This year marks the start of the UN Decade of Healthy Ageing 2021–2030 which aims to promote action to foster healthy aging and improve the lives of older people. Maintaining good health and independence while avoiding disability, frailty, functional, and cognitive decline are key challenges of aging. High-quality research into each of these components is needed to develop strategies and recommendations for healthy aging.
In the current issue of International Psychogeriatrics, Constenoble et al. (Reference Constenoble, Rossi, Knoop, Debain, Smeys, Bautmans, Verte, De Vriendt and Gorus2022) address the question of how psychological resilience, functional independency, and pre-frailty interact. This is a highly relevant topic in aging research, as both frailty and functional limitations are frequent among older adults. Identifying individuals at risk for future frailty and functional impairment at an early stage provides an opportunity for intervention and prevention. The World Health Organization (WHO) labeled frailty as the “holy grail of geriatric medicine” (World Health Organization, 2017). Recent research suggests that frailty is a precursor of functional impairment (Wu et al., Reference Wu, Kim, Xue, Lee, Varadhan and Odden2019; Zamudio-Rodriguez et al., Reference Zamudio-Rodriguez, Letenneur, Feart, Avila-Funes, Amieva and Peres2020) and that it can modify the clinical expression of Alzheimer’s disease pathology in a way that frail individuals might be at risk for dementia even if they have a low level of Alzheimer’s disease pathology, like plaques and tangles (Wallace et al., Reference Wallace, Theou, Godin, Andrew, Bennett and Rockwood2019). In contrast, people with a low amount of frailty can better tolerate Alzheimer’s disease pathology. An interaction between frailty and Alzheimer’s disease pathology exists independently from activities of daily living (ADL) performance (Wallace et al., Reference Wallace, Theou, Godin, Andrew, Bennett and Rockwood2019). According to Wallace et al. (2021), when assuming a causal relationship between frailty and dementia, the prevention of severe frailty could reduce the risk of dementia by 14%. Even though there is still no global consensus on an operational definition of frailty, it is most commonly defined as a physical state of slowness, weakness, exhaustion, inactivity, and unintentional weight loss (Fried et al., Reference Fried2001). It is an age-associated syndrome that precedes disability, and its different stages distinguish robust from pre-frail from frail individuals. According to the WHO Clinical Consortium on Healthy Ageing (World Health Organization, 2017), frailty can be prevented by enhancing intrinsic capacity, which refers to the combination of an individual’s physical and mental capacities. In combination with interactions with the surrounding environment (i.e. the home, community, and broader society, and all the factors within them), intrinsic capacity largely defines a person’s functional ability. A crucial step to healthy aging is to optimize functional ability. The process of maintaining physical fitness and building cognitive and functional reserve to optimize functional ability is a life-long journey that should be promoted and implemented at an early age. The increased prevalence of multimorbidity in older age can lead to more rapid functional and cognitive decline in individuals with less functional and cognitive reserve and even relatively minor illness or injury may result in significant functional decline. In addition, transition to a higher level of frailty is more common than reversion to a lower level of frailty and often frailty can result in a spiral of worsening disability, falls, hospitalization, and death (Clegg et al., Reference Clegg, Young, Iliffe, Rikkert and Rockwood2013).
The demand for clinicians is to shift their focus from disease-centered to maintaining and enhancing intrinsic capacity and functional ability. Is this easier said than done? What do we need to change and what are the barriers and facilitators to support and enable healthy aging? This is certainly not a quick and easy process, however an important one. Health systems need to transform to ensure access to integrated care focusing on the needs, rights, and capabilities of older individuals. Person-centered assessments of intrinsic capacity and functional ability have been recommended as a way of understanding healthy aging and predicting morbidity and mortality in older people (World Health Organization, 2019). This approach takes into account conditions that are associated with a decline in intrinsic capacity, such as cognitive decline, limited mobility, malnutrition, visual impairment, hearing loss, and depressive symptoms. An integrated approach to the screening, assessment, and management of these conditions facilitates addressing the health and social care needs of older adults comprehensively. Given that multi-component exercise interventions, consisting of aerobic and resistance training in combination with balance and flexibility exercises, can reduce frailty (Jadczak et al., Reference Jadczak, Makwana, Luscombe-Marsh, Visvanathan and Schultz2018), it is important to widely promote and implement exercise programs for older adults. An optimal combination of moderate to high intensity, duration (45–60 minutes), and frequency (three times per week) seems to be critical in achieving positive effects on frailty (Jadczak et al., Reference Jadczak, Makwana, Luscombe-Marsh, Visvanathan and Schultz2018). As frailty affects physical, cognitive, social, and psychological domains, a targeted, interdisciplinary approach including exercise, management of polypharmacy, falls, nutrition, loneliness, cognitive impairment, and depressive symptoms is required (Merchant et al., Reference Merchant, Morley and Izquierdo2021).
“Reablement” and “restorative care” have been suggested as an approach to manage functional decline (Poulos and Poulos, Reference Poulos and Poulos2019). This approach first identifies the nature of and contributors to functional decline for an individual through clinical and functional assessments. After collaborative goal setting which includes meaningful and achievable goals for the individual, strategies to improve functional ability are being implemented, including evidence-based lifestyle interventions, environmental modifications, and provision of community support services to address persisting functional limitations that affect daily living (Poulos and Poulos, Reference Poulos and Poulos2019). It is obvious that only a collaborative, interdisciplinary approach between healthcare providers, allied health, and caregivers will lead to the best possible result for the individual.
The assessment of functional performance gives clinicians insight into if and to what extend an individual can perform ADL independently. Impairment in instrumental ADL (IADL) in older people with normal cognition and in those with mild cognitive impairment is associated with an increased risk of dementia (Jang et al., Reference Jang, Numbers, Lam, Sachdev, Brodaty and Reppermund2021), and it has been shown that IADL impairments in middle age (50–64 years) can increase the risk of hospitalization, nursing home admission, and death within 6–11 years (Brown et al., Reference Brown, Diaz-Ramirez, Boscardin, Lee, Williams and Steinman2019). Functional status is not routinely assessed in primary care due to constraints in time and resources, and lack of standardized processes (Nicosia et al., Reference Nicosia, Spar, Steinman, Lee and Brown2019). In geriatric assessments, ADL and IADL performance is usually measured with subjective measures such as questionnaires or interviews administered to the individual or their informant. While these measures are easy to administer and cost-efficient, they have their limitations. Subjective IADL measures can be influenced by mood, personality, memory lapses, reporting bias, caregiver burden, and decreased insight. Reliable and objective assessments of functional ability and change over time are critical to monitor decline to enable focussed support and intervention, and to monitor improvement after targeted interventions. Performance-based assessments have the advantage of objectively scoring individuals on their ability to perform everyday activities rather than relying on subjective self- or informant ratings. They involve presenting individuals with functional tasks in a standardized way. However, most of the existing instruments are fairly time- or resource consuming to be administered in everyday practice or research studies. Some require long training for the clinician, and some can only be administered by specially trained occupational therapists. Ideally, we would have a computerized performance-based IADL measure that can be administered remotely to increase accessibility and to facilitate testing for patients who are not able to attend clinical visits. The COVID-19 pandemic has shown the importance of computerized/online services in many areas. Automated data exporting and reporting would be useful for clinical referrals and in research settings and would facilitate interpretation and communication of results across different clinical settings. More research is needed in this area to develop and validate computerized, performance-based IADL measures.
In conclusion, further research and more resources are needed to continue addressing and promoting healthy aging, reducing frailty, and increasing functional ability in older people. Healthy aging is not defined as the absence of diseases but rather as a dynamic process of maintaining and increasing functional ability, embracing all older people and requiring a whole-of-society approach (World Health Organization, 2020). Appropriate research funding, multi-disciplinary collaboration, clinical training, education, and capacity-building are important areas for policy and governments to focus and support to ensure that the UN decade of healthy aging’s vision of a world in which everyone can live a long and healthy life becomes a reality. I end with the words of Anna Dixon in her call for concerted global action for a successful decade of healthy ageing: “Now we have a vital opportunity to do things differently. As we enter the Decade of Healthy Ageing, we need governments, businesses and community organizations across the world to rise to the challenge of the age shift and to take action so that everyone is able to live healthier and happier longer lives” (Dixon, Reference Dixon2021).
You have
Access
This year marks the start of the UN Decade of Healthy Ageing 2021–2030 which aims to promote action to foster healthy aging and improve the lives of older people. Maintaining good health and independence while avoiding disability, frailty, functional, and cognitive decline are key challenges of aging. High-quality research into each of these components is needed to develop strategies and recommendations for healthy aging.
In the current issue of International Psychogeriatrics, Constenoble et al. (Reference Constenoble, Rossi, Knoop, Debain, Smeys, Bautmans, Verte, De Vriendt and Gorus2022) address the question of how psychological resilience, functional independency, and pre-frailty interact. This is a highly relevant topic in aging research, as both frailty and functional limitations are frequent among older adults. Identifying individuals at risk for future frailty and functional impairment at an early stage provides an opportunity for intervention and prevention. The World Health Organization (WHO) labeled frailty as the “holy grail of geriatric medicine” (World Health Organization, 2017). Recent research suggests that frailty is a precursor of functional impairment (Wu et al., Reference Wu, Kim, Xue, Lee, Varadhan and Odden2019; Zamudio-Rodriguez et al., Reference Zamudio-Rodriguez, Letenneur, Feart, Avila-Funes, Amieva and Peres2020) and that it can modify the clinical expression of Alzheimer’s disease pathology in a way that frail individuals might be at risk for dementia even if they have a low level of Alzheimer’s disease pathology, like plaques and tangles (Wallace et al., Reference Wallace, Theou, Godin, Andrew, Bennett and Rockwood2019). In contrast, people with a low amount of frailty can better tolerate Alzheimer’s disease pathology. An interaction between frailty and Alzheimer’s disease pathology exists independently from activities of daily living (ADL) performance (Wallace et al., Reference Wallace, Theou, Godin, Andrew, Bennett and Rockwood2019). According to Wallace et al. (2021), when assuming a causal relationship between frailty and dementia, the prevention of severe frailty could reduce the risk of dementia by 14%. Even though there is still no global consensus on an operational definition of frailty, it is most commonly defined as a physical state of slowness, weakness, exhaustion, inactivity, and unintentional weight loss (Fried et al., Reference Fried2001). It is an age-associated syndrome that precedes disability, and its different stages distinguish robust from pre-frail from frail individuals. According to the WHO Clinical Consortium on Healthy Ageing (World Health Organization, 2017), frailty can be prevented by enhancing intrinsic capacity, which refers to the combination of an individual’s physical and mental capacities. In combination with interactions with the surrounding environment (i.e. the home, community, and broader society, and all the factors within them), intrinsic capacity largely defines a person’s functional ability. A crucial step to healthy aging is to optimize functional ability. The process of maintaining physical fitness and building cognitive and functional reserve to optimize functional ability is a life-long journey that should be promoted and implemented at an early age. The increased prevalence of multimorbidity in older age can lead to more rapid functional and cognitive decline in individuals with less functional and cognitive reserve and even relatively minor illness or injury may result in significant functional decline. In addition, transition to a higher level of frailty is more common than reversion to a lower level of frailty and often frailty can result in a spiral of worsening disability, falls, hospitalization, and death (Clegg et al., Reference Clegg, Young, Iliffe, Rikkert and Rockwood2013).
The demand for clinicians is to shift their focus from disease-centered to maintaining and enhancing intrinsic capacity and functional ability. Is this easier said than done? What do we need to change and what are the barriers and facilitators to support and enable healthy aging? This is certainly not a quick and easy process, however an important one. Health systems need to transform to ensure access to integrated care focusing on the needs, rights, and capabilities of older individuals. Person-centered assessments of intrinsic capacity and functional ability have been recommended as a way of understanding healthy aging and predicting morbidity and mortality in older people (World Health Organization, 2019). This approach takes into account conditions that are associated with a decline in intrinsic capacity, such as cognitive decline, limited mobility, malnutrition, visual impairment, hearing loss, and depressive symptoms. An integrated approach to the screening, assessment, and management of these conditions facilitates addressing the health and social care needs of older adults comprehensively. Given that multi-component exercise interventions, consisting of aerobic and resistance training in combination with balance and flexibility exercises, can reduce frailty (Jadczak et al., Reference Jadczak, Makwana, Luscombe-Marsh, Visvanathan and Schultz2018), it is important to widely promote and implement exercise programs for older adults. An optimal combination of moderate to high intensity, duration (45–60 minutes), and frequency (three times per week) seems to be critical in achieving positive effects on frailty (Jadczak et al., Reference Jadczak, Makwana, Luscombe-Marsh, Visvanathan and Schultz2018). As frailty affects physical, cognitive, social, and psychological domains, a targeted, interdisciplinary approach including exercise, management of polypharmacy, falls, nutrition, loneliness, cognitive impairment, and depressive symptoms is required (Merchant et al., Reference Merchant, Morley and Izquierdo2021).
“Reablement” and “restorative care” have been suggested as an approach to manage functional decline (Poulos and Poulos, Reference Poulos and Poulos2019). This approach first identifies the nature of and contributors to functional decline for an individual through clinical and functional assessments. After collaborative goal setting which includes meaningful and achievable goals for the individual, strategies to improve functional ability are being implemented, including evidence-based lifestyle interventions, environmental modifications, and provision of community support services to address persisting functional limitations that affect daily living (Poulos and Poulos, Reference Poulos and Poulos2019). It is obvious that only a collaborative, interdisciplinary approach between healthcare providers, allied health, and caregivers will lead to the best possible result for the individual.
The assessment of functional performance gives clinicians insight into if and to what extend an individual can perform ADL independently. Impairment in instrumental ADL (IADL) in older people with normal cognition and in those with mild cognitive impairment is associated with an increased risk of dementia (Jang et al., Reference Jang, Numbers, Lam, Sachdev, Brodaty and Reppermund2021), and it has been shown that IADL impairments in middle age (50–64 years) can increase the risk of hospitalization, nursing home admission, and death within 6–11 years (Brown et al., Reference Brown, Diaz-Ramirez, Boscardin, Lee, Williams and Steinman2019). Functional status is not routinely assessed in primary care due to constraints in time and resources, and lack of standardized processes (Nicosia et al., Reference Nicosia, Spar, Steinman, Lee and Brown2019). In geriatric assessments, ADL and IADL performance is usually measured with subjective measures such as questionnaires or interviews administered to the individual or their informant. While these measures are easy to administer and cost-efficient, they have their limitations. Subjective IADL measures can be influenced by mood, personality, memory lapses, reporting bias, caregiver burden, and decreased insight. Reliable and objective assessments of functional ability and change over time are critical to monitor decline to enable focussed support and intervention, and to monitor improvement after targeted interventions. Performance-based assessments have the advantage of objectively scoring individuals on their ability to perform everyday activities rather than relying on subjective self- or informant ratings. They involve presenting individuals with functional tasks in a standardized way. However, most of the existing instruments are fairly time- or resource consuming to be administered in everyday practice or research studies. Some require long training for the clinician, and some can only be administered by specially trained occupational therapists. Ideally, we would have a computerized performance-based IADL measure that can be administered remotely to increase accessibility and to facilitate testing for patients who are not able to attend clinical visits. The COVID-19 pandemic has shown the importance of computerized/online services in many areas. Automated data exporting and reporting would be useful for clinical referrals and in research settings and would facilitate interpretation and communication of results across different clinical settings. More research is needed in this area to develop and validate computerized, performance-based IADL measures.
In conclusion, further research and more resources are needed to continue addressing and promoting healthy aging, reducing frailty, and increasing functional ability in older people. Healthy aging is not defined as the absence of diseases but rather as a dynamic process of maintaining and increasing functional ability, embracing all older people and requiring a whole-of-society approach (World Health Organization, 2020). Appropriate research funding, multi-disciplinary collaboration, clinical training, education, and capacity-building are important areas for policy and governments to focus and support to ensure that the UN decade of healthy aging’s vision of a world in which everyone can live a long and healthy life becomes a reality. I end with the words of Anna Dixon in her call for concerted global action for a successful decade of healthy ageing: “Now we have a vital opportunity to do things differently. As we enter the Decade of Healthy Ageing, we need governments, businesses and community organizations across the world to rise to the challenge of the age shift and to take action so that everyone is able to live healthier and happier longer lives” (Dixon, Reference Dixon2021).