# Implementing the WHO ICOPE program in clinical practice: three years of lessons from monitoring 27,082 participants using the ICOPE Monitor digital tool

Caroline Berbon, Catherine Takeda, Laurent Balardy, Christine Lafont, Néda Tavassoli, Isabelle Carrie, Sophie Guyonnet, Justine de Kerimel, Céline Mathieu, Delphine Pennetier, et al.

<figure><img src="image_1.png" /></figure>

## To cite this version:

Caroline Berbon, Catherine Takeda, Laurent Balardy, Christine Lafont, Néda Tavassoli, et al. Implementing the WHO ICOPE program in clinical practice: three years of lessons from monitoring 27,082 participants using the ICOPE Monitor digital tool. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2024, 10.1093/gerona/glae278. hal-04938523

HAL Id: hal-04938523

https://hal.science/hal-04938523v1

Submitted on 20 Feb 2025

HAL is a multi-disciplinary open access archive for the deposit and dissemination of scientific research documents, whether they are published or not. The documents may come from teaching and research institutions in France or abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est destinée au dépôt et à la diffusion de documents scientifiques de niveau recherche, publiés ou non, émanant des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

<figure><img src="image_2.png" /></figure>
Implementing the WHO ICOPE program in clinical practice: three years of lessons
from monitoring 27,082 participants using the ICOPE Monitor digital tool

Caroline Berbon, Catherine Takeda, Laurent Balardy, Christine Lafont, Néda Tavassoli, Isabelle Carrie, Sophie Guyonnet, Justine de Kerimel, Céline Mathieu, Delphine Pennetier, Véronique Bezombes, Fatemeh Nourhashemi, Bruno Vellas, Sandrine Andrieu, Maria-Eugenia Soto-Martin.

IHU HealthAge & WHO Collaborating Center for Frailty, Clinical & Geroscience Research, and Geriatric Training, Toulouse University Hospital, France (C Berbon MSc, C Takeda MD, L Balardy MD, C Lafont MD, N Tavassoli PharmD PhD, I Carrie PhD, S Guyonnet PhD, J de Kerimel MSc, C Mathieu MSc, D Pennetier PhD, V Bezombes MSc, F Nourhashemi MD PhD, B Vellas MD PhD, S Andrieu MD PhD, M E Soto-Martin MD PhD); Maintain Aging Research team, Centre d'Epidémiologie et de Recherche en Santé des Populations, Université de Toulouse, Inserm, Université Paul Sabatier, Toulouse, France (C Berbon, L Balardy, S Guyonnet, F Nourhashemi, B Vellas, S Andrieu, M E Soto Martin); Clinical Epidemiology and Public Health Department, Toulouse University Hospital, Toulouse, France (S Andrieu).

**Correspondence to:** Caroline Berbon, University Hospital Institute HealthAge Geroscience and prevