequent

meals should be tried first.

•  OSN adds to food. It should not replace food. A person taking OSN should understand the

need to keep eating as well as possible.

•  People need instruction in how to mix OSN, how much to take at a time and when to take it.

•  OSN should be taken between meals, not at mealtimes.

•  People often need continuing support and encouragement (from family members, carers and

health workers) to keep taking OSN.

•  People may become tired of the taste and texture of one kind of OSN. A variety of flavours

could be used where available.

•  Weight should be closely monitored and recorded regularly.

•

Ideally, the goal should be to stop OSN once the risk of malnutrition has passed and the diet
provides adequate nutrition.

7.4.1
Risk of undernutrition

Health workers can provide personalized diet advice, with close
weight monitoring, to prevent the development of undernutrition.
They should start by recording eating patterns (types and amounts
of foods including fluids, and frequency) then adapt these eating
patterns to suit the individual’s cultural or personal preferences to
increase protein and required nutrients. If an older person is unable
to increase their food intake, including protein, OSN should be
considered (Box 7.2).

When a risk of undernutrition is identified, it is important to also
consider multimodal exercise, as nutrition and exercise are key
factors to maintain and improve muscle strength and function.
Adequate energy and protein intake will make multimodal exercise
programmes more effective.

 6.4.2

7.4.2
Malnutrition

In cases of malnutrition, health workers need to give immediate
personalized dietary advice (nutritional counselling) and assess
and manage contributing factors. A health worker with specialized
knowledge (e.g. dietitian) should conduct an in-depth assessment
of nutritional status, offer customized dietary advice and prescribe
OSN, if needed and available.

Additional high-quality protein, calories and adequate amounts of
vitamins and minerals can be provided by OSN where deficiency
is identified. Specialized knowledge is needed to develop a plan
for OSN that is tailored to an individual’s needs and physical and
psychological impairments. The assessment allows for choice
of the best method of supplementation – whether through
nutrient-rich foods, vitamin or mineral supplementation or through
specialized commercial products or non-commercial nutritional
formulations (46)(47). OSN should be prescribed only when a
person cannot consume sufficient calorie- and nutrient-dense
regular food or when OSN is a temporary strategy in addition to
regular food to increase caloric intake. Community health workers
can support and monitor people using OSN (Box 7.2).

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7.5
Assess and manage
associated diseases
and risk factors

7.5.1
Sarcopenia

Sarcopenia, a loss of muscle mass and strength, that results in
decreased muscle function may require rehabilitation interventions
including nutritional management with a focus on protein intake.

 4.2.1,  6.5.3

7.5.2
Gastrointestinal conditions

All functions of the gastrointestinal system such as movement of
foods, enzyme and hormone secretion, digestion and absorption,
can be affected in older age. Gastrointestinal diseases are one
of the common etiologies for unintentional weight loss (48).
Physical examination and history taking can identify common
gastrointestinal diseases such as constipation, diarrhoea,
inflammatory bowel diseases and peptic ulcers, and disease
management should be provided.

7.5.3
Oral diseases and issues with chewing or
swallowing

Oral diseases and issues with chewing or swallowing have a major
impact on nutritional status. The main oral diseases include dental
caries (tooth decay), periodontal (gum) disease, edentulism (total
tooth loss) and oral cancer (49). Losing teeth is often wrongly thought
of as an inevitable part of ageing and is socially accepted in many
cultures. However, it can be psychologically traumatic, socially
damaging and negatively affect intrinsic capacity and functional
ability. Most oral diseases are preventable through self-care
(Box 7.1, p. 77)  and  with access to appropriate oral health services.

Health workers at primary care facilities can identify oral diseases
and conditions by asking about:

•

•

•

•

•

•

•

difficulty in eating/chewing food

difficulty in swallowing food or drink

number of remaining natural teeth (less than 20 natural teeth
correlated with worse outcomes)

dental caries

gums bleeding while brushing

experience of having a dry mouth

pain/swelling/non-healing ulcer.

Oral diseases can be addressed by a trained health worker in
a primary care facility, in line with local rules and regulations,
including through arresting dental caries, filling after the removal
of a decayed tooth and managing periodontal disease with saline
and/or disinfected mouthwash. However, further assessment
and management require a referral to a health professional with
specialized knowledge (e.g. dentist, dental assistant, hygienist).

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Some older people may benefit

from food being more finely

chopped, minced or pureed.

For a person with dysphagia, it

is recommended to avoid mixed

texture foods (e.g. soup with

solid pieces) to reduce the risk

of aspiration.

Difficulties with swallowing (dysphagia), comprise problems
occurring during the passage of solids or liquids from the mouth to
the stomach, including sucking, chewing and biting, manipulating
food in the mouth, salivation and swallowing. Severe complications
in swallowing may include aspiration, dehydration or weight loss.
These difficulties can occur as a result of a number of conditions
more common in older age, including oesophageal dysfunction,
stroke, Parkinson’s disease and dementia.

7.6
Assess and manage
social and physical
environments

Advice should include the importance of considering the
consistency and texture of food and drink to make swallowing
easier and reduce the risk of choking or aspiration.

7.6.1
Social eating habits

Training to strengthen the muscles for swallowing and improve
coordination of the swallowing mechanism, can be provided,
including exercises with chewing, singing and saying words quickly
to maintain the muscles around the mouth. Salivary gland massage
could be instructed to stimulate saliva production. If an older person
has a significant impairment in swallowing, they should be referred to
rehabilitation services if available and accessible.

  4.2.1

Dentures
Dentures are removable false teeth that fit over the gums to replace
missing teeth and eliminate potential problems caused by gaps.
Dentures can help prevent problems with eating, subsequent
undernutrition and speech. They can also improve self-confidence
by changing a person’s appearance. Dentures can be measured
and fitted by a health professional with specialized knowledge (e.g.
dentist, dental technician) who can also provide advice on how to
wear, clean and look after them. They should be checked regularly,
including for fit, especially if the person’s weight is changing.

M O R E   I N F O R M AT I O N

 Promoting oral health in primary health
care settings. OpenWHO; 2024
(https://openwho.org/courses/oral-health-
promotion-PHC).

Making eating a social activity can have a positive impact, not only
in terms of nutrition and hydration status, but also psychologically,
helping to foster belonging and prevent loneliness.

Carers and community stakeholders can help to overcome barriers
to older people’s social eating habits by organizing social dining
events for older people, including providing food at meetings
or activities, and families eating meals together. Community
organizations can facilitate access to healthier food options (e.g.
through community gardens, community food markets).

7.6.2
Social care and support 10

11

Social care and support for an older person with or at risk of
malnutrition and/or dehydration might include supporting access
to prepared and ready-to-eat meals, helping with cooking,
providing drinks, including collection of water.

If an older person or/and their carer has difficulties in accessing
food, community stakeholders may be able to help, by organizing
grocery deliveries and providing financial advice and support. If
an older person has difficulties in feeding, they may also be able
to provide assistance with appropriate positioning at a table and
feeding.

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84

7.6.3
Assistive products

Simple eating and drinking aids can help a person with
weakness or poor coordination to eat and drink independently.

Community health workers can identify when these simple assistive
products may be helpful. Dentures may also be needed for those
with tooth loss, to manage problems with eating. Simple training is
available in how to identify and provide eating and drinking aids.

7.6.4
Support for carers
11

12

Carers should have access to advice on the importance of
hydration and how to prepare food for older people, including
softer foods if chewing or swallowing is difficult. They should also
be provided with information on how to help with feeding.

Carers should be supported with information on what to expect at
the end of life. A reduction in eating and drinking is a normal part of
the end-stage of a serious illness. Carers may find this difficult as
food is often how people show love for each other. Information and
support should be provided, including helping carers find other
ways to show their love, like oral and skin care.

Having a healthy diet is equally as important for the carer, but carers
may neglect their own diet, particularly if feeling overwhelmed
or stressed by their caregiving role. If an older person needs
assistance with feeding, a carer may focus on that rather than
eating and enjoying their own meal. Sharing meals with family or
friends can help, as others will be available to provide support.

M O R E   I N F O R M AT I O N

 Training on eating and drinking aids. TAP; 2024
(https://www.gate-tap.org/).

Vision

8 Care pathway to manage

vision impairment

Vision is a critical component of intrinsic capacity, enabling
people to be mobile and to interact safely with their peers and the
environment. Around 80% of distance vision impairment and 67%
of near vision impairment occur in people aged 50 years or older
(50). Far-sightedness (presbyopia), cataracts, glaucoma and age-
related macular degeneration are common eye conditions among
older people.

Vision impairment severely impacts quality of life and is associated
with depression, cognitive decline, anxiety, social isolation
and higher risk of falls. It can cause difficulties in moving safely,
maintaining family and other social relationships, ability to work and
secure an income and in accessing information.

Key points

 With a simple eye chart, health workers in the community can
conduct a basic assessment for vision impairment.

 The majority of cases of vision impairment and blindness can be
prevented through early detection and timely management of
eye diseases.

 Spectacles can often correct loss of near or distance vision.

 Assistive products such as magnifiers and white canes can
support those with vision impairment that cannot be corrected
with spectacles.

 Environmental modifications such as better lighting can
improve the functional ability of older people with vision
impairment and prevent falls.

 Community stakeholders can support older people with vision
impairment by mapping and auditing local environments and
establishing peer support groups.

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Care pathway to manage
vision impairment

86

PASSProvide health and lifestyle advice, including advice on eye and vision careConduct basic assessment regularly     Regardless of result:8.18.4.1ASSESS(BASIC)3.1ReassessDEVELOPa care planIMPLEMENT& MONITOR321AManage common eye diseasesRefer to comprehensive vision and eye care•    Treat eye diseases •    Manage vision impairment•    Review and update spectacles prescriptionC•Need for low-vision assistive products  •Need for adaptation of home and home surroundings (risk of falls)•Social care and support needs (ADLs, social participation)•Carers' support needsB•Hypertension and diabetes•Steroid useASSESS(IN-DEPTH)A, B and CAssesssocial and physical environmentsAssessfor diseases and risk factorsFAIL(A, B and C can be assessed in any order)Consolidate interventions, considering results of A, B and CConsider potential interventionsConsider potential interventionsAssessvision impairment and eye diseasesProvision of reading spectacles and screening for hypertension for vision impairment8.2Refer to primary care8

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87

• Sudden or rapidly progressing vision impairment • Provision of spectacles for correction of distance vision impairment• Control of retinal disease related to hypertension and diabetes and other eye diseases (e.g. glaucoma, cataracts, macular degeneration) (8.5)• Issues with the external eye (e.g. signiﬁcant discharge including pus, abnormal red on the white part of the eye, abnormal haziness or red on the coloured part of the eye)Need for specialized knowledge and training1Assess vision impairment  and common eye diseasesHypertension and diabetesSteroid useNeed for assistive productsNeed for adaptation of home and home surroundingsSocial care and support needsCarers' support needs3Provide low-vision assistive products (optical and non-optical) (8.6.1)Optimize physical environments (home and home surroundings) to reduce the risk of falls (4.2.5)    Advise on the use of household objects with larger more legible font  (8.6.2)Support tasks of daily living, opportunities for social participation (8.6.3)Provide psychosocial support  (8.6.3)Provide advice and training including adaptation of communication  (8.6.4) 2Management of CVD risk factors (8.5.1)Annual retinal check  (8.5.1)Regular review of steroid prescription (8.5.2) Regular eye and vision examination (8.5.2)  Common eye diseases such as such as red eye, abnormal lashes, conjunctivitis and dry eye disease can be further assessed by examining the appearance of the external eye, eyelids and eyelashes using a torch. Interventions for diseases and risk factorsInterventions for social and physical environment         8.5         8.3         8.6Refractive errorUncorrected refractive error is the most common cause of vision impairment globally. Refractive error occurs when the shape of the eye prevents light from focusing directly on the retina, leading to blurred vision. Common types of refractive errors include myopia (distance vision impairment), hyperopia (near vision impairment), presbyopia (age-related near vision impairment) and astigmatism (blurred vision at any distances).A person’s ability to identify or distinguish an object or letter clearly at a given distance (visual acuity) is measured using a tumbling E chart.  Visual acuity assessment is an important clinical measure when evaluating refractive error. To conduct this assessment, a space with good lighting and big enough to ensure the correct testing distance (e.g. 3 m for distance vision, 40 cm for near vision) is required. If the person already wears spectacles, examine visual acuity while wearing them.The external eyeTop lidEyelashTear ductCornea(clear layer over the coloured part of the eye) Bottom lidConjuctivaPupilIris8

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88

8.1
Health and lifestyle
advice to promote
eye and vision care

8.2
Community-based
health care to address
vision impairment

Community health workers and other community stakeholders can
provide advice to all older people, including those with potential
vision impairment, to support  eye and vision care, including:

8.2.1
Provision of reading spectacles

For all older people:

•

•

Addressing common misconceptions, such as vision
impairment being part of the normal ageing process.

Importance of management of risk factors for vision impairment,
including diabetes, hypertension and use of steroids.

•  Having regular eye check-ups with a health worker and seeking

advice if experiencing any problems.

•

•

Taking regular breaks from near work activities such as use of
electronic media (phones, tablets, etc), reading and sewing.

Limiting exposure to ultraviolet lights by wearing sunglasses
and hats.

•  Washing hands regularly, avoiding rubbing or touching the

eyes and only using mild soap to wash eyelids.

•

Smoking cessation, as smoking increases the risk of eye
diseases (e.g. cataracts, macular degeneration).

For older people with (potential) vision impairment:

•  How to optimize the home and home surroundings to reduce the

risk of falls, by using lighting, contrast and colours.

•

Following advice on how and when to use spectacles, for example,
if you have been told you need them for reading.

If an older person is identified as potentially having vision
impairment through a basic ICOPE assessment, and an in-depth
assessment (for eye diseases, external abnormality and vision
impairment) is not immediately available, community health
workers can help. They can facilitate access to readymade reading
spectacles, where available, for those with near vision impairment.
Many people aged 50 years and older have difficulty seeing or
reading at short distances. Reading spectacles can be an effective
and quick solution to correct presbyopia (near vision impairment)
by making close-up objects appear larger.

Readymade reading spectacles may be available at low cost in various
magnification strengths (+1.00, +1.50, +2.00, +2.50, +3.00). There
are several ways to prescribe reading spectacles. One commonly
used method is to combine a person’s age with trial and error.

Age group

Power of reading spectacles

40–50 years

+1.00 DS to +2.00 DS

≥ 50 years

+2.00 DS to +3.00 DS

Reading spectacles should be trialled in a well-lit room using the
near vision acuity test card (p. 23). The frame should fit the person
comfortably and correctly, making sure it is not too small or loose
and it fits over the ears without pressing on the side of the head.
When simple reading spectacles do not resolve the problem,
comprehensive eye and vision examination by a health professional
with specialized knowledge (e.g. ophthalmic nurse/optometrist/
ophthalmologist) is advisable.

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Vision

Community stakeholders can provide information on where
readymade reading spectacles are available locally and how
they work. Community-based groups, including older people’s
organizations, can work with health workers to facilitate mobile
outreach services to provide and trial reading spectacles with
older people.

8.2.2
Screening for hypertension

The risks for eye diseases and vision impairment posed by hypertension
can also be screened. Community health workers should test blood
pressure, if they have appropriate training and equipment, to identify
the risk factors for CVDs and give advice on the management of these
risk factors.
hypertension and diabetes, they should be referred to primary care for
follow up and a systematic retinal check should be recommended.

 3.1.4  If a person has already been diagnosed with

M O R E   I N F O R M AT I O N

 Training in provision of reading glasses,
magnifiers, and telescopes. TAP; 2024
(https://www.gate-tap.org).

 Vision and eye screening implementation
handbook. WHO; 2023 (https://iris.who.int/
handle/10665/375590).

89

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Vision

90

8.3
Assess vision impairment
and eye diseases

Eye care services may be offered within primary care facilities,
through proper supervision and the training of existing health
workers, or the adoption of standalone primary eye care services,
either in fixed facilities or through mobile units.

Health workers in primary care facilities can carry out eye and vision
examination. They can measure the ability of a person to identify
or distinguish an object or letter clearly at a given distance (visual
acuity). They can also examine for common eye diseases, such as
red eye, abnormal lashes, conjunctivitis, dry eye disease and eyelid
inflammation, using a torch.

In some cases when specialized knowledge is needed, a referral
to a health professional (e.g. ophthalmic nurse/optometrist/
ophthalmologist) should be made. That includes more in-depth eye
examinations such as subjective refraction, direct ophthalmoscopy
and retinal imaging, provision of spectacles or contact lenses for
distance vision impairment (myopia) as well as diagnosing and
treating eye diseases such as cataract and retinopathy due to
diabetes and hypertension.

The results of basic assessment for other linked domains of intrinsic
capacity, such as cognitive decline and depressive symptoms,
should also be verified and an in-depth assessment conducted as
necessary.

5   10

A “tumbling E” chart is widely

applicable, while a LogMAR (EDTRS)

chart requires knowledge of the

Latin alphabet.

Box 8.1 Cataract

Cataract is clouding of the lens of the eye, which prevents
clear vision, often related to the ageing process. Diabetes
and obesity are risk factors. Along with refractive errors,
it is the leading cause of preventable vision impairment
and blindness (51). Reduction of smoking and ultraviolet
light exposure may prevent or delay the development
of cataract. Early detection and surgical correction can
restore vision and save large numbers from losing their
sight. Surgical intervention involves the removal of the
clouded lens in the eye and the implantation of an artificial
intraocular lens.

888
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Vision

8.4
Manage vision
impairment and eye
diseases

Interventions to manage vision impairment and eye diseases should
always be provided as part of a comprehensive personalized
care plan addressing the underlying diseases (e.g. hypertension,
diabetes) and other factors, along with interventions that address
other domains of intrinsic capacity. In addition to provision of
reading spectacles and screening for hypertension there are
multiple other ways to manage vision impairment.

8.4.1
Management of common eye diseases

Health workers can provide treatment and/or first aid care
at primary care facilities with advice on follow up for people
presenting with red eye and/or abnormal lashes, infective and
allergic conjunctivitis, dry eye disease, eyelid inflammation
(blepharitis), ocular foreign body and keratitis (corneal
inflammation). If there is little or no improvement, timely referral to a
health professional with specialized knowledge  is needed.

8.4.2
Management of refractive errors

Management of refractive errors includes regular eye examinations
and comprehensive vision and eye care. Corrective measures such
as spectacles, contact lenses and refractive surgery can effectively
manage refractive errors. These treatments are safe and can
significantly improve vision, enhancing quality of life.

8.4.3
Irreversible vision impairment and blindness

Many people have low vision for which prescription spectacles
cannot correct their vision sufficiently. For these people, low-
vision assistive products can make tasks involving near vision
possible, such as reading a book or newspaper, identifying
money, reading labels, sewing and inspecting small objects or
parts of large objects. They should be referred to rehabilitation
services, if available and accessible, for advice on how to
enable their participation in social life by maximizing the use of
residual vision and providing practical adaptations to address
the social, psychological and economic consequences of vision
impairment.

 4.2.1

Community stakeholders can support people with low or no
vision to navigate their local community. This could include
accompanying a person walking or taking a journey on a
route they would like to learn, for example, from their home
to a family member’s home. Doing this a number of times will
help the person to get used to the environment and build their
confidence in making the journey. Developing audio maps of
local environments, describing where things are and how to
find particular facilities and services could also be useful.

M O R E   I N F O R M AT I O N

 Package of eye care interventions.
WHO; 2022 (https://iris.who.int/
handle/10665/354256).

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92

8.5
Assess and manage
associated diseases
and risk factors

8.5.1
Hypertension and diabetes

8.6
Assess and manage
social and physical
environments

8.6.1
Low-vision assistive products

Hypertension and diabetes are important risk factors for retinal
diseases and glaucoma (a leading cause of preventable vision
impairment and blindness). Diabetic retinopathy is the most
common microvascular complication of diabetes. In addition to
managing CVD risk factors (
 3.1.4), a systematic retinal check
(i.e. annually or biennially, depending on the setting) for people
with hypertension or/and diabetes, followed by treatment is
recommended. Retinopathy can be detected and monitored
using ophthalmoscopy by a health professional with specialized
knowledge or retinal imaging with either local interpretation or
telemedicine-based programmes with centralized grading.

8.5.2
Steroid use

In some people, long-term treatment with corticosteroids can
increase pressure in the eyeball or lead to cataract. This increased
pressure (glaucoma) can lead to vision impairment and blindness,
by damaging the optic nerve, if not treated. Anyone receiving
long-term steroid treatment needs regular comprehensive
eye and vision examination including eye pressure checks. The
appropriateness of steroid prescription including dosage should
be regularly reviewed.

A range of assistive products can be used to help older people
with vision impairment continue with their daily lives and interests.
These include optical assistive products such as magnifiers,
telescopes and spectacles, non-optical assistive products such
as audio books and players, talking watches, white canes, screen
readers and adapted mobile phones. Many mobile telephones
and computer programs now have text-to-speech functions. Pill
organizers with raised text or braille might be helpful.

8.6.2
Environment modification at home and in home
surroundings

In addition to the use of low-vision assistive products, simple changes
can be made to the home and home surroundings to reduce the risk
of falls for older people with vision impairments.
 4.2.5   Besides
these modifications, changes to make daily tasks and leisure
activities easier can include:

•  Use of the most legible type: For printed materials and

electronic display screens on computers and telephones, large,
sans serif type (such as the type in this handbook) that stands
out clearly from a uniform background colour is easiest to read.

8

Vision

For example, keeping similar

items like cutlery together in

drawers and not mixing them

with screwdrivers. Clothes

can be organized in drawers

or cupboards as coordinated
outfits or by arranging them

according to the occasions on

which they are worn.

•  Choosing household objects with larger type and good

contrast: Products are commonly available that use larger
letters and numbers or good contrast, for example, clocks,
watches and large-print books. For leisure, large game boards
and pieces, and playing cards with large print and symbols can
be bought or made.

•  Use of talking assistive products: Consider talking watches,

thermometers and scales.

8.6.3
Social care and support 10

11

Older people with vision impairment may require support with
ADL. Besides assistance with daily activities such as eating
and dressing, older people can be supported to organize their
belongings to make them easy to find and distinguish.

Older people with vision impairment may feel unhappy, lonely
or hopeless, and have an increased risk of depression, anxiety,
fatigue or grief related to (progressive) vision loss. They can
experience social isolation, particularly if they find it difficult to
get out of the house to attend social gatherings and events and
may benefit from psychological support.

Carers and community stakeholders can help by organizing
local events and accompanying people to attend, mapping
local environments and establishing peer support groups. They
can also advocate for and implement solutions to improve the
readability of signs in both private and public facilities (e.g. in
health care facilities, restaurant menus) as well as in outdoor
spaces (e.g. traffic and street signs).

8.6.4
Support for carers
11

12

Training for carers of older people with vision impairment could
include, how to help the person move around, ranging from
modifying the home environment to make it safer to how to walk
with someone with vision impairment. It could also focus on how to
adapt communication styles and methods, including:

•

Be patient – give the person enough time to navigate an
environment especially if it is unfamiliar.

•  Offer help when needed, but respect the person’s

independence, allowing them to do things for themselves
when possible.

•  Describe the environment, for example, surroundings, layout,

objects and people in a room.

•

•

•

Be alert – walk a few steps ahead to provide cues and alert the
person to potential hazards, such as steps.

Avoid assuming what the person with vision impairment can or
cannot do. Allow them to express their needs and preferences.

Encourage the use of assistive products to help the person
stay independent and connected.

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Vision

94

Hearing

9 Care pathway to manage

hearing loss

Age-related hearing loss may be the most common sensory
impairment in older people. Untreated hearing loss interferes with
communication and can lead to social isolation. Limitations of
other domains of intrinsic capacity, such as cognitive decline, can
make these social consequences worse. Hearing loss is linked to
many other health issues, including depression and anxiety, poor
balance and falls. Hearing loss has been identified as a potentially
modifiable risk for dementia (52). Its management through the use
of hearing devices can effectively reduce this risk.

Key points

 Health workers in the community can conduct a basic
assessment for hearing loss with simple portable equipment or
a whisper voice test.

 Simple actions in the household and community can reduce
the impact of hearing loss, including adopting communication
strategies.

 Hearing aids can be fitted by a trained health worker. However,
some people may need guidance from a specialist on fitting and
use to ensure the hearing aid works to maximum benefit.

 Community stakeholders can support older people with
hearing loss by providing information and advice, adapting
communication styles during community events and meetings
and establishing peer support groups.

95

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Hearing

Care pathway to manage
hearing loss

96

PASSProvide health and lifestyle advice, including advice on caring for ears and when to suspect hearing lossConduct basic assessment regularly         Regardless of result:9.1ASSESS(BASIC)3.1Reassess•Inappropriate medication(s) (ototoxic medication)•Noise exposure •History of sudden or rapidly progressive hearing loss •Unilateral or asymmetric hearing loss •Complaint of ear pain, discharge or dizziness•History of ear diseases, such as recurrent or chronic otitis mediaIF MODERATE TO SEVERE HEARING LOSS(Audiometry: 35–< 80 dB)Refer to trained health worker• Provide hearing aids If no hearing aids available, inform about communication strategiesIF DEAFNESS(Audiometry: ≥ 80 dB)1324Consider potential interventionsRefer to specialized hearing care• Evaluate and provide hearing       device (hearing aids or        cochlear implants)If no hearing device available, inform about communication strategies       9.2       9.2CFirst, perform ear exam using otoscopy If wax impaction, treat and repeat hearing testBDEVELOPa care planIMPLEMENT& MONITORIF NORMAL OR MILD HEARING LOSS(Audiometry: < 35 dB)Provide advice on caring for ears and when to suspect hearing loss Encourage regular hearing check-up (every 1–3 years)       9.1Assess for red ﬂagsDiagnostic audiometryAssesshearing capacity•Need for home adaptations•Need for assistive products (vibrating or ﬂashing alarms, sound ampliﬁers)•Social care and support needs (ADLs, social participation)•Carers' support needsConsider potential interventionsAssesssocial and physical environmentsFAILASSESS(IN-DEPTH)A, B and CA*Consolidate interventions, considering results of A, B and C9.2Communication strategies for hearing lossRefer to primary care9

Hearing

1

Ear exam using otoscopy

Ear wax

•  Use one hand to gently pull the

pinna backwards and upwards to

straighten the ear canal.

•  With the other hand, gently pull

the tragus forwards with your ﬁnger

 to open the ear canal.

•  Shine a light into the ear canal (with

the otoscopy, if available, or ask an

assistant to help with a torch), to help you

look for:

–  Ear wax, pus, or discharge

–  Swelling and redness

–  Foreign body in the ear canal

Ear wax can be removed by doing an ear washout.

Wax is made by the ear canal to clean the ear and is

normally expelled from the canal by the ear itself.

Impacted wax can lead to pain and hearing loss, and

aﬀect the performance of hearing aids. If an older

person fails the hearing screening test, wax impaction

should be identiﬁed and addressed if present.

Need for specialized knowledge
and training

•  Fitting hearing aids for moderate hearing loss (9.4.3)

 •  Evaluation and management of severe hearing loss/

deafness and provision and use of hearing device

•  Management of an underlying problem that causes

Ear wax can be removed with an ear washout with

clean, body temperature water (37 ºC). If the wax

cannot be safely removed, refer to a specialized care.

or contributes to hearing loss

•

If any red ﬂags identiﬁed (9.5)

Hearing test should be repeated after wax removal.

Noise exposure

3

Interventions for red ﬂags

       9.5

Inappropriate medication(s) (ototoxic medication)

Review medication and withdraw

or prescribe alternatives (9.5.1)

Advise on safe listening volume

and use of earplugs (9.5.2)

2 Diagnostic audiometry

       9.3.2

Complaint of ear pain, discharge or dizziness

History of sudden or rapidly progressive hearing loss

Unilateral or asymmetric hearing loss

Refer to specialized hearing care

A non-invasive hearing test that measures the ability

to hear diﬀerent sounds, pitches or frequencies. The

test requires a quiet room and earphones. There are

two tests: pure tone audiometry and speech

audiometry.

History of ear diseases such as recurrent or chronic otitis media

4

Interventions for social and physical environments

       9.6

Need for home adaptation

Arrange the home to aid communication (9.6.1)

Need for assistive products

Provide assistive products such as vibrating or ﬂashing telephones

and doorbells, portable sound ampliﬁers (9.6.2)

Social care and support needs

Support tasks of daily living, opportunities for social participation (11.6)

Carers' support needs

Advise carers on communication strategies (9.2)

97

•

See a health worker if hearing loss is suspected, based on:

– Often asking people to repeat themselves.

– Turning up the volume on the radio or television.

–  Having difficulty following conversations in noisy places.

–  Having difficulty in understanding what is said over the phone.

– Having a ringing sensation in the ear (tinnitus).

–  Having problems hearing sounds like a doorbell, alarm

or telephone.

– Being told by others that you speak loudly.

Community stakeholders can also arrange advice sessions or
discussions on how hearing loss can be managed, including through
the use of hearing aids and other assistive products. They can also
help to address stigma associated with hearing aid use. Awareness-
raising campaigns can educate people that hearing loss is nothing to
be ashamed of or to hide. One out of every 20 people has a hearing
loss that needs management (53).

9.1
Health and lifestyle
advice to promote ear
and hearing care

Community health workers and other community stakeholders
can play a role in the provision of general ear and hearing care and
lifestyle advice for all older people, including those with hearing loss.
Information that can be shared includes do’s and don’ts for healthy
ears, importance of regular hearing checks, as well as when to seek
health care, including when to suspect hearing loss.

Advice for all older people:

•  Clean only the outer part of the ear with a soft cloth.

•  Do not put things inside the ears, for example, Q tips/cotton
buds, hopi candles, oils, liquids such as kerosene, sticks,
homemade remedies or dirty fingers.

•  Do not swim or wash in dirty water.

•  Do not share earphones or earplugs with other people.

•  Do not listen to loud sounds or music, and use earplugs in noisy

places.

•  Have regular hearing check-ups with a health worker and seek
advice in the case of ear pain, discharge or any difficulty in
hearing.

9

Hearing

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Hearing

9.2
Community-based
health care to address
hearing loss

9.2.1
Communication strategies

•

In groups, do not all talk at once. Encourage people to
speak one at a time.

•  Do not give up speaking to a person with hearing loss.

•

•

If the person has difficulty speaking, use visual aids like
pictures or written notes to assist them.

Be aware of and look out for different reasons for
communication challenges that are not related to hearing
loss, such as cognitive decline.

If an older person is identified as having potential hearing loss
through a basic ICOPE assessment and diagnostic audiometry is not
immediately available, community health workers and community
stakeholders can advise on communication strategies, whether or not
hearing aids are available. Advice should include:

•  Give the person your full attention, particularly if they also have

speech difficulty.

•

Let the person see your face when you speak and make eye
contact to show you are actively listening and that you value
what they have to say.

M O R E   I N F O R M AT I O N

 Tips for healthy ears. WHO; 2023
(https://www.who.int/publications/m/item/
community-resource-5-tips-for-healthy-ears).

 Hearing loss in adults. WHO; 2023
(https://www.who.int/publications/m/item/
community-resource-1a-when-to-suspect-hearing-
loss-in-an-adult).

•  Make sure there is good light on your face to help the listener to
see your lips. Do not exaggerate or distort lip movements.

 Basic ear and hearing care resource. WHO; 2020
(https://iris.who.int/handle/10665/331171).

  Tips for hearing aid users. WHO; 2023
(https://www.who.int/publications/m/item/
community-resource-4-tips-for-hearing-aid-users).

•  Get the person’s attention before you speak.

•

•

Reduce background noise or move to a quieter setting.

Speak clearly and more slowly. Do not shout.

•  Give the person time to speak. Don't interrupt or finish

sentences for them.

•

•

Remember that the person may need extra time to
communicate. Be patient and respectful.

Use nonverbal signals like nodding your head to indicate you
are following the conversation.

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Hearing

Make sure to always examine both

ears, even if the person’s complaint is

in one ear only.

100

•  Speech audiometry: Older people benefit from this

additional test. In a speech audiometry test a series of pre-
recorded simple words are played at increasing volumes,
and the person is asked to repeat the words when they hear
them. This test cross-checks the results of the PTA. It helps
to determine whether speech recognition is consistent with
the PTA results, if there is an asymmetry of speech perception
that is not predicted by the PTA, and identifies which ear to fit
with a hearing aid if only one hearing aid is being fitted.

•

Tympanometry: This tests the compliance (or mobility) of the
eardrum – how effective the eardrum is at transmitting sound
to the middle ear cavity and therefore the inner ear. This test
can support the pure tone and speech audiometry results to
determine the type of hearing problem.

The care pathway shows the management of hearing loss by three
categories (normal, moderate to severe and deafness). Where the
capacity of the health system permits, and it is considered more
suitable, mild hearing loss (20 to < 35 dB) can also be identified
(Table 9.1, p. 101). Those assessed to have normal hearing capacity
should still be assessed for red flags and social and physical
environments.

In addition to hearing tests, results of basic assessment for other
linked domains of intrinsic capacity, such as cognitive decline and
depressive symptoms, should also be verified and an in-depth
assessment conducted as necessary.

5   10

9.3
Assess ear problems
and hearing capacity

An important step before any diagnostic tests for hearing
capacity is to identify and treat wax using otoscopy.

9.3.1
Otoscopy

Otoscopy is the procedure that allows identification of conditions
that cause hearing loss, such as earwax or perforations of the
tympanic membrane. There are many kinds of otoscope. Some
can connect to a computer or mobile phone and record pictures
or videos of what is being viewed. An otoscope needs a speculum,
an attachment (usually plastic) for looking into the ear canal.

9.3.2
In-depth hearing assessment

An in-depth hearing assessment can involve three tests with
equipment – a diagnostic audiometer for pure tone; speech
audiometry; and a tympanometer for middle ear assessment.
These tests can help to identify the need for hearing devices and
support. Doing these tests needs specialized training.

•  Pure tone audiometry (PTA): This tests a person’s ability to

hear sounds of different pure tone frequencies (pitches).
It consists of playing pre-recorded sounds louder and
louder until the person can hear them to identify the hearing
threshold. It tests air conduction and bone conduction of
sounds to assess hearing thresholds at frequencies from
125 Hz (very low) to 8000 Hz (very high). This test helps to
determine the severity and type of hearing loss.

9

Hearing

Table 9.1
Hearing loss classified according to severity

Grade

Hearing threshold in
better hearing ear (dB)

Hearing experience in a
quiet environment

Normal hearing

< 20 dB

No problem hearing sounds

Mild hearing loss

20 to < 35 dB

Moderate to severe
hearing loss

35 to < 80 dB

Deafness

≥ 80 dB

Does not have problems hearing
conversational speech in a quiet
environment

Difficulty hearing conversational
speech in a quiet environment; if
severe hearing loss, even with raised
voices

Extreme difficulty hearing raised
voices

9.4
Manage hearing loss

People with hearing loss may report feelings of embarrassment,
anxiety and loss of self-esteem, leading to less participation
in social activities, social isolation and loneliness, all of which
contribute to depression.
10

Interventions to manage hearing loss should always be provided
as part of a comprehensive personalized care plan responding
to underlying factors, along with interventions that address
other domains of intrinsic capacity. In addition to supporting
communication strategies, there are multiple other ways to
manage hearing loss, including provision of hearing devices and
referral to rehabilitation services.

 4.2.1

Basic education and counselling on hearing loss should be
provided to encourage and support psychological acceptance
and adjustment. This includes communication strategies,
adaptations in environments, how to use hearing aids and peer
mentoring. Older people and their family members and carers
may benefit from counselling to help them accept and adjust to
their hearing loss, including learning to overcome the stigmatizing
attitudes of others.

9.4.1
Moderate to severe hearing loss

It is important that older people with moderate to severe hearing
loss are provided with information and support to help them to
adjust and live with their hearing loss. The benefits of hearing
devices such as hearing aids should be explained both to the
person with hearing loss and their carers along with information
on where to get them and how to use them. Once a person has a
hearing aid, a health worker can support and encourage its use.

101

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Some countries have regulations that

provide access to hearing aids over-

the-counter without prescription,

such as pre-programmed hearing aids

and self-fitting hearing aids. These

hearing aids are commonly suitable

for those with mild or moderate

hearing loss, without any red flags.

Pre-programmed hearing aids are

already programmed according to the

most common types of hearing loss in

older people.  A trained health worker

can decide which pre-programmed

hearing aid is suitable and fit it.

102

9.4.2
Deafness

An older person with severe hearing loss or deafness or who does
not benefit from the above interventions will need another approach,
such as provision of a cochlear implant, if available. This can only be
decided in consultation with a hearing care specialist.

9.4.3
Hearing devices

Most hearing devices should be provided by a trained health
worker who is authorized, in line with local rules and regulations.
If hearing devices are not available, community health workers
and other community stakeholders can provide information on
communication strategies.

Hearing aids: A hearing aid is an electronic device that is worn on
or inside the ear. It helps to amplify sounds to allow a person with
hearing loss to better hear speech and other sounds. It is usually the
most useful and convenient technology for older people with hearing
loss. Audiometry alone should not determine whether a person
needs a hearing aid. A person must be assessed for their overall need
before a hearing aid is suggested. It is important to explain to people
that hearing aids do not cure or treat hearing loss. Advice should be
provided regarding their use and maintenance, including regular
replacement of the battery and earpiece.

Advice and information for the use of hearing aids include:

•  How hearing aids work and the importance of using them

regularly during waking hours.

•  Caring for a hearing aid, including:

–   keeping it in a safe, cool place when not in use, and

away from water and heat at all times;
–   removing it while bathing or showering;
–   opening the battery drawer at night;
–   making sure it is switched off when not being used;
–   cleaning the earpiece with a dry cloth every day.

•  Changing or recharging the batteries and where to access

affordable batteries.

•  Common problems when using hearing aids and how to

address them.

•

The likelihood of hearing aids being effective – to manage
expectations.

Cochlear implants: A Cochlear implant is an electronic medical
device for people with severe hearing loss who are unable to
benefit from hearing aids. It has two parts, an external processor
that picks up the sounds and delivers them to the implantable
part that is surgically placed in the ear. It turns sounds into
electrical impulses and sends them to the nerves of the ear. A
person must be evaluated carefully to see if a cochlear implant
will help. If cochlear implantation is not available or feasible, an
older person and their family should be informed about different
communication strategies.

M O R E   I N F O R M AT I O N

 Training on hearing assistive products. TAP; 2024
(https://www.gate-tap.org/).

 Hearing aid service delivery approaches for
low- and middle-income settings. WHO; 2023
(https://iris.who.int/handle/10665/376092).

 Primary ear and hearing care: training manual. WHO;
2023 (https://iris.who.int/handle/10665/366334).

9

Hearing

9.5
Assess and manage
red flags

There are a number of “red flags” in relation to hearing loss,
including potential causes and issues that should be considered
as requiring referral to a health professional with specialized
knowledge (e.g. ear nose throat specialist).

9.5.2
Noise exposure

Noise-induced hearing loss can be caused by a variety of
environments and behaviours at work, home or from recreational
activities. The volume of sounds, the duration of listening and
frequency of exposure to loud sounds all have an impact on hearing.
In the case of hearing loss caused by the unsafe use of personal
audio devices, there are simple, effective practices such as keeping
the volume within safe listening levels and limiting the time spent
engaged in noisy activities.

9.5.1
Inappropriate medication(s)

9.5.3
Other red flags

Certain medications can cause damage to the inner ear, resulting
in hearing loss and/or loss of balance (54), for example:

Conditions that may underlie hearing loss and need specialized
diagnosis and management include:

•

•

•

•

•

antibiotics such as streptomycin and gentamicin;

antimalarials such as quinine and chloroquine;

injection treatment of multidrug-resistant tuberculosis;

diuretics such as furosemide; and

nonsteroidal anti-inflammatory drugs such as aspirin.

A full medication review and adjustment of medications may
require specialized knowledge. Where such ototoxic treatment is
essential, it is important that hearing is checked regularly to detect
hearing loss at the earliest stage and take appropriate action.

•

•

•

•

history of sudden or rapidly progressive hearing loss;

unilateral or asymmetric hearing loss;

complaint of pain in the ear, ear discharge or dizziness with
moderate to severe hearing loss; and

history of ear diseases, such as recurrent or chronic otitis
media (middle ear infection).

103

9.6
Assess and manage
social and physical
environments

9.6.1
Home adaptation

Environmental modification at home and in the home
surroundings can help those with hearing loss. Examples include,
adding lights to ensure people can be seen during conversations,
arranging furniture so that chairs face each other to aid
communication, fixing doorbells in different places in the home
and installing flashing alarms.

9.6.2
Assistive products

Besides hearing devices, assistive products that can help people
with hearing loss include telephone amplifiers, portable sound
amplifiers, text messaging devices, apps and programmes that
enable captioning and subtitling of audio content on different
media channels and to convert speech to text. Hearing induction
loops can also be helpful. They comprise a wire or wires placed
around a space (e.g. meeting room or service counter). The wires
send signals from a microphone and amplifier to certain types
of hearing aids.

9.6.3
Social care and support 10

11

Regular social interaction may reduce the risk of cognitive
decline, depression and other psychological and behavioural
consequences of hearing loss. In times of particular distress,
social support networks can help.

Community stakeholders and family members can play a role
by continuing to communicate with a person with hearing loss
and organizing activities that keep the person involved in social
networks.

Alongside support to enable social participation, people with
hearing loss may need other forms of assistance in their daily lives.
For example, if communication is a challenge, support might be
needed with making phone calls or appointments.

9.6.4
Support for carers
11

12

Carers can support an older person with hearing loss by adopting
the communication strategies detailed above. They may also
need support themselves.

9

Hearing

Community stakeholders

can help to identify what is

available locally and provide

information and support.

Community organizations that

run classes to support older

people to learn about and use

digital technology could include

sessions focused on how to

use captioning and speech

to text apps.

104

Psychological capacity

10 Care pathway to manage

depressive symptoms

People with “depressive symptoms” have two or more
simultaneous symptoms of depression most of the time for at
least 2 weeks, but do not meet the criteria for a diagnosis of
depression. Depressive symptoms are common in older people
with long-term and disabling conditions and can be associated
with declines in all other domains of intrinsic capacity. It is also
common for those who are socially isolated or who are carers
with demanding care responsibilities to experience depressive
symptoms. They can affect all aspects of life, including
relationships with family, friends and community.

Depressive symptoms represent one dimension of many
that compose psychological capacity (anxiety, personality
characteristics, coping and mastery).

This chapter provides guidance on preventing and managing
depressive symptoms in older people. Further guidance on
interventions for depression (moderate to severe) as well as anxiety
can be found in the mhGAP intervention guide and mhGAP guideline.

Key points

 By asking questions, health workers in the community can
identify those with depressive symptoms.

 Using psychological interventions, trained and supervised
non-specialist health workers can help people with depressive
symptoms.

 For a person with depression (moderate to severe), a more
specific, targeted or tailored approach is needed.

 If an imminent risk of self-harm or suicide is identified, prompt
referral to specialized care is needed.

 Community stakeholders can raise awareness and
understanding of depressive symptoms in order to address

stigma. They can also help to address social isolation.

105

10

Psychological capacity

Care pathway to manage
depressive symptoms

106

       10.1Provide health and lifestyle advice, including advice to promote mental healthConduct basic assessment regularly          Regardless of result:ASSESS(BASIC)3.1PASSIf risk is imminent:Refer immediately to health professionals with specialized knowledge and trainingMobilize family, friends, concerned colleagues or other individuals to ensure close monitoring Link the person to community resources including mental health or suicide phonelines Remove access to means of self-harmReassessC•Inappropriate medication(s)•Anaemia, malnutrition, hypothyroidism•Pain•Major loss (bereavement) in the last 6 months •Disability due to illness or injury•History of mania•Social isolation and lonliness•Social care and support needs (ADLs, social participation)•Carers' support needsAssesssocial and physical environmentsAssessfor diseases and risk factorsBIF DEPRESSIVE SYMPTOMS (0–2 additional symptoms)IF DEPRESSION (MODERATE TO SEVERE)(> 3 additional symptoms)Assess the risk for self-harm/suicideManage depression          10.4.4Stress managementPsychoeducationBrief structured psychological interventions        10.4       10.2DEVELOPa care planIMPLEMENT& MONITORA3Consider potential interventions2Consider potential interventions          https://apps.who.int/iris/handle/10665/250239 See mhGAP intervention guide (depression)ASSESS(IN-DEPTH)A, B and CFAIL1Assessdepressive symptomsConsolidate interventions, considering results of A, B and C       10.2Stress management including relaxation techniques for depressive symptomsRefer to primary careFirst, identify and treat potentialcauses (see B     )10 Psychological capacity

107

       10.5       10.3       10.6• Imminent risk of self-harm or suicide (10.4.4) • Management of  bipolar disorder or  psychosis (delusions, hallucinations, disorganized behaviour, disturbances of emotion) (10.5.4) • Provision of brief structured psychological interventions (10.4.2) • Management of chronic pain, that requires comprehensive care (6.5.2)  Need for specialized knowledge and training• Meet the person in a private space, if possible.• Be empathic and sensitive.• Show extra sensitivity with difficult topics.• Remind the person that what they tell you will remain conﬁdential unless there is a risk of self-harm or suicide.• Don’t judge people by their behaviours and appearance.• Acknowledge that it may have been difficult for the person to disclose information.• If carers are present, suggest speaking with the person alone. Tips when asking questionsSocial isolation and lonelinessSocial care and support needsCarers' support needs3Identify and tackle loneliness and social isolation (11.3.3)Support tasks of daily living including with ADLs (11.6)Encourage participation in community activities (11.3.4)   Provide psychoeducation and psychosocial support (12.4)2Review medication and withdraw or prescribe alternatives (10.5.1)Management of diseases (10.5.2)Assess and manage pain (6.5.2)Advice for culturally appropriate adjustment and mourning processesAdvice on stress reduction and strengthen social supportSee the mhGAP intervention guide (psychoses)Inappropriate medication(s)Anaemia, malnutrition, hypothyroidismPainMajor loss (bereavement) in the last 6 months Disability due to illness or injuryHistory of maniaIf a person has more than two additional symptoms, they may have depression (moderate to severe). It is important to distinguish depressive symptoms from depression because their treatments differ.1• Trouble falling or staying asleep, or sleeping too much• Feeling tired or having little energy• Poor appetite or overeating• Feeling bad about yourself or that you are a failure or that you have let yourself or your family down• Trouble concentrating on things such as reading the newspaper or watching television• Moving or speaking so slowly that other people could notice• Being so restless or agitated that you have been moving around a lot more than usual• Thoughts that you would be better off dead or of hurting yourself in some wayAssess depressive symptomsIf a person reports at least one of the core symptoms – feeling down, depressed or hopeless and having little interest or pleasure in doing things – do a further assessment. ASK: Over the last two weeks, have you been bothered by any of the following problems?Interventions for diseases and risk factorsInterventions for social and physical environments10 Psychological capacity

108

10.1
Health and lifestyle
advice to promote
mental health

Community health workers and other community stakeholders can
provide advice to all older people, including those experiencing
depressive symptoms  about healthy lifestyles to promote mental
health and manage depressive symptoms.

Advice for all older people includes the importance of:

•

Taking regular physical activity.

•  Getting good quality sleep, including by maintaining the same

routine of sleep and waking times.

•

Eating a healthy and balanced diet.

•  Maintaining social connection and being socially active.

•

•

The benefits of stress reduction techniques.

Avoiding and reducing harmful use of alcohol and other
psychoactive substances. Alcohol use disorders and
depression can both increase risk of suicide and affect quality
of sleep.

Alongside healthy lifestyle advice, community stakeholders can
provide other information about depressive symptoms and other
mental health conditions. Raising awareness can help older people
and carers to be better equipped to understand and manage
depressive symptoms. Normalizing mental health conditions can
also help to reduce stigma, discrimination and social exclusion and
can support people to be more open about their feelings. It is also
important to educate people that depressive symptoms are not a
normal or inevitable part of ageing, but if they occur, they can be
treated or managed.

10.2
Community-based
health care to address
depressive symptoms

10.2.1  Stress management

If an older person is identified as potentially having depressive symptoms
through a basic ICOPE assessment and an in-depth assessment is not
immediately available, community health workers can provide guidance
on stress management. This an be provided through unguided self-help or
guided formats. This guidance can also be provided to carers.

 12.1

Physical exercise, restorative sleep and spending quality time with loved
ones are all useful to help manage stress. Physical exercise should be
encouraged, tailored to the person’s locomotor capacity and preferences,
due to its positive effect on reducing stress, relieving symptoms of anxiety
and sadness, boosting energy levels and improving sleep.

 6.1

Relaxation techniques and engaging in pleasant activities of interest
with friends or loved ones can also be beneficial. Deep breathing and
stretching and muscle relaxation are quick and effective ways to reduce
the physical and psychological impact of stress. It can be useful to practise
these techniques daily to help maintain resilience and so that a routine is
established for any difficult times when they are particularly needed.

M O R E   I N F O R M AT I O N

 Field test version: mhGAP community
toolkit: Mental Health Gap Action Programme
(mhGAP). WHO; 2019 (https://iris.who.int/
handle/10665/328742).

 Doing what matters in times of stress: an
illustrated guide. WHO; 2020 (https://iris.who.int/
handle/10665/331901).

10 Psychological capacity

10.3
Assess depressive
symptoms

10.4
Manage depressive
symptoms

An important first step when conducting an in-depth assessment
for depressive symptoms is to identify and treat any potential
reversible causes that can resemble or exacerbate depressive
symptoms (

 10.5

).

A health worker should also
assess psychological stressors
such as bereavement and
traumatic events that can
explain depressive symptoms.

More information on p. 107

Following this, by asking a series of questions, a health worker
can identify those with depressive symptoms and distinguish
depressive symptoms from depression (moderate to severe) at
a primary care facility. If a person reports at least one of the core
symptoms – feeling down, depressed or hopeless and having little
interest or pleasure in doing things – and one or two additional
signs, they may have depressive symptoms. If a person has more
than two additional symptoms, they may qualify for a diagnosis of
moderate to severe depression. A person with moderate to severe
depression usually has considerable difficulty with daily functioning
in personal, family, social or other situations.

In addition to an in-depth assessment for depressive symptoms,
results of basic assessments for other linked domains of intrinsic
capacity, such as cognitive decline, vision impairment and hearing
loss should also be verified and in-depth assessments conducted
as necessary.

5   8   9

 See the section on depression in the mhGAP intervention guide for
details of how to conduct an assessment. Tools can be used for the
assessment of depression, e.g. the Patient Health Questionnaire
(PHQ-9).

Interventions to manage depressive symptoms should always
be provided as part of a comprehensive personalized care plan
responding to underlying factors, along with interventions that
address other domains of intrinsic capacity.

In addition to guidance on stress management, there are
multiple other ways to manage depressive symptoms including
psychoeducation and brief structured psychological interventions.
It is recommended to apply a stepped care approach, starting with
a self-help low-intensity intervention (stress management) and
monitoring symptoms and provision of further interventions, in case
of no improvement or worsening.

10.4.1
Psychoeducation

Psychoeducation refers to educational programmes targeting an
older person with depressive symptoms and their carers focused
on improving understanding of their symptoms, including likely
cause, symptom monitoring and coping strategies, taking into
account their specific difficulties with ADL and problem-solving.
This information:

•  Helps improve a person’s knowledge about their condition and

enables informed decision-making about treatment.

•

Improves understanding about how and why treatment can be
helpful, encouraging adherence, and realistic expectations.

•  May increase feelings of control and empowerment and reduce

anxiety.

•

Provides hope for recovery.

•  Can improve carers’ and family members’ knowledge, helping

them to better support the person.

109

10 Psychological capacity

It is important to provide brief

amounts of information at a time,

use simple language and relevant

examples, and check the person

or group’s understanding of the

information provided.

110

Psychoeducation can be delivered individually or in group settings
if the therapeutic components are adapted for delivery in a
structured psychoeducational format.

10.4.2
Brief structured psychological interventions

Psychological interventions are the informed and intentional use
of clinical techniques developed from psychological principles
to help people modify their psychological skills (e.g. emotional,
interpersonal, behavioural and cognitive skills). If there is no
improvement of depressive symptoms by providing guidance
on stress management and psychoeducation, brief structured
psychological interventions, such as behavioural activation
therapy, CBT, problem-solving therapy and third-wave therapies,
may be considered.

Different formats for the delivery of psychological interventions
(average 8–10 sessions) can be considered with older people
including individual and/or group face-to-face psychological
treatments. Health professionals in mental health such as
psychologists would usually administer these interventions. Health
workers in primary care facilities could provide them if they are skilled
and trained in the mental health issues faced by older people, as the
benefits outweigh the harms.

While face-to-face psychological treatments are likely to have
better outcomes than unguided self-help, the latter may be
suitable for those who either do not have access to face-to-
face psychological treatment or are not willing to access such
treatments.

•  Behavioural activation therapy: This focuses on improving

mood by (re)engaging in activities that are task-oriented and
used to be enjoyable, in spite of current low mood. It may be used
as a stand-alone treatment, and it is also a component of CBT.

•  Cognitive behavioural therapy (CBT): A person with

depressive symptoms may have unrealistic, distorted
negative thoughts that can lead to harmful behaviour. CBT,
which combines thinking differently (e.g. through identifying
and challenging unrealistic negative thoughts) and doing
things differently (e.g. by helping the person to do more
rewarding activities) can be helpful.

•  Problem-solving therapy: A problem-solving therapy

involves the systematic use of problem identification and
problem-solving techniques over a number of sessions. It
offers direct and practical support by breaking problems
down into specific, manageable tasks and then developing
coping strategies for specific problems.

•

Third-wave therapies: These include mindfulness-based
interventions, acceptance and commitment therapy,
metacognitive therapy and dialectical behavioural therapy.
“Mindfulness-based interventions” is used here as an umbrella
term for mindfulness, meditation and yoga techniques, as well
as mindfulness-based cognitive therapy and mindfulness-
based stress reduction. Mindfulness consists of paying
attention to what is happening in the present moment instead
of being carried along by a train of thoughts about the past,
future, wishes, responsibilities or regrets.

Community stakeholders can provide information on available
services and support and can help break down stigma around
mental health. This can be particularly effective if trusted and
respected community leaders, including faith leaders, are involved.
Community-based organizations can help to identify those in their
communities who may be experiencing depressive symptoms and
who may need support, as well as their carers, who may experience
symptoms themselves. They can help by referring people to
appropriate services, establishing peer support groups, organizing
events to promote social participation and helping with day-to-day
tasks which may be causing stress.

10 Psychological capacity

10.4.3
Cognitive decline

5

Cognitive decline and dementia may be associated with depressive
symptoms. Results of a basic assessment for cognitive decline
should be validated and an in-depth assessment conducted
as necessary. The cognitive functions that can be affected
in depression are attention and memory, as well as executive
functions. Depression could be a psychological response to an
individual’s self-awareness of mild cognitive decline that has not
yet begun to interfere with daily functioning.

A person with dementia often complains of mood or behavioural
problems, such as lack of interest, loss of emotional control or
difficulties carrying out usual work, domestic or social activities.
Psychological interventions, such as CBT, interpersonal therapy,
structured counselling and behavioural activation therapy, should
be considered for people with dementia and mild to moderate
depression (see mhGAP guideline).

10.4.4
Manage moderate to severe depression

For a person with depression (moderate to severe), a more specific,
targeted or tailored approach is needed. That includes assessment
of potential thoughts, plans or acts of self-harm or suicide offering
evidence-based interventions such as  antidepressants and brief
structured psychological interventions.

Asking about self-harm or suicide does NOT provoke acts of
self-harm. It often reduces anxiety associated with these
thoughts or acts and provides a sense of relief. However, it is
important to establish a relationship with the person before
asking such questions. To introduce questions about suicide,
acknowledge that when people are very upset or feel hopeless,
they may have thoughts about death or ending their own life
and that these thoughts are not uncommon, and people should
not feel ashamed.

After checking whether the person agrees to discuss these issues,
questions like “In the past month, have you had serious thoughts
of ending your life or a plan to end your life? Or have you taken any
actions to end your life in the past year?” can be asked.

If imminent risk of self-harm or suicide is identified, the person
should be referred immediately to health workers with training in
mental health or specialized care, if available. Family members,
friends and other colleagues or neighbours should be mobilized
to monitor the person and access to means of self-harm should
be removed. The person and their carers should be linked with
community resources, for example, mental health or suicide
phonelines that provide advice and support.

Prescription of antidepressants requires knowledge of managing
mental health conditions. Antidepressant medicine alone for people
with depression (moderate to severe) should only be considered
when structured psychological interventions are not available.

M O R E   I N F O R M AT I O N

 mhGAP intervention guide for mental,
neurological and substance use disorder i
n non-specialized settings: mental health Gap
Action Programme (mhGAP), version 2.0. WHO; 2016
(https://iris.who.int/handle/10665/250239).

 Mental Health Gap Action Programme (mhGAP)
guideline for mental, neurological and substance use
disorders, [3rd ed.]. WHO; 2023
(https://iris.who.int/handle/10665/374250).

 Psychological interventions implementation
manual: integrating evidence-based psychological
interventions into existing services. WHO; 2024
(https://iris.who.int/handle/10665/376208).

111

10 Psychological capacity

10.5
Assess and manage
associated diseases and
risk factors

An assessment of diseases and risk factors for depressive symptoms
should start by identifying and treating possible causes (
Common conditions and risk factors that can cause depressive
symptoms include medication(s), anaemia, malnutrition,
hypothyroidism, and pain. In some cases, treatment of these
conditions results in improvement in depressive symptoms. If
depressive symptoms persist, further assessment will be required.
Uncovering possible cause(s) of depressive symptoms involves a

).

full diagnostic work-up, sometimes including blood tests.

10.5.1
Inappropriate medication(s)

Some medications can lead to depressive symptoms. These
include, but are not limited to medicines that act primarily on the
central nervous system, such as antihistamines, psychotropic
medicines, muscle relaxants and other non-psychotropic drugs
with anticholinergic properties, and steroids. The potential harm of
these medicines can also outweigh their benefits for some people.
Eliminating unnecessary, ineffective medicines as well as medicines
that share an active ingredient reduces polypharmacy.

 4.2.4

10.5.2
Anaemia, malnutrition and hypothyroidism

Various diseases affect depressive symptoms, such as heart
diseases, chronic obstructive pulmonary disease, cancer,
autoimmune diseases, anaemia, malnutrition and hypothyroidism.
It is important to control these diseases, which can resemble or
exacerbate depressive symptoms.

Anaemia and malnutrition can lead to depressive symptoms
because of deficiencies of iron, vitamins such as folate, vitamin
B6 and vitamin B12. Depressive symptoms can also play a role in
the development of anaemia. For example, loss of appetite and
lack of interest in performing daily activities (such as shopping
and cooking), both associated with depressive symptoms, can
reduce quality and quantity of nutrition, potentially leading to the
development of anaemia and malnutrition. To manage depressive
symptoms, it is crucial to manage anaemia and improve
nutritional status.

7

Hypothyroidism is a common disorder in older people, especially
women. The symptoms of hypothyroidism can be non-specific
such as fatigue and dry skin and can include depressive
symptoms. The diagnosis of hypothyroidism usually requires a
blood test and care should be managed by health workers with
specialized knowledge.

10.5.3
Pain

There is a bidirectional relationship between pain and
depressive symptoms. Individuals reporting chronic pain often
have depressive symptoms and depressive symptoms can
present as physical symptoms such as vague aches and pains.
Some people experience a vicious cycle in which pain worsens
depressive symptoms, and the resulting depression magnifies
feelings of pain. It is important to address pain and depressive
symptoms in a comprehensive, holistic manner.

 6.5.2

10 Psychological capacity

10.5.4
Other associated conditions

The presence of the following associated conditions would
suggest a different approach from treatment for depressive
symptoms is needed.

•  Major loss (bereavement) in the last 6 months: Bereavement
is a normal process of loss, grief and recovery associated with
death. Grief has both mental and physical effects and people
grieve in different ways, for example, showing strong emotions
or a limited reaction. In most cases, grief diminishes over
time. A discussion on and support for culturally appropriate
adjustment and/or mourning processes are important to
manage grief. If a person’s symptoms involve considerable
difficulty with daily functioning lasting longer than 6 months
and include severe preoccupation with or intense longing
for the deceased person and intense emotional pain, grief
disorder should be suspected. In this case, a health worker with
specialist knowledge should be consulted.

•  Disability due to illness or injury: People who experience

disability due to illness or injury undergo stress; they must also
cope with life transitions. The stages of adjusting to a new form
of disability include shock, denial and adjustment/acceptance.
Older people with new disabilities are at risk of developing
anxiety and depression. In most cases the symptoms are likely
to diminish over time, particularly if the person gets social
support and engages in stress reduction.

•  History of mania: Mania is an episode of mood elevation

and increased energy and activity. People who experience
manic episodes are classified as having bipolar disorder,
characterized by alternate manic and depressive episodes.
History of mania can be identified by checking several
symptoms, including decreased need for sleep, increased
talkativeness or rapid speech and impulsive or reckless
behaviours occurring simultaneously, lasting for at least 1 week,
and severe enough to interfere significantly with work and
social activities or requiring hospitalization or confinement.
Management of mania requires health professionals with
training in mental health or specialized care, if available.

10.6
Assess and manage
social and physical
environments

10.6.1
Social isolation and loneliness

Loss of interest in activities that used to be interesting or
pleasurable is common in people with depressive symptoms and
can lead to social isolation and loneliness. It is important to try and
understand any factors that may be leading to or exacerbating
social isolation and loneliness, in addition to depressive symptoms,
which could include challenging personal relationships. Asking an
older person if there are activities they would like to try and engage
with and providing support to enable this can be helpful.

 11.3.3

10.6.2
Social care and support

An older person with depressive symptoms may find it difficult to
manage everyday activities and may need social care and support.
This can start with providing help with addressing basic needs,
facilitating access to services and connecting with family and other
forms of social support.

It is important to identify and discuss relevant issues that place stress
on the person and/or impact their life including, but not limited to,
family and relationship problems, housing, finances, access to basic
security and services, stigma, discrimination and maltreatment
(abuse of older people including neglect).

 11.4

113

•

•

•

Supporting what carers can do to help the person adhere to
treatment (e.g. by assisting with making appointments).

Educating the carer about crisis plans and what to do in
emergency situations, including the person they are caring for
displaying thoughts or acts or self-harm or suicide.

Explaining the importance of respecting the dignity and rights
of the person with depressive symptoms.

It is also important to acknowledge that caring for someone with
depressive symptoms can be challenging, and the carer may need
support for their own health and well-being. The psychosocial
impact and needs of the carer should be assessed to ensure the
appropriate support can be provided.

10.6.3
Support for carers
11

12

Carers of people with depressive symptoms should be provided
with information and advice, including through psychoeducation
interventions. Psychoeducation may produce a wide range of
positive effects including a reduction in a carer’s depressive
symptoms, if present, care burden and stress, and anxiety; as well as
increased well-being and health-related quality of life.

Health workers can support carers by:

•  Helping them to understand that depressive symptoms are

a common occurrence. They are not a sign of weakness or
laziness and cannot be controlled by willpower.

•

Encouraging openness and communication between carers
and the person they care for, including:

–   Listening with empathy without judgement.

–    Being there for them and making them feel they are not

alone and are understood.

–    Acknowledging their feelings.

•

•

Providing knowledge on depressive symptoms and mental
health services.

Explaining that people with depressive symptoms tend to have
unrealistic negative thoughts about themselves and their lives,
but that this will likely improve once their symptoms improve.

10 Psychological capacity

114

Social care and support

11 Care pathway for social

care and support

All older people might require social care and support at some
point to enable them to live meaningful and dignified lives. This
need may arise irrespective of their intrinsic capacity, and may
change over time. Social care and support needs may result from
changes in intrinsic capacity and functional ability, for example
the need for support with BADLs and IADLs, but needs and
preferences for support and acceptability for how it is provided
will differ both individually and socioculturally. Provision of social
care and support enables an older person to continue to do the
things that are important to them in the place of their choice.

The most appropriate person to ask about social care and
support needs, in most instances, is the older person themselves.
However, there may be situations in which questions should be
directed to someone else. If an older person has cognitive decline,
for example, questions about BADLs and finances may be best
asked of someone who knows the person well, such as a family
member or carer.

Key points

 Health workers in the community and other community
stakeholders can ask questions to identify needs for social
support.

 Interventions and advice from multiple sectors, such as from
social services, including LTC, finance, social protection and
legal services, are important in supporting older people.

 Personal assistance might be required to support older people
with significant losses in intrinsic capacity with daily tasks,
including bathing, dressing, toileting and eating.

 Health workers in primary care and community stakeholders
should observe potential signs of abuse and neglect of older
people and take action.

 Community stakeholders are crucial providers of social care
and support, often involved in organizing and managing home-
based care programmes and community clubs and activities.

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Social care and support

Care pathway to provide
social care and support

116

Reassess*These are examples of questions that could be used. Please adapt to your context.If YES to one or more question, OR a loss in intrinsic capacity, continue with assessmentthe needs for personal assistance with daily activities (example: BADLs, IADLs):• Transferring e.g. from bed to chair• Personal hygiene - toileting, bathing, dressing• Meal preparation and feeding• Use of medication and adherence to treatment• Ability to use a telephone and manage transportation3AIf a loss in intrinsic capacityYESYESDo you have problems with your home, for example, house condition, location, safety?Do you often feel lonely?Do you have concerns because of:• safety and security• housing condition including maintenance??YESDo you often have insufficient funds to pay for your food, housing and health care costs??• Are you able to manage your money and ﬁnancial aﬀairs? • Would you like advice about ﬁnancial allowances or beneﬁts?• Do you have close relationships (e.g. with spouse, family, friends)?• Are you aware of social activities and opportunities to contribute in the community?• Are you able to stay in touch with friends and family via phone, computer etc?• location • living independently • size of homeAsk supplementary questions1Home environment Financial situation Social isolation and lonelinessDo you have difficulty in pursuing leisure interests and other activities that are important to you??You are not able to pursue… because of: •   cost•   distance  •   lack of opportunities•   transportYESSocial engagement and participationASSESSA and BASK*If abuse is suspected       11.1       11.5BADLs and IADLs Basic activities of daily living (BADLs) are the basic skills required to independently care for oneself in daily life: bathing, dressing, toileting, transferring, continence and feeding.Instrumental activities of daily living (IADLs) are more complex activities that facilitate independent living: ability to use a telephone, shopping, food preparation, housekeeping, laundry, transportation method, use of medication, handling ﬁnances.Provide health and lifestyle advice, including information on opportunities for social engagementRe-ask regularly          Regardless of result:BAssessrisk of abuse by observing behaviour and  for signs of neglect or abuse 2If any immediate threat to life or physical safety refer for specialist assessment, adult protection,          such as temporary shelter or law enforcement systems        Table 11.1Assessensure legal protection (11.3.2)

Social isolation and loneliness

       11.3.3

11

Social care and support

Need for specialized knowledge
and training

Social care and support involve many sectors in

addition to health, including housing, ﬁnance,

transport and law enforcement which can provide

services for:

•  Signiﬁcant home adaptation or repair and

access to these services, or for legal advice in

relation to housing disputes such as safety

 and cost (11.3.1)

•  Financial support and provision of ﬁnancial

advice, including eligibility and entitlements for

social protection payments (pensions,

allowances, grants) (11.3.2)

•  Assessment of the need for delegation of

ﬁnancial and health care decision-making and to

•  Provision of advice on employment, education

and volunteering opportunities, support groups

and rights (11.3.3)

•  Assessment of risk of abuse and provision of

protection and law enforcement (11.4)

•  Assessment of eligibility for and provision of

formal LTC services (11.6)

•  Assessment of the need for assistive products,

ensuring access and providing advice on their

use and maintenance (4.2.2)

1

Social support

       11.3

2 Abuse of older people

       11.4

Home environment

       11.3.1

•  Consider home adaptation

•  Consider alternative accommodation

•  Consider referral to social welfare or community

housing programmes or support networks

Financial situation

       11.3.2

•  Consider referral to social services for access to
social protection (pensions, grants, allowances)

•  Consider referral for ﬁnancial advice

•  Provide advice on delegation of ﬁnancial

decision-making with protection against ﬁnancial
abuse, if needed

•  Provide support to address challenging personal

relationships

•  Provide a list of opportunities for social activities,
volunteering, employment and education in the
community

•  Provide advice and support with using digital techno-
logy to maintain contact with friends and family

•  Refer for further assessment through social

services

•  Oﬀer close monitoring of the situation, for

example, through visits by a community health
worker or social worker and encouragement to
attend a health facility or other service for support

•  Consider referral to psychosocial services, such as

counselling

•

If any immediate threat to life or physical safety,
refer to law enforcement systems and provide
temporary shelter, where possible

3

Personal care and assistance with
daily activities

       11.6

•  Modify home environment to improve mobility and

prevent falls (4.2.5)

•  Consider use of assistive products (e.g. shower

chairs, dressing aids, modiﬁed cutlery, plates and
cups, pill organizers) with information on access
and maintenance (4.2.2)

•  Assess the need for rehabilitation services and

Social engagement and participation

       11.3.4

ensure access, if available (4.2.1)

•  Discuss personal interests and preferences

•  Assess support from spouse, family or other
carers, and identify the needs of the carer

•  Provide a list of local community services, such as

•  Review needs for support from care workers (12.3)

leisure facilities and clubs, adult education
programmes, volunteering and employment
advisory services

•  Provide advice on services that support participa-

tion, for example, subsidized transport, free
activities and discounts for older people

•  Provide support to maintain contact with trusted

organizations and institutions, including religious or
spiritual networks and leaders

•  Link to locally available services such as

home-based care, day-care, or residential LTC
facilities, as available and culturally acceptable

117

11.1
Advice on social support
and opportunities to
participate

If an older person’s answers to initial questions on social support
suggest they may need support from others, a community health
worker or other community stakeholder can provide advice and
guidance while waiting for an in-depth assessment or if an in-depth
assessment is not available. This guidance can include:

•

•

•

•

Simple modifications that could be made to the home
environment, for example, removing trip hazards.

 4.2.5

Basic advice on available financial support, for example, social
protection entitlements or organizations supporting income-
generating activities.

Encouragement to reach out to and engage with friends, family
and neighbours.

Suggestions of how to participate in the community, for
example, through joining an older people’s club.

•  Community-level information and resources for those with

potential need for personal care and assistance with daily
activities.

11.2
Assess social support
needs

Social support should be included as part of a
personalized care plan. Support may focus on
enabling an older person’s participation in community
and social life to reduce social isolation and loneliness and
addressing key factors in their lives such as their home environment
and financial situation. There are several opportunities to identify
need for social support, including during a basic assessment in the
community or as part of an in-depth assessment at a primary care
facility. The risk for abuse should be also considered as some older
people may face greater risks than others (Table 11.1, p. 122).

An older person with significant loss of intrinsic capacity would
also benefit from a full assessment of social care and support
needs to indicate whether they have reached the point of no longer
being able to take care of themselves without the help of others.
This assessment includes the initial four questions followed by an
assessment of the risk of abuse and their need for personal care
and assistance with daily activities.

The issues addressed through these questions and assessments,
and the specific challenges older people may face are highly
contextual. The questions provided in the social care and support
pathway serve as examples, and should be adapted to suit the
context.

11

Social care and support

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11

Social care and support

11.3
Manage social support
needs

A number of sectors will need

to work together to deliver

interventions to address challenges

including housing services, social

services, occupational health,

benefit advisory services (where

available), and humanitarian actors

in response to emergency and

disaster situations that may lead to

displacement.

Social support includes support with the home
environment, financial security, loneliness, social
participation and engagement including through access
to community facilities and public services. Health workers
should be aware of local opportunities, services and support,
including community-based groups  which are often key service
providers.
specialized knowledge, including social welfare, employment,
education and voluntary services, transport services and faith
leaders. Age-friendly cities and communities programmes are a
good source of this information.

 4.1.3   They should also facilitate links with those with

11.3.1
Home environment

The place where an older person lives can affect their health,
well-being, independence and social participation, particularly if
there are challenges with the size of the home, access, condition,
location, safety and security.

Problems with the home environment can be mitigated by
introducing new security measures, having a number to call
in the event of an emergency and making adaptations for a
safer environment to maintain independent living.
Financial benefits may be available to help with accommodation
costs, and for repair and maintenance. If these measures do
not help, a move to more suitable accommodation should be
considered if possible.

 4.2.5

11.3.2
Financial situation

A person’s financial situation is strongly associated with health,
independence and well-being in older age. Problems can include
having too little money to meet basic needs or to fully participate
in society and worries that money will run out. Older people may
also be concerned that they will become unable to manage their
finances.

Financial problems, including being unable to pay for basic needs
may be mitigated though independent advice about financial
planning and management, and eligibility and entitlement for
available social protection, including pensions, disability grants
and carers’ allowances. Advice may be needed from those
with specialized knowledge in these areas, including benefit
advisory services, employment services, organizations providing
support with income-generating activities and social workers.
Arrangements can be put in place for devolved authority to
a trusted third party for managing finances, provided legal
protection is in place to prevent financial abuse, especially for
those with cognitive decline.

If carers provide financial support for older people, or incur costs
due to their caregiving role, they should also receive information
and advice, including on how costs for care may change as an older
person’s functional ability declines and their need for care and
support increases.

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Social care and support

11.3.3
Social isolation and loneliness

11.3.4
Social engagement and participation

Every older person is unique and will have different priorities,
values and things they like to do. It is important to find out about the
things older people enjoy and find meaningful by understanding
the person’s life, priorities and preferences, for example their
hobbies, leisure activities, work, learning and spiritual activities.
This information should guide the development of the personalized
care plan in relation to social engagement and participation.

Supplementary questions can be asked to identify any barriers
to social participation such as cost, accessibility (distance and
transport) and opportunity. Health workers should know about
local opportunities for engagement and participation, discuss
whether these might be of interest to the older person and
support them to participate. Charges for some of these services
may be subsidized to allow older people and those on reduced
incomes to participate.

Social isolation and loneliness are common in older people with
some lacking social networks and up to a third of older people
reporting they feel lonely (55). Loneliness is subjective and is
measured by asking people how they feel. Both social isolation
and loneliness are associated with an increased likelihood of
preventable mortality and diseases and mental conditions such as
CVD, stroke, anxiety, depression and dementia. It is important that
these conditions are considered and results of a basic assessment
for relevant domains of intrinsic capacity are validated through an
in-depth assessment where necessary, if loneliness is identified as
a potential issue.

5   9   10

If an older person discloses that they feel lonely or they have few
social connections, there are follow-up questions that can identify
need for support and suitable interventions. There is often a stigma
attached to loneliness, and the reason someone feels lonely may
be linked to challenging personal relationships. Being alone (or
living alone) is not the same as being lonely – an older person can be
lonely even when surrounded by other people, if the quality of their
relationships is poor.

It can be helpful to ask an older person, who expresses loneliness,
if increased social contact with family and friends, or meeting
others with similar interests, would help to reduce their sense of
loneliness, and also to understand whether they are aware of local
social activities. These discussions should inform interventions to
be included in a care plan.

Use of community facilities such as clubs, faith groups, day centres
and sports, leisure or education services should be encouraged.
There may be opportunities to contribute through volunteering
or paid employment. Social connections can also be increased
through opportunities to engage with people of different
generations. Having a pet also reduces loneliness for many older
people (56). Community stakeholders can provide support by
organizing events and facilitating older people’s access to reduce
social isolation.

 4.1.3

It is important to discuss issues in

a sensitive way, being aware that

how questions are asked and the

setting may influence responses.

The older person should be

reassured that the discussion is

confidential, to help overcome any

fears about revealing the nature

of personal relationships.

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Social care and support

11.4
Abuse of older people

Around one in six older people experience some form of
abuse (57), a figure higher than previously estimated (58). Abuse can
take many forms, including neglect, psychological, physical, sexual
and financial (including property and inheritance rights). Anyone
can experience abuse, but there are a number of risk factors that
make an older person more vulnerable, notably, cognitive decline,
poor mental or physical health, and disability. Other factors include
social isolation, history of abuse, family violence or conflict, ethnic
background and low income or living in poverty. Although not
often recognized or adequately tackled, violence against women
continues in older age. In 2018, for women aged 60 and over the
lifetime prevalence of physical and/or intimate partner violence is
23% (59).

In line with these risk factors, an older person with loss of intrinsic
capacity should be assessed for signs of abuse. Due to the links
between abuse of older people and social isolation and low
income, an assessment should also be conducted with any older
person identified to have issues with their home environment,
financial situation, social isolation and loneliness or social
participation. Specific consideration should be given to an
assessment for signs of abuse of an older person with cognitive
decline, as changes in behaviour could be linked to their condition,
rather than potential abuse.

During any interaction, a community health worker should look for
signs of despair, fear and poor eye contact and note the physical
appearance and hygiene of the older person, such as the state of
their nails, skin and grooming.

 3.5

In addition, during a physical examination in a primary care facility
a health worker should look for physical signs of abuse. If injuries
are noted, the health worker should look at the stage of healing,
the size of bruises and consistency of the injury with the reported
cause. Identification of dehydration, malnutrition, noncompliance
with medications or health care appointments increase suspicion
of neglect.

If there is any suggestion of abuse, further assessment and
management will be needed. The health worker should inform the
older person of their concerns and that they will ask for specialist
help, for example, from social workers or law enforcement services.
They should also record their concerns and the action taken, and
closely monitor the situation while waiting for referral. If a health
worker identifies any immediate threat to life or physical safety,
they should refer for specialist assessment and action (e.g.
temporary shelter), adult protective service or law enforcement
systems. Referral to psychosocial services, including counselling,
should also be considered, if available.

Observational information based on the behaviour of the older
person and that of their carers or relatives, or signs of physical
abuse should be used to identify potential abuse (Table 11.1, p. 122).

M O R E   I N F O R M AT I O N

 Abuse of older people: key facts. WHO; 2024
(https://www.who.int/news-room/fact-sheets/
detail/abuse-of-older-people).

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Social care and support

Table 11.1
Observational cues for potential abuse

Behaviour of the older person

Behaviour of the carer

Physical abuse

Neglect

•  Seems fearful of or hostile towards the

carer

•  Does not want to answer when asked,

•  Hinders or prevents the health worker
and the older person from talking in
private, or keeps finding reasons to
interrupt the flow of the assessment

or looks with anxiety at the carer before
responding

•

Interrupts or insists on answering
questions that are addressed to the
older person

•  Provides a conflicting account of

events from that of the older person

•

•

•

Injuries (cuts, burns, bruises and
scratches) that are unlikely to have
happened accidentally

Injuries that do not match the
explanation given for them

Injuries and wounds in concealed
places or protected areas (e.g.
underarms)

•  Malnutrition, dehydration and pressure

sores

•  Poor body and oral hygiene

•  Dirty, severely worn clothing,

unchanged incontinence pad/pants

•  Noncompliance with medications,
appointments or health worker
directions

•  Delay between onset of illness or injury

and seeking medical attention

•  Behaviour changes when the carer

enters or exits the room

•  Refers to the carer in terms such as

“strong willed” or often “tired” or “bad
tempered”, or as becoming irritable/
very anxious/highly stressed

•  Shows exaggerated respect or extreme
deference for the carer, or appears very
restless or indifferent in their presence

122

•  Finds excuses to prevent health and/

rough handling (often upper arms)

•  Bruising that is shaped like fingers from

•  Multiple injuries at different stages of
healing including untreated injuries

•  Medication underuse or overuse

•  Recurrent visits to a health care facility,
particularly an emergency department,
for similar injuries

or social workers visiting to provide
assistance at home for the older person

•  Demonstrates a high level of

dissatisfaction about having to take
care of the older person

•  Attempts to convince the health worker

that the older person is “crazy” or
“demented”, or that the person does
not know what they are saying due to
confusion, when this is not the case

•

Is unengaged, inattentive, overwhelmed,
frustrated, hostile, angry, tired or
impatient during the interview

•  Evidence that the carer (or older

person) has issues with alcohol or
substance use

11

Social care and support

•  Use of medication: Ability to adhere to prescribed treatment
for diseases including medication and assistive products (e.g.
hearing aid) is critical for older people with multimorbidity.
Safe medication use includes remembering to take medication
as prescribed – the right medication, in the right dose, at the
right time. The efficacy of medication may also be affected by
any challenges with meal preparation and feeding. Adhering to
treatment may be difficult for people with cognitive decline or
vision impairment.

•  Ability to use a telephone and manage transportation: This

can affect utilization of health and social care services because
of difficulties with making appointments, either by phone,
online or in person, understanding correspondence with health
workers about upcoming or past appointments and getting to
and from facilities. This may be challenging for older people
with limited mobility, hearing loss or vision impairment and
cognitive decline.

Older people with depressive symptoms may struggle with any of
these tasks. This may be linked to a lack of interest in doing these
things, rather than their physical capacity.

M O R E   I N F O R M AT I O N

 WHO Long-term care for older people: package
for universal health coverage. WHO; 2024
(https://iris.who.int/handle/10665/376585).

11.5
Assess social care needs
(Personal care and assistance)

A person’s specific needs for personal care and
assistance will depend on how to compensate for
their loss of intrinsic capacity in order to optimize their
functional ability (i.e. to meet their basic needs; learn, grow and
make decisions; be mobile; build and maintain relationships;
and contribute), alongside their preferences, choices and goals.

An in-depth assessment can be conducted to determine needs
by understanding an older person’s abilities in relation to BADLs
and IADLs. Frequently used questionnaires that measure function
include the Katz Index of Independence in Activities of Daily
Living and the Lawton Instrumental Activities of Daily Living Scale.
Various factors affect IADL limitations including gender, culture
and social norms.

An assessment and provision of personal care should include
but not be limited to:

•

Transferring: This covers a number of activities, such as moving
from a bed to a chair. Limited mobility increases the risk of falls
and the need for personal care with these activities.

•  Personal hygiene: Toileting, bathing, dressing – ability to get
to and use the toilet, to wash yourself, to get dressed and with
grooming, including brushing teeth and hair and cutting nails.
This may particularly be the case for older people with limited
mobility or cognitive decline.

•  Meal preparation and feeding: Ability to shop for groceries,
prepare meals and to eat independently may be affected by
limited mobility, cognitive decline and vision impairment. It may
also be both a result of and a factor in undernutrition.

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Social care and support

11.6
Manage social care
needs

Many older people do not want to rely on others for
help with daily tasks, and support and training should
be provided to enable them to do as much as they can.
For example, an older person who needs assistance with bathing,
may still be able to wash some parts of themselves, and should
be encouraged to do so. Similarly, someone who is unable to
reach down to put on their shoes, may be able to put on their other

clothes. Carers should be supported with information and advice,
on how to provide personal care, but also the importance of the
older person maintaining as much independence as possible. When
a carer is tired and overstretched, getting tasks done as quickly as
possible may seem preferable, so the benefits of taking time with
the older person, encouraging them to do what they can, should be
explained by health workers including social care workers.

Older people who have a significant loss of intrinsic capacity and
difficulties with BADL and IADL may benefit from rehabilitation
services (
 4.2.2) and/or
 4.2.1 ), provision of assistive products (
environmental adaptations to optimize functional ability. Accessing
these types of support can help the older person with daily tasks and
also reduce the demands on their carer(s).

Box 11.1 Social prescribing

Social prescribing is a means of connecting people to a range of non-clinical services in the
community to improve their health and well-being and can be used as a way to address social
care and support needs. It can take various forms and can be adapted in different communities
and contexts. For example, health workers at primary care facilities refer an older person to a
“case worker” or “care coordinator” who works with an older person to identify their social care
and support needs and develops a personalized plan. The case worker or care coordinator
also regularly follows up with the older person. Social prescribing can be included as part of a
personalized care plan.

 3.3

An important step in social prescribing is mapping local services, associations and organizations
in the community to inform possible referrals. This mapping should include services for welfare,
legal, financial, housing support and food security; social care services, including mental health
and disability support; support for survivors of abuse; social activities; employment services;
activities for lifelong learning and education; health care and health promotion services, including
physical activity and nutrition; in urban areas, opportunities for spending time outdoors; culture-
related activities; and volunteering opportunities.

With appropriate support and supervision from health workers, a member of a civil society
organization can act as a case worker or care coordinator working closely with multidisciplinary
health workers. Community stakeholders are also often best placed to map available services.

124

In addition to the personal care provided by a carer in an older
person’s home, other services and support should also be sought
as needed. This includes home-based care, day care services and
other facility-based care and support, as available and culturally
acceptable. Community stakeholders can provide information and
advice and link older people and carers with formal LTC services.
They can also support carers’ psychosocial well-being, through
facilitating respite and peer support.

12

11

Social prescribing can be a mechanism through which to deliver
social care and support to ensure the delivery of services through
formalized relationships with community stakeholders ( Box 11.1).

M O R E   I N F O R M AT I O N

 A toolkit on how to implement social
prescribing. WHO; 2022 (https://iris.who.int/
handle/10665/354456).

 Social prescribing. Open WHO; 2024
(https://openwho.org/courses/social-prescribing-WPRO).

12

Carer support

Care pathway to
support carers

The demands and stress of caring for older people with significant
losses in intrinsic capacity and functional ability can affect the
health and well-being of carers. The role carers play is rarely well
recognized or valued or adequately supported, exacerbating the
challenges associated with providing care. Being a carer can also
result in reduced opportunity to undertake paid work, particularly
for women. Carers’ needs should be identified and interventions
to support them should be included in a personalized care plan.

Key points

 Health workers in the community can identify carers’ needs and
ways to support their health and well-being.

 A range of interventions – advice, training, respite care,
financial support and psychological interventions – can help
carers to sustain a satisfactory and healthy caring relationship
and provide quality care while maintaining their own health
and well-being.

 In cases where a carer is an older person, an assessment
of the carer’s own health, including intrinsic capacity, is
recommended.

 Health workers, including community health workers, should
be aware of signs of abuse to look for during an assessment of
either an older person or their carer.

 A carer’s role should be recognized, valued and supported and
efforts should be made to redistribute care work. Community
stakeholders can advocate for this recognition while also
providing ongoing training, including refresher training and
support to carers.

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Carer support

Care pathway to
support carers

126

ReassessYESProvide support for carer:• training for skills and knowledge for caregiving• respite care • other community resources (e.g. volunteer programmes, peer support groups)to both questionsDo you feel supported in your role as a carer??Do you feel conﬁdent in your ability to provide care??NOWhen talking with the carer, make sure to do it privately, in a separate room without the older person(to either question)Assess depressive symptomsAssess anxietyProvide psychosocial interventions•   stress management•   mindfulness-based interventions•   psychoeducation•   psychotherapy/counselling•   multicomponent interventions10Promote self-careEncourage carer to go for health check-upIf the carer is an older person, advise to get an ICOPE basic assessment and supportConsider risk of carer burnout and possible abuse21ASKmental healthStrengthen link with formal LTC system and community support Explore local ﬁnancial support optionsﬁnancial situationphysical healthProvide respite careProvide advice and support to increase social engagementsocial well-beingAssess impact of carer roleif negative impact on:Re-ask regularly        12.1Regardless of result:Provide health and lifestyle advice for carer, including advice to promote self-careASSESS       12.4       12.4.3       10.212 Carer support

127

2The risk of abuseThe two-way relationship between the person receiving care and the carer may be complex. Healthy, happy carers are capable of extraordinary support, but sometimes the caring relationship can be more challenging, including being unwanted by one or both participants. Without adequate support, carers can become overwhelmed and experience burnout. This increases the risk of abuse of the person being cared for. Abuse can take the form of neglect, ﬁnancial or material abuse or physical, emotional or sexual abuse. Neglect may be intentional or may occur due to a lack of skills or knowledge regarding how to provide care or lack of external support or supervision. Carers can also experience abuse, including from the person they are caring for. This abuse can take the same forms as those detailed above, and may occur for similar reasons. A carer of a person with dementia may face particular risks due to challenging behaviours associated with dementia in some people.Neither the older person nor the carer may disclose an abusive situation to a health worker. Observational information based on the behaviour of the older person, their carers or families is therefore important, as are noting any signs of physical abuse (Table 11.1).If an abusive relationship is suspected, a  more detailed assessment is needed, following local referral pathways, where they exist, and relevant and available services should be engaged. In many cases the provision of additional support for carers may be more eﬀective in addressing an abusive relationship than punitive measures. Health workers should seek legal advice.• Provision of support for a carer with depression or anxiety• Carer themself has signiﬁcant loss of intrinsic capacity and/or multiple diseases• Imminent risk of self-harm or suicide of carer (10.4.4)• Abusive relationship is suspected (11.4)• Provision of brief structured psychological interventions (10.4.2)• Financial support and provision of ﬁnancial advice, including eligibility and entitlements related to caregiving (11.3.2)Need for specialized knowledge and trainingTraining and advice needed for carers1Cognitive decline: the importance of maintaining a daily routine, how to use memory aids, what to do in response to challenging behaviour and how to respond when/if the person they are caring for does not remember them.Limited mobility: how to assist the person to move safely, while also protecting themselves from injury, how to access and use assistive products.Undernutrition: how to access and use (or help the older person to use) assistive products, particularly for feeding, the types and amount of food and liquid required and how best to prepare them.Vision impairment: how to help the person move around, modifying the home environment to make it safer, how to walk with someone with vision impair-ment and help them to map their environment, how to adapt communication styles and methods and how to use assistive products.Hearing loss: how best to communicate with the person, how to use and maintain hearing aids and assistive products.Depressive symptoms: how to communicate openly with older person, what to do if the immediate risk of self-harm is suspected, how to prevent social isolation. Urinary incontinence: how to assist with personal care, use of incontinence pads and products, encouraging prompted voiding, and cleaning and safely disposing of soiled clothes, bedding and incontinence pads. Carers should be supported with speciﬁc training and advice to enable them to provide good quality care. Besides how to identify deterioration in signs of functioning, management of medications, navigating health and social services and systems, as well as managing their own needs, the type of training and information will depend on the loss of intrinsic capacity of the person they are caring for.       12.4.1Factors that increase the likelihood of being abused:Care recipient with •  signiﬁcant care dependence •  behavioural and psychological symptoms of dementia  •  low income or living in povertyFactors that increase the likelihood of becoming a perpetrator of abuse:Carer with •  poor mental health •  substance abuse and dependency •  stress and burnout •  ﬁnancial dependency on the person being cared forOther factors that can increase the likelihood of an abusive relationship include a history of family or partner violence and a poor long-term relationship.12 Carer support

128

12.1
Health and lifestyle
advice to promote
carers’ well-being

12.2
Community-based
health care to promote
carers’ well-being

Providing care can be tiring and stressful, particularly for family
carers living with the person they are caring for, impacting carers’
health and well-being. Community health workers and other
community stakeholders can provide advice to support carer
well-being, including:

•

Starting again (or continuing) activities that were previously
enjoyed.

•  Maintaining a regular sleeping routine.

•

Being as physically active as possible.

•  Having a healthy balanced diet and eating proper meals

regularly.

•

•

•

Spending time with friends and family.

Participating in community and other social activities.

Taking regular breaks.

Carers may provide regular (including daily), occasional or routine
care or be involved in organizing care delivery by others. In countries
with policies in place, carers may receive social benefits such as paid
leave and cash-for-care transfers. Based on a carer’s needs, varied
types of support should be considered, both for the carer’s well-
being and to enable them to provide quality care.

Community-based organizations can play a role in identifying carers
who may need support. They can establish peer support groups
and provide spaces such as community halls for carers to meet and
share their experiences. They may be able to organize trips or coffee
mornings to give carers an opportunity to take time for themselves to
do something enjoyable and to share their experiences, feelings and
knowledge with others.

Available resources and information on where and how to seek
support in the community should also be provided (e.g. provision of
respite care at home or through a day care centre, if available, and
culturally acceptable). Organizations that run or manage home-
based care programmes, either working with paid care workers or
volunteers, can provide information and advice and, where possible,
provide care to an older person, giving the family carer some respite.

If a carer is identified as being negatively impacted by their role,
and an in-depth assessment is not immediately available, there are
actions community health workers can take to provide support.
Alongside health and lifestyle advice, they can provide guidance
on stress reduction and relaxation (
mindfulness techniques.

 10.2) and some simple

12 Carer support

Such assessments should be

made routinely, as a carer's need

for support may change over time,

and different support mechanisms

may need to be introduced

according to their changing

situation.

When talking with a carer, a health worker should look for any signs
of exhaustion, anger, frustration or disrespect. If the carer appears
stressed or burnt out, attention should be paid to any signs of abuse
 11.4  They
or neglect by the carer of the person they are caring for.
should also be aware of potential signs suggesting the carer may be
being abused by the care recipient. These situations may well not
be disclosed by the carer so it is important for the health worker to
observe what might be happening (               , p. 127).

2

12.3.2
Assessment of depression and anxiety

Caregiving is associated with poorer mental health outcomes for
carers compared with the general population, with depression and
anxiety being particularly common. It also may be complicated
by feelings of bereavement over loss of the previous relationship
between the older person and the carer, particularly if the carer
is a spouse. It is important for health workers to acknowledge
that caregiving can be extremely frustrating and stressful. Health
workers should consider whether a carer needs an assessment to
identify depression or/and anxiety and if they need any care and
support.

10

12.3
Assess carers’ needs

It is important that a carer’s need for support is assessed,
including their health and well-being, the social and economic
impacts of providing care and their confidence in fulfilling
their caregiving role.

12.3.1
Ask the carer

The discussion around a carer’s needs is best done away from the
person they are caring for, to reduce the carer’s embarrassment
or hesitation about speaking openly. This can either be done at
the same time as the assessment with the older person, but in a
separate room or space, or may require a separate appointment.
The accounts of the older person and the carer may differ for
various reasons, including memory problems of the older person,
if they have cognitive decline, so the results of the older person’s
basic and in-depth assessments should be borne in mind.

The carer support pathway provides two example questions to
identify how a carer feels and the support they currently receive
or may need. A response to either question that suggests the
carer is struggling or facing challenges should lead to practical
support being offered, including training, respite care and linking
with community resources. The carer should also have an in-depth
assessment of the impact of their role, including their psychological
and physical health, and their social and financial well-being.
Responses from a discussion on psychological well-being may
suggest the need for an in-depth assessment for depressive
symptoms and anxiety, for which a separate meeting with the carer
should be arranged.

For those for whom providing care is having a negative financial
impact, examples of how to access financial support and advice
should be provided.

129

12 Carer support

130

12.4
Support for carers

A range of support may be needed including
direct help and support from paid care workers
and organizations, assistive products and home
modifications to facilitate the provision of care,
especially if the carer is living with the person being
cared for, psychosocial support to address anxiety or depression,
and respite care. Provision of information and training for carers is
also important.

Health workers and community stakeholders can create a network
to share available resources for the training of carers and where
to access psychosocial and other forms of support. Peer support
groups for carers may be included or combined with other
interventions as part of multicomponent interventions to support
carers. Digital assistive products can be useful in supporting carers
in their role, both through enabling those receiving care to continue
doing things for themselves and providing carers with tools to
improve the quality of care they can provide (Box 12.1).

Box 12.1  Digital assistive products

Innovative digital assistive products, such as remote
monitoring and assistive robots, can enhance the functional
ability of older people, improving their quality of life as
well as that of their carers, increasing choice, safety,
independence and a sense of control, and enabling ageing
in place. The use of these products should be based on the
needs and preferences of older people and their carers, and
availability of resources and appropriate training.

12.4.1
Training

Care workers, supported and supervised through the health and
social care system or a service-providing organization should
support carers with training and advice. To understand the carer’s
training needs, the health worker including care worker can ask
what caring tasks are needed based on loss of intrinsic capacity
and functional ability of the older person being cared for and how
often these tasks are undertaken. They can also observe aspects of
care that could be improved through training, advice and practical
support. Support should reflect the carer’s choices and emphasize
optimizing quality of care and the carer’s well-being.

Topics for training for carers might include, but should not be limited
to, the care of older people who need assistance; how to identify
deterioration in signs of functioning; prevention and responses to
falls; management of medications; management of pain; navigating
health and social services and systems; how to communicate
effectively with the person being cared for; and managing their own
needs. The type of training a carer should receive will be determined
by the care needs of the person they are supporting. Specific training
topics related to the loss of intrinsic capacity and UI are suggested
(              , p. 127). Training and education opportunities should be
provided for carers who are interested to gain more formal skills,
which could translate into future work opportunities.

1

WHO iSupport is a self-help skills and training programme for carers
of people with dementia that aims to prevent and/or decrease mental
and physical health problems associated with caregiving and to
improve the quality of life of those caring for people with dementia.

12 Carer support

In some contexts, day care may
not be deemed appropriate or
culturally acceptable, and may not
be in line with an older person’s
preferences. In this case, other
types of community-based care
and support can offer similar
opportunities for respite, for
example, lunch clubs and older
people’s social gatherings and
activities.

12.4.2
Respite care

12.4.3
Psychological interventions

Respite care refers to the temporary relief from caregiving duties
through the provision of substitute care in the form of home-based
care, day care or temporary admission of the person being cared
for to a care facility. Respite from caregiving may help to keep
the caring relationship healthy and sustainable, and if properly
organized and managed, periods away from the usual carer should
not have a negative effect on the person receiving care.

When caring has become too demanding, respite care should
be considered. A health worker should explore whether another
person can temporarily supervise and care for the older person and
support this to happen. This could be another member of the family
or household, or a trained social care worker, whether professional
or volunteer, in the home or in a care facility.

The opportunity for an older person to attend a day care centre or
receive day care at home can relieve the main carer, who can then
rest or carry out other activities. Day care is a type of community
support service, which provides personal care (bathing, feeding,
shaving, toileting), recreational and social activity programmes,
meals and transportation, several hours a day for a number of days
a week. Day care also provides support services for carers such as
home visits, family activities, support groups and training.

M O R E   I N F O R M AT I O N

 Mental Health Gap Action Programme
(mhGAP) guideline for mental, neurological
and substance use disorders, [3rd ed.] WHO; 2023
(https://iris.who.int/handle/10665/374250).

A health worker can address a carer’s psychological
stress with psychosocial interventions, including
mindfulness-based interventions, multicomponent interventions,
psychoeducation and psychotherapy/counselling. This can be
particularly helpful when the care being provided is complex and
extensive and the strain on the carer is great. Different modes of
delivery of psychosocial interventions can be used: face-to-face
or digital/remote interventions, which have been reported to be
effective. Group-based interventions are likely most effective.

Psychosocial interventions include:

•  Mindfulness-based interventions, such as mindfulness,

meditation, yoga techniques, mindfulness-based cognitive
therapy and mindfulness-based stress reduction.

•  Psychoeducation, which comprises educational programmes
that provide standardized information and focus on increasing
carers’ knowledge of common conditions in older age and
developing specific coping skills to deal with caregiving
challenges.

 10.4.1

•  Psychotherapy/counselling, focused on interventions that

involve implementation of specific forms of individual or
group therapy or counselling, including behaviour therapy,
cognitive therapy, conventional CBT and newer theoretical
orientations such as acceptance-commitment programmes.
These are usually delivered by a health professional with
specialized knowledge, such as psychologists or therapists,
and place strong emphasis on the development and utilization
of the therapeutic relationship as part of the treatment process.

•  Multicomponent interventions, which use multiple approaches
such as counselling, support groups and respite provided in the
one programme without any one being dominant.

131

12 Carer support

132

12.4.4
Interventions to support physical health
and social well-being

Carers should be advised to look after their own health, including
through having regular health checks, including for their intrinsic
capacity if they are older. They should also be given advice and
support to tackle loneliness and isolation and maintain or increase
their social engagement and participation.

 11.3.3, 11.3.4

12.4.5
Financial support

If providing care is having a negative impact on a carer’s finances, a
health worker should provide advice and link the carer to available
sources of information and support, including financial advice
and available support through formal LTC systems. The carer
themselves may also be eligible for financial support through
social protection schemes including carer’s allowances and
non-contributory pensions. Employers may have some provision
for carers in terms of leave allowances and flexible working
arrangements.

M O R E   I N F O R M AT I O N

 Long-term care for older people: package for
universal health coverage (Annex 6). WHO; 2024
(https://iris.who.int/handle/10665/376585).

 WHO iSupport for dementia: training and support
manual for carers of people with dementia. WHO;
2019 (https://iris.who.int/handle/10665/324794).

Urinary incontinence

13 Care pathway to manage

urinary incontinence

Urinary incontinence (UI) is a common condition affecting many
older people, with women more likely to be affected than men (11).
but is not a natural or inevitable consequence of ageing. It is under
recognized and under-reported. This could be due to a number
of factors, including stigma and older people thinking it is normal
in older age. It is associated with depression, loss of mobility,
cognitive decline and comorbidities such as urinary tract infection
(UTI), obesity, stroke and diabetes. It has a significant impact on
quality of life and well-being. Urinary incontinence can affect
an older person’s self-esteem and confidence about going out,
and subsequently their social participation, leading to possible
isolation and loneliness (60).

Key points

 Health workers should be proactive in discussing UI but
mindful of how to ask questions, due to the sensitivity of the
issue and people feeling embarrassed and reluctant to have
an assessment.

 There are effective behavioural strategies and interventions,
such as pelvic floor muscle training to manage UI.

 Adopting a life-course approach to UI can enable the
identification of risk factors earlier in life, including obesity,
that can be addressed to prevent its onset.

 Assistive products such as toilet chairs, urinals and containment
products, help to manage UI and improve quality of life.

 Community stakeholders can raise awareness that UI is not
a “normal” part of ageing and support older people with UI

through the establishment of peer support groups.

133

13

Urinary incontinence

Care pathway to manage
urinary incontinence (UI)

134

ReassessCBASKabout UIDEVELOPa care planIMPLEMENT& MONITORConsolidate interventions, considering results of A, B and CAASSESSA, B and C1•Fluid balance*•Constipation•Inappropriate medication(s)•Urinary tract infection (UTI)•Delirium•Vulval symptoms (women)•Incontinence-associated dermatitis •Diabetes and obesity2Consider potential interventionsBladder training with a bladder diaryPelvic ﬂoor muscle training (women) If cognitive decline, prompted voiding       13.2       13.4.1       13.4.2       13.3Assess urologic conditionFluid balanceBe mindful about the appropriate ﬂuid balance, as restriction of ﬂuid intake might increase the risk of UTI and dehydration. *•Toilet access•Need for containment products•Social care and support needs (toileting, bathing, provision of gloves, soap)•Carers' support needs3Consider potential interventionsAssess social and physical environmentsAssess for diseases and risk factorsAssess urinary incontinenceDo you have any problems with bladder control, such as accidental leakage of urine??NOBladder training to manage UIRefer to primary careYESFirst, Identify and treat potential causes (see B     )Provide health and lifestyle advice,including advice to prevent UIRe-ask regularly       13.1Regardless of result:How does UI affect your life??       7.3.2Need for specialized knowledge and trainingToilet accessNeed for containment productsSocial care and support needsCarers' support needs3Home modiﬁcations for easier access (13.6.1)Consider assistive products (e.g. raised toilet seat, commode, chair) (13.6.1)Support access to containment products (13.6.2) Provide assistance with toileting, bathing, dressing and hygiene and sanitation products (gloves, wipes, soap) (13.6.3)Provide psychosocial support (13.6.3)Provide training on prompted voiding and appropriate use of containment products (13.6.4)       13.5       13.6Fluid balanceConstipationInappropriate medication(s)Urinary tract infection (UTI)DeliriumVulval symptoms (women)Incontinence-associated dermatitis  Diabetes and obesityEncourage normal ﬂuid balance and trial of caﬀeine restriction (13.5.1)Treat constipation including through high ﬁbre diets and physical activity (13.5.2)Review medications and withdraw or prescribe alternatives (13.5.3)Treat UTI if symptomatic (13.5.4)Identify cause and treat (5.5.1)Prescribe topical vaginal moisturizers (13.5.6)Skin hygiene and treat secondary infection (13.5.7)Management of diseases and CVD risk factors (13.5.8)1Asking questions about urinary incontinence The discussion should also include the negative impact of UI on the person’s life, to motivate and encourage further assessment and inform potential interventions. It is important to note that many older people feel UI is normal and this view may inﬂuence its perceived impact.  Ask the older person if UI is aﬀecting their daily behaviors and activities including:• Going out • Engaging with friends, family, community• Hobbies and social participation • Physical activity including exercise • Fluid intake• The kind of clothes they choose to wear • Sex life• Psychological state: embarrassment, anxiety, conﬁdence  • Need for assistive products, including containment            products such as pads Urinary incontinence can be a sensitive subject with people feeling embarrassed to raise issues themselves or answer questions when asked. It is preferable to have a health worker of the same sex as the older person conduct the conversation. When having a discussion on UI: • ﬁnd a private place to talk • spend time to build trust and conﬁdence• actively listen and avoid language that suggests you are making judgements• use simple language if necessary, e.g. wetting yourself• Full assessment and management of a potential urologic conditions (13.3) suggested by:  –  Palpable bladder –  Pelvic mass –  Macro haematuria (blood is visible to the naked eye in the urine) –  Recurrent symptomatic UTI –  Large prostate (men)   –  Prolapse (descent of the uterus, cervix or vaginal walls) (women) –  Suspected ﬁstula (women)• UI with history of pelvic irradiation and surgery • If the interventions to manage UI do not work after 3−6 months (13.4)2Interventions for diseases and risk factorsInterventions for social and physical environments13 Urinary incontinence

135

Need for specialized knowledge and trainingToilet accessNeed for containment productsSocial care and support needsCarers' support needs3Home modiﬁcations for easier access (13.6.1)Consider assistive products (e.g. raised toilet seat, commode, chair) (13.6.1)Support access to containment products (13.6.2) Provide assistance with toileting, bathing, dressing and hygiene and sanitation products (gloves, wipes, soap) (13.6.3)Provide psychosocial support (13.6.3)Provide training on prompted voiding and appropriate use of containment products (13.6.4)       13.5       13.6Fluid balanceConstipationInappropriate medication(s)Urinary tract infection (UTI)DeliriumVulval symptoms (women)Incontinence-associated dermatitis  Diabetes and obesityEncourage normal ﬂuid balance and trial of caﬀeine restriction (13.5.1)Treat constipation including through high ﬁbre diets and physical activity (13.5.2)Review medications and withdraw or prescribe alternatives (13.5.3)Treat UTI if symptomatic (13.5.4)Identify cause and treat (5.5.1)Prescribe topical vaginal moisturizers (13.5.6)Skin hygiene and treat secondary infection (13.5.7)Management of diseases and CVD risk factors (13.5.8)1Asking questions about urinary incontinence The discussion should also include the negative impact of UI on the person’s life, to motivate and encourage further assessment and inform potential interventions. It is important to note that many older people feel UI is normal and this view may inﬂuence its perceived impact.  Ask the older person if UI is aﬀecting their daily behaviors and activities including:• Going out • Engaging with friends, family, community• Hobbies and social participation • Physical activity including exercise • Fluid intake• The kind of clothes they choose to wear • Sex life• Psychological state: embarrassment, anxiety, conﬁdence  • Need for assistive products, including containment            products such as pads Urinary incontinence can be a sensitive subject with people feeling embarrassed to raise issues themselves or answer questions when asked. It is preferable to have a health worker of the same sex as the older person conduct the conversation. When having a discussion on UI: • ﬁnd a private place to talk • spend time to build trust and conﬁdence• actively listen and avoid language that suggests you are making judgements• use simple language if necessary, e.g. wetting yourself• Full assessment and management of a potential urologic conditions (13.3) suggested by:  –  Palpable bladder –  Pelvic mass –  Macro haematuria (blood is visible to the naked eye in the urine) –  Recurrent symptomatic UTI –  Large prostate (men)   –  Prolapse (descent of the uterus, cervix or vaginal walls) (women) –  Suspected ﬁstula (women)• UI with history of pelvic irradiation and surgery • If the interventions to manage UI do not work after 3−6 months (13.4)2Interventions for diseases and risk factorsInterventions for social and physical environments13 Urinary incontinence

136

13.1
Health and lifestyle
advice to prevent urinary
incontinence

13.2
Community-based
health care  to address
urinary incontinence

Urinary incontinence remains a stigmatized and often taboo subject,
which can lead to people not seeking support and not getting the
services they need. Community stakeholders can provide health
and lifestyle advice to all older people including those with UI to
reduce risks and manage UI, highlighting the importance of:

•  Maintaining good drinking habits, i.e. drinking at least

1.6–2 L (6–8 glasses or cups) a day, unless indicated by a health
professional due to underlying diseases (e.g. heart or kidney
diseases). Drinking less can reduce the bladder’s capacity and
make UI worse, and can lead to dehydration.

 7.3.2

•  Decreasing caffeine and alcohol, particularly at night, which

can increase the need to urinate. Coffee, tea or caffeinated fizzy
drinks can be substituted with low-caffeine versions.

•  Having a healthy diet, including fibre to reduce the risk of

constipation, which can make UI worse as straining to go to the
toilet can weaken the pelvic floor.

•  Managing weight – being obese can weaken the pelvic floor

muscles.

 7.3.3

•  Doing physical exercise can help strengthen muscles, which

can help with UI. Individual advice should be sought on the
types of exercise that would be best.

•

Tobacco cessation, as smoking weakens the bladder and
coughing puts a strain on pelvic floor muscles.

13.2.1
Bladder training

If an older person is found to potentially have UI and an in-depth
assessment is not immediately available, community health
workers can support the older person and their carer with bladder
training. A bladder diary is used to track a person’s toileting
patterns and inform appropriate interventions and behaviour
change. This can help reinforce learning of new habits. A progressive
voiding schedule can be effective, especially for those with urgency
UI by voiding the bladder every 2 hours and gradually increasing the
time between urination, in combination with distraction techniques,
such as, sitting on a hard surface, or doing an activity that requires
concentration. It is important not to be prescriptive and to recognize
an individual’s limits and abilities. Bladder training with a bladder
diary should be implemented for at least 6 weeks.

B ladder diar y

Date,
time

Fluid intake

Urine

Type

Quantity
(mL)

Volume
(mL or
*S/M/L)

Leakage

Volume
(S/M/L)

Urgency
of need
to urinate
(1–5)

Activity
engaged
in

Pad
change

Awareness campaigns can also be helpful in addressing the stigma
associated with UI and in encouraging people to seek health care.

*  If it is not possible to measure or estimate in mL, record volume as small, medium

or large

13 Urinary incontinence

13.3
Assess urinary
incontinence and
urological conditions

Urinary incontinence is the involuntary leakage of urine. It occurs
in association with not only lower urinary tract dysfunction but also
loss of mobility, cognitive decline and other diseases. An important
step, before an in-depth assessment for UI is to identify and treat
any reversible causes (

 13.5

).

Date,

time

Fluid intake

Urine

Leakage

Type

Quantity

Volume

Urgency

Volume

Activity

Pad

(mL)

of need

(S/M/L)

engaged

change

(mL or

*S/M/L)

to urinate

(1–5)

in

Potential UI can be identified by asking about leakage, with sudden
urgency and/or caused by coughing or lifting. Information about
severity and quantity of urine lost, frequency of incontinence
episodes, and duration of the complaint should be sought. There
are different types of UI (Box 13.1); however, diagnosing the
type of UI is not essential at primary care to be able to provide
interventions.

Box 13.1  Types of urinary incontinence

•  Urgency urinary incontinence: UI immediately preceded by a sense of urinary urgency.

Most common in older people.

•  Stress urinary incontinence: UI occurring with abrupt increase of intra-abdominal pressure
(e.g. coughing, lifting), due to pelvic floor weakness or a weak urinary sphincter. Associated
with obesity and women who have experienced vaginal childbirth.

•  Mixed incontinence: Combination of stress and urgency UI.

•  Overflow incontinence: UI from overly full bladder due to impaired bladder contractile

function and/or bladder outlet obstruction. This is common in men.

•  Disability-associated incontinence: Due to cognitive decline, limited mobility or

comorbidities.

Assessment of urologic conditions should be conducted by a
trained health worker and include the examinations listed below.
In most cases, urologic assessment is not necessary during the
initial assessment, but reversible causes should be identified and
treated.

•

Abdominal examination to identify a palpable bladder.

•  Digital rectal examination to identify a pelvic mass, large
prostate (for men, approximately ping pong ball size, e.g.
bigger than 40 cc) and stool impaction (constipation).

•

•

Urinalysis to identify haematuria and UTI. Be aware of the
limitation of urinalysis stick as it does not differentiate between
haemoglobin and myoglobin. Microscopy (if available) is
recommended to confirm haematuria.

For women, external genitalia examination to check for prolapse
(descent of the uterus, cervix or vaginal walls) and fistula (a hole
between the vagina and bladder), suspected by abnormal
vaginal discharge, continuous urine loss or odour in urine.

Results of basic assessment for other linked domains of intrinsic
capacity, such as cognitive decline, limited mobility and
depressive symptoms should also be verified and an in-depth
assessment conducted as necessary.

5  5

6   10

137

13 Urinary incontinence

13.4
Manage urinary
incontinence

Interventions to manage UI should always be provided as part of a
comprehensive personalized care plan responding to underlying
factors, along with interventions that address other domains of intrinsic
capacity. In addition to bladder training, there are multiple ways
to manage UI including pelvic floor muscle training for women and
prompted voiding for those with cognitive decline.

13.4.1
Pelvic floor muscle training

The pelvic floor muscles span the
bottom of the pelvis and support
the pelvic organs (the bladder and
bowel, and the uterus in women)
(Fig. 13.1).

Pelvic floor muscle training can be recommended to older women with
UI. As this is commonly provided in health services as part of postnatal
care, if adequately trained and resourced, health workers should be
able to provide information and support to older women (Box 13.2).
Undertaking three sets of 10 contractions with adequate relaxation
between contractions daily, should be advised. To improve pelvic floor
function, these exercises should be maintained for at least 3 months.

Fig. 13.1
Pelvic floor muscles

Uterus

Bladder

Pelvic
bone

Rectum

Pelvic floor
muscle

138

Box 13.2  How to exercise pelvic floor muscles

Health workers can provide information to older women
on pelvic floor exercises. It is important for older women to
learn to do the exercises in the right way, and to periodically
check that they are still being done correctly. Health workers
can help older women to understand the exercises by using
diagrams, drawings and models and by sharing the following
tips:

•

•

In the upright position, the woman should sit
comfortably with feet and knees wide apart. If
preferred, they can also lie down flat with legs slightly
apart. They should remember to keep breathing
throughout and keep their stomach, leg and buttock
muscles relaxed.

The woman should imagine she is trying to stop herself
from passing gas from the bowel and at the same time
trying to stop the flow of urine from the bladder. She
should feel a lifting and tightening around the vagina
and anus.

•  Women may not be able to contract and relax their

pelvic floor adequately at first. This can take practice
and most women will learn how to do it if they are given
some time to try.

13 Urinary incontinence

These measures may be

challenging if the older person

has dementia or limited ability

to collaborate or if more than

two people are needed to

transfer them.

13.4.2
Prompted voiding

People with cognitive decline will need specific support for UI.
This should include prompted voiding to increase the person's toilet
use and decrease the number of UI episodes. A carer should suggest
the older person go to the toilet every 2 hours throughout the day
and assist them to do so. They can try to reinforce the positive
behaviour of frequent toilet visits by spending time in the toilet,
having a conversation and not rushing the older person. The carer
should also ask the person whether they are wet, to encourage them
to notice and act on this. If the person cannot reliably self-report,
the carer should check for wetness during toilet visits, and record
each wet check in a bladder diary to build up a pattern of urination
that could help to pre-empt incontinence episodes.

The effect of each of the above interventions should be monitored
for 3–6 months. If no improvement is seen the older person should
be referred to specialized care.

13.5
Assess and manage
associated diseases
and risk factors

An assessment of diseases and risk factors for UI should start by
identifying and treating possible causes, including fluid imbalance,
constipation, medication, UTI and delirium. Identifying reversible
cause(s) of UI involves a full diagnostic work-up at a primary care
facility. It may be necessary to explore several different potential
explanations of symptoms to arrive at an appropriate approach for
a care plan.

13.5.1
Fluid balance

Excessive fluid intake can be a risk factor for UI. Fluid balance
should be checked to identify potential cause of excess urine
output. Certain drinks and foods such as caffeine may act as
diuretics, increasing volume of urine produced. Normal fluid
balance should be encouraged and the risks of restricting fluid
intake (increased risk of UTI, dehydration) explained. A reduction in
caffeine can be tried for 6 weeks.

 7.3.2

13.5.2
Constipation

Infrequent stools or difficult stool passage, due to reduced
bowel movement, can be a cause, or contributing factor to UI.
Stool impaction can be identified by symptoms, stool diaries and
physical assessment (e.g. digital rectal exam). High-fibre diets,
adequate fluid intake, regular physical activity, and having a bowel
movement at the same time every day (e.g. after breakfast) can
help manage constipation.

139

13 Urinary incontinence

140

13.5.3
Inappropriate medication(s)

13.5.6
Vulval symptoms (women)

A review of medications should be undertaken to identify any
medications that might lead to UI.

Medications that might lead to urinary incontinence:

•

•

•

Diuretics

Alpha adrenoreceptor antagonists

Angiotensin-converting enzyme (ACE) inhibitors

•  Calcium channel antagonists

•

Psychotropic medicines (clozapine, selective serotonin reuptake

inhibitors, benzodiazepines, lithium)

Anti-Parkinsonian medicines

Antihistamines

•

•

Following a review, medications can be withdrawn or alternatives
prescribed if deemed appropriate by a health worker.

13.5.4
Urinary tract infection (UTI)

Acute UTI should be suspected on the basis of urinalysis. It can
cause symptoms such as an urgent or frequent need to urinate,
a burning feeling while urinating and blood in the urine. UTIs can
manifest commonly as delirium or confusion in the absence
of a fever. The treatment of bacteriuria is only indicated when
symptoms are present or when there is evidence that it may be
the cause of UI. Recurrent symptomatic UTIs (two or more
infections in 6 months or three or more infections per year) require
a referral to specialized care.

13.5.5
Delirium

Delirium is a sudden, fluctuant loss of the ability to direct, shift,
sustain and focus attention and can be a cause of UI. A person with
delirium may be unaware of their bladder filling or the need to void.

 5.5.1

Vulval symptoms include discomfort (e.g. itching, dryness or
burning, pain) around the outer part of the female genitals as a part
of genitourinary syndrome of menopause. They have a profound
negative impact on quality of life. Women should be made aware
of these problems and treated, including with topical vaginal
moisturizers and oestrogen, if appropriate, available and accessible.

13.5.7
Incontinence-associated dermatitis

An examination of external genitalia should be conducted to assess
possible skin inflammation due to prolonged contact with urine.
Prolonged use of containment products such as incontinence pants
or pads can lead to dermatitis and infection. Incontinence-associated
dermatitis appears initially as erythema which looks different on
different skin tones: on lighter skin: ranging from pink to red; and on
darker skin: skin may be paler, darker, purple, dark red or yellow.

The affected area usually has poorly defined edges and may be
patchy or continuous over large areas. Advanced incontinence-
associated dermatitis shows areas of superficial skin erosion with
pain. If dermatitis is found, advise on mild cleansing and protecting
the skin with appropriate topical products including barrier creams
or films, treat any secondary infection and recommend appropriate
containment products.

13.5.8
Diabetes and obesity

Diabetes is associated with UI due to excessive urine output and
alterations in bladder muscle function. Obesity has been shown to
be a strong risk factor for UI, specifically, the higher prevalence of
UI in older women is linearly correlated with higher BMI (61). As intra-
abdominal pressure increases with obesity, the increased bladder
pressure weakens the pelvic floor. Management of CVD and risk
factors should be provided through healthy diet and physical
activity including exercise, together with medication. For older
people, the benefits of weight loss need to be weighed against
potential risks, such as concurrent muscle mass reduction.

 7.3.1

13 Urinary incontinence

Community stakeholders can

provide maps of where public

toilets are located, and speak

with local shops, cafés and

other businesses to ask if their

toilet facilities could be made

available to older people.

13.6
Assess and manage
social and physical
environments

13.6.1
Access to a toilet

An older person’s access to a toilet, should be assessed, including
distance within the home to the toilet, and for those with shared
toilet facilities outside of the home, distance, terrain, safety and
security. The usability of the toilet itself should also be considered,
including the type of toilet (sit or squat), need for grab rails, space
for people using mobility assistive products to manoeuvre.
Commode (toilet) chairs and urinals may be useful if the distance
to a toilet is not manageable, or if the person is unable to use the
toilet. Additional lighting in the toilet, contrasting strips to indicate
any steps and a coloured marker on the flush, could be helpful for
people with vision impairment. Clothing that is easy to undo or take
off might also be beneficial.

It can also be useful to assess access to toilet facilities in the local
community. A lack of access may hinder an older person’s ability or
willingness to go out and participate in activities, leading to social
isolation and loneliness.

13.6.2
Containment products

If treatment for UI is not possible or does not work, the use
of containment products can help to improve quality of life.
Absorbent containment products include incontinence pants
and pads; different products should be used at different times
and for different activities. For example, a smaller product could
be used during the day while a larger one may be needed at night.
Containment products may be reusable or disposable. Reusable
products should be washed and dried carefully. These products
can be prohibitively expensive but may be subsidized, in some
contexts through various mechanisms.

Community stakeholders can support access to containment
products through working with local authorities and health workers
to make products available (and affordable) and holding them to
account on their commitments.

Indwelling urinary catheters should be avoided as they cause
infections and other harms such as blood or debris in the catheter
tube that might block the drainage system.

M O R E   I N F O R M AT I O N

 Training on self-care assistive products and
absorbent (containment) products. TAP; 2024
(https://www.gate-tap.org/).

141

13 Urinary incontinence

142

13.6.3
Social care and support 10

11

Social care and support needs may include assistance with
toileting, bathing and dressing. If a person with UI who uses
containment products needs support from a carer to go to the
toilet and get dressed, the ease of use of containment products
should be considered, including whether it is possible to change
without removing outer clothing. Day care and other LTC facilities
in the community should ensure adequate space for older people
to be assisted in going to the toilet and changing.

Older people with UI might benefit from psychosocial support,
including peer support. Community stakeholders can establish support
groups, to give older people the opportunity to share their experiences
and seek advice from others in a similar situation. This could help to
empower older people with UI to speak up and ask for help.

13.6.4
Support for carers
11

12

Looking after someone with UI can be physically and psychologically
challenging. Carers, including family members at home with the
older person all day, should receive training in how best to provide
care, including how to safely assist the older person to walk and to
transfer on to and off of a toilet; how to assist with personal care,
including cleaning and skin care to avoid infection; appropriate
use of incontinence pads and other products to avoid a reliance
on these products if they are not necessary; how to encourage the
person to keep drinking and not restrict their fluid intake; how to
encourage prompted voiding; and how to clean and safely dispose
of soiled clothes, bedding and incontinence pads.

It is also important to provide support and advice for carers
on how to manage any feelings of embarrassment or anxiety
associated with providing personal care. Carers may find it difficult
to discuss issues related to UI with the person they are caring for,
and may feel uncomfortable providing personal care. They should
be given advice and information on how to approach sensitive
conversations and how to provide personal care in a way that
promotes dignity and autonomy.

14

Implementation
considerations for ICOPE

ICOPE can support a transformation in health and social care
systems and services to deliver an integrated, person-centred
continuum of care for older people with the aim of optimizing
functional ability. The overarching ICOPE care pathway within a PHC
approach can support the identification of the older population's
needs and provision of services (Fig. 1.1, p. 5). The implementation
of ICOPE should therefore align closely with efforts to strengthen
PHC, utilizing the levers of PHC outlined in the WHO and UNICEF
Operational Framework for Primary Health Care.

ICOPE has been piloted in multiple countries around the world
across a range of income levels and with different structures and
capacities within their health and social care systems. Learnings
from these pilots highlight key considerations for implementation
relevant to project and system managers.

Key points

 Before implementing an ICOPE care pathway an assessment of
readiness at service and system level is recommended.

 Adapting and developing local care pathways starts with
mapping available resources and identifying the entry points
and opportunities to implement the ICOPE approach.

 Engagement of older people and their carers is key for successful
and sustainable implementation of integrated care.

 Optimizing the intrinsic capacity and functional ability of older
people begins in the community. Health and social care systems
should support and enable delivery of community-level
services through strengthened primary care and engagement
with community stakeholders.

 Health workers should receive training, support and proper
remuneration to enable the delivery of person-centred
integrated care within routine practice.

 ICOPE requires the integration of health and social care,
including LTC. Care can be delivered by and with multiple
sectors and across settings. Effective coordination and
collaboration across sectors, settings and services is crucial.

143

The information collected through a mapping exercise should
inform the development of care pathways specific to the local
context. This exercise should focus on working with existing
routine practice and using basic and in-depth assessment tools
already available and validated that address intrinsic capacity and
functional ability, and building workforce capacity and incentives
and strengthening services where needed. Adapted care
pathways should be translated into relevant languages and piloted
to test their feasibility and acceptability.

Health workers can undertake similar exercises to identify
available resources in their own health care setting, building a
multidisciplinary team and a collaboration mechanism among
different health and social care services, and identifying entry
points to integrate the ICOPE care pathway into routine clinical
practice. This process can inform where, how and with whom to
start piloting the approach. The first phase of a pilot should be to
assess the feasibility of implementing ICOPE and identify barriers
and enablers to its implementation.

14.1
Adapting ICOPE to local
contexts

Prior to implementing ICOPE at scale, countries should conduct
an assessment of readiness to deliver integrated care to inform an
adaptation of the approach to the local context. The WHO ICOPE
implementation framework provides a scorecard to guide the
assessment of overall capacity of health and social care services and
systems to deliver integrated care in primary care, and also informs
implementation action plans based on readiness to implement
(none to minimal, initiating, sustaining). Scoring can highlight the
areas of opportunity and be used to monitor ongoing progress of
implementation.

This is an important step as all health and social care systems are
different, with varied service delivery approaches, workforce
structures and regulations, referral pathways and resource
capacities. It is possible to start implementing ICOPE by piloting
and adapting the approach in a community or clinical setting,
engaging relevant local stakeholders.

To inform local or national adaptation, a comprehensive
mapping exercise (Box 14.1, p. 145) should be undertaken with
the involvement of older people, carers, health and social care
workers from different settings, public health authorities and
community stakeholders. The mapping process can be used to
build support and collaboration for the approach.

14 Implementation considerations for ICOPE

ICOPE should be adapted to
ensure the steps of the care
pathway can be effectively
implemented within and by
existing services and settings
in a culturally appropriate and
sustainable way.

144

14 Implementation considerations for ICOPE

Box 14.1  Elements of comprehensive mapping to inform adaptation of ICOPE

Older people and their carers:

Partnerships:

•

Situation analysis of health and well-being of older people informed
by key informant interviews and a survey (population or facility based).

•

Formalized engagement between health and social care sectors across
different settings and community stakeholders.

•  Older people and their carers’ health literacy.

•  Clarity of roles and responsibilities.

•

Identification of where older people in need of care are, including those
unable to access health care facilities, whose engagement will need to
happen at home or in the community.

Models of care: A model of care is a conceptualization of how services
should be delivered, including the processes of care, organization of
providers and management of services. It is supported by mapping:

•

Availability, accessibility (cost, distance, transportation, age
friendliness), acceptability and quality of services for older people
at different levels of the health system.

•  Care pathways (usual first and regular point of contact, referral

mechanisms).

•

Recognition, training and support for community stakeholders.

Coordination:

•  Mechanisms for collaboration between health and social care services and

workers.

•  Ways of working that enable a multidisciplinary team approach.

•

•

•

Structure and capacity of LTC services and workers.

Utilization of social support such as social prescribing.

Existing partnerships with other sectors, including transport, education,
employment, justice and law enforcement.

•

•

•

•

•

Entry points for implementation of ICOPE within existing service
delivery (e.g. through noncommunicable diseases clinics or mobile
outreach services).

Available infrastructure (diagnostics, health and care data collection
and sharing mechanisms, space for assessment).

Screening and assessment tools for impairments of intrinsic
capacity.

Essential medicines, vaccines and health products including
assistive products.

Human resources:

•  Who the health workers are in primary care, including community health
workers, their capacity (time, knowledge, skills, remuneration) and
composition of multidisciplinary teams (if they already exist).

•

•

The training currently received, and necessary knowledge currently not
being provided.

Roles and responsibilities of different health workers across health care settings
(primary, secondary, tertiary) and social care settings including LTC facilities.

•  Other human resources including volunteers and community stakeholders.

Availability, accessibility and acceptability of social care services,
including LTC, and community services for social support.

Financial resources:

•

Budget currently available that could be utilized for promoting quality
person-centred care for older people.

•  Costings of the provision of integrated care and budget gaps.

Note: The elements of comprehensive mapping to inform adaptation of ICOPE can be undertaken in any order.

145

14 Implementation considerations for ICOPE

Box 14.2  Summary of actions from the ICOPE
implementation framework

Actions for systems (macro level)

•  Strengthen governance and accountability systems

Engage stakeholders in policy and service development; develop
policy and regulation to support integrated care and responses to
abuse of older people; undertake continuous quality assurance
and quality improvement; regularly review capacity to deliver care
equitably.

•

Enable systems strengthening
Develop workforce capacity, financing and human resources
management; use technology to exchange information among
service providers; collect and report data on intrinsic capacity
and functional ability; use digital technologies to support self-
management.

Actions for services (meso level)

•

Engage and empower people and communities
Engage older people, their families and civil society in service
delivery; support and train carers.

•  Support the coordination of services provided by multidisciplinary

teams
 Identify older people in the community who need care, undertake
comprehensive assessments and develop comprehensive care
plans; establish networks of health and social care workers.

•  Orient services toward community-based care

Deliver effective and acceptable care focused on functional
ability through community-based workers and services backed by
adequate age-friendly infrastructure.

14.2
Implementation considerations

Following the readiness assessment and adaptation of
ICOPE, there are a number of further considerations for its
implementation. The WHO and UNICEF Operational Framework
for Primary Health Care provides interdependent and inter-
related levers (strategic and operational) to guide countries’
efforts to strengthen PHC-oriented health systems.

The ICOPE implementation framework sets out 19 actions, that
complement the PHC levers, to support Member States, focused
on the system (macro) and services (meso) levels (Box 14.2). The
macro-level components are intended to support policy-makers,
system-level planners, funders and decision-makers; while
the meso-level actions are targeted at service and programme
managers and decision-makers. In alignment with operational levers
of PHC, such as models of care, PHC workforce, digital technology
and monitoring and evaluation, the following implementation
considerations, drawn from the implementation framework and
learning gained through ICOPE pilot programmes, aim to support
implementation at the service level.

14.2.1
Integrating health services, prioritizing
primary care

Most health systems around the world are designed to treat and
cure diseases, often through vertical services. Despite efforts to
strengthen PHC, they are often not equipped to deliver integrated
person-centred care that requires a more horizontal comprehensive
approach, allowing for flexibility and multidisciplinary working.
Therefore, primary care services as a first and regular point of
contact, and the first component of PHC, need to be prioritized
with the delivery of a continuum of integrated care as a key aim, to
enable quality care including the implementation of the ICOPE care
pathway. This can be supported by including ICOPE interventions in
an essential service package at primary care.

146

14 Implementation considerations for ICOPE

Multidisciplinary teams that
optimize health workers’ skills mix,
should enable the delivery
of a continuum of integrated
person-centred care.

Consideration should be given to the level of coordination
between health systems including the suitability and age-
friendliness of infrastructure and availability of appropriate
tools and technologies, including medicines, vaccines and
health products such as assistive products, ensuring effective
referral mechanisms, both within the health service, including to
specialized care at secondary and tertiary levels, and between
health and social care services, and establishing and/or
strengthening systems for data collection and sharing.

14.2.2
Human and financial resources

Additional investment is most likely needed to support the
implementation of ICOPE, particularly in relation to human
resources to ensure a more effective and efficient approach while
better aligning with current and future needs of the population.
Capacity building of multidisciplinary health workers usually
involves the provision of competency-based training at all levels,
especially at primary care, to increase understanding of ICOPE
and how it can be applied.

In many contexts, community health workers play an increasingly
significant role in the delivery of health services but may lack
training and support and often work in a voluntary or unpaid
capacity, all of which affect sustainability (e.g. recruitment,
retention). Provision of job security, supportive supervision
and career development pathways are important. Alternative
workforce configurations might be needed, based on the setting
and resource availability to respond to evolving health needs and
populations. Task sharing among health workers can support the
delivery of integrated care and may also require adjustment of
regulation, recognition of new roles and specific remuneration.

Building incentives for public health and rewards for health
workers for integrated care, financing mechanisms and
performance monitoring can encourage the shift towards quality
care for older people. Authorities responsible for developing
training and curricula and providing accreditation, and national
and local professional societies can play an important role.

14.2.3
Coordination among health and social care sectors

Structures and mechanisms are required at the service level to enable
referral between health and social care and collaboration between
health and social  workers, facilitated by a care coordinator, as part of
a multidisciplinary team. This coordination should include LTC services
and integration of information and quality assurance systems.

WHO’s Long-term care for older people: package for universal
health coverage, provides a list of LTC interventions for countries
to consider, prioritize and provide. In some countries, the
mechanism for assessment for eligibility for LTC services and care
provision is organized by different sectors. Whatever the local
arrangements, the principles of a person-centred integrated
approach are the same, although different staff (in the community
or in residential settings) and specialist skills may be needed. The
health and social care sectors will be better able to adopt and apply
ICOPE when national policies support an integrated approach to
health and social care. These policies should take into account how
health and social care services are provided and by whom, including
the role of the private sector in the provision of LTC, in particular, and
the need for strengthened public-private partnerships.

14.2.4
Digital technology

The use of digital technology as a potential enabling factor has
been highlighted by learning from ICOPE pilots, which have
shown its use leading to improvements in the efficiency and
effectiveness of integrated care.

Digital tools can support health workers to access training
(e-learning), to conduct the basic and in-depth assessments of
the ICOPE care pathway, and to monitor and analyse outcomes of
interventions. Digital technologies can also enable and improve
communication with older people and their carers, such as
through telehealth and mobile health and using video and other
online media to raise awareness of integrated care and provide
health and lifestyle advice. Digital technology can be used to
support functional ability, reduce the need for care and to assist
carers in their role (Box 12.1, p. 130).

147

M O R E   I N F O R M AT I O N

 Evidence, policy, impact: WHO guide for evidence-
informed decision-making. WHO; 2021
(https://iris.who.int/handle/10665/350994).

 Integrated care for older people (ICOPE)
implementation framework: guidance for systems
and services. WHO; 2019 (https://iris.who.int/
handle/10665/325669).

 Long-term care for older people: package for
universal health coverage. WHO; 2024 (https://iris.
who.int/handle/10665/376585).

 Operational framework for primary health care:
transforming vision into action. WHO and UNICEF;
2020 (https://iris.who.int/handle/10665/337641).

 WHO guideline on health policy and system support
to optimize community health worker programmes.
WHO; 2018 (https://iris.who.int/handle/10665/275474).

14 Implementation considerations for ICOPE

Advances in information and communications technologies
(electronic health records) also facilitate data sharing in real-time
among health workers, including community health workers and
social care workers, and support aggregation of data to monitor
and improve the targeting of public health efforts.

Ageist assumptions that older
people cannot or do not want to
use digital technology should be
tackled.

When considering the use of digital technology, potential
challenges need to be considered, including digital literacy
among older people and inequalities in access to technology,
interoperability, integrity, data governance, cybersecurity and
usability.

14.2.5
Monitoring and evaluation

Monitoring, evaluation and review of health progress and
performance are essential to ensure that priority actions and
decisions are implemented as planned against agreed objectives
and targets for older people. Robust monitoring and evaluation of
ICOPE, including a focus on the health status (intrinsic capacity and
functional ability) of an older person and older populations, should
be included as part of this wider monitoring and evaluation process.
Building capacity to collect, analyse and use data for local decision-
making is crucial. Reliable service-level data collected through
standardized indicators support understanding of the effectiveness
of ICOPE and inform priority setting and changes to service delivery,
helping to assure accountability, including towards older people and
their carers.

Community stakeholders can play a role in accountability,
including: holding health systems accountable to older
populations’ needs; and contributing to accountability in the
governance, planning, delivery and evaluation of health care.

The development of an approach to monitor ICOPE within the
monitoring and evaluation lever of PHC can also be taken forward as
part of a broader monitoring and evaluation of healthy ageing, guided
by the WHO framework and indicators for measuring the progress and
impact of the UN Decade of Healthy Ageing (2021-2030).

Within the context of PHC,
countries will need to assess gaps,
determine priorities, establish
baselines and targets, and track
progress and performance
towards UHC across their health
and social care systems.

148

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153

Annex: Example of a simplified care plan

This is an example of a simple summary care plan that can be shared by the case manager or care coordinator with the older person.
It is not intended to capture a full medical history or act as a medical record.

Date:  DD / MM / YY

Location:  xxx primary care clinic

Proposed and agreed interventions

Personal information

Date of birth (Age):  (75)               Gender:  Male   ID:  XXX

Person-centred goals

(Short term) I would like to join my granddaughter’s school soccer game
next month. To do so, I want to be able to walk to the school.

(Long term) I would like to keep being able to walk to church over
the next year. This is becoming more difficult.

Assessment summary

Intrinsic capacity

– Limited mobility with knee pain

– Moderate hearing loss without red flags

Diseases and risk factors

– Controlled hypertension and hyperlipidemia

– Osteoarthritis of knees

Social and physical environment

Living with his wife on the third floor without a lift. His son,
daughter-in-law and grandchildren live locally and visit weekly.

Participating in community activities regularly, including church
groups and having coffee with friends but limited mobility has begun
to reduce his participation recently and he sometimes struggles to
follow conversations if the environment is noisy.

154

Proposed
interventions

Agreed by
older person

Actions

Multimodal exercise
programme with referral to
rehabilitation service

Yes

Referral letter is being prepared to make
an appointment with rehabilitation
service

Referral to the hearing care

Yes

Pain assessment and
management

Continued management of
diseases (hypertension and
hyperlipidemia)

No

Yes

Diet advice to increase protein
intake

No

Assessment of risk of falls
at home

Assessment of carer
(his wife) needs

No

Yes

Mobility assistive products

Yes

Referral letter is being prepared to make
an appointment with hearing care

Declined referral for pain assessment.
Advised to make a record when pain is
felt and intensity of pain (0-10)

Continue checking blood pressure at
home

Take medications as prescribed and next
blood test in 2 months

Stated did not want to increase protein
consumption. Advised to try to eat
locally available protein rich foods.

Advised how to make home and home
surroundings safe

An assessment is being scheduled with
the carer (wife)

Referral letter to be prepared to make an
appointment with rehabilitation service

Assessor name: xxx

Date recommended for next appointment: DD/MM/ YY

155

For more information:

https://www.who.int/teams/maternal-new-
born-child-adolescent-health-and-ageing/ageing-
and-health/integrated-care-for-older-people-icope

Department of Maternal, Newborn,
Child & Adolescent Health and  Ageing (MCA)
World Health Organization
Avenue Appia 20
1211 Geneva 27
Switzerland

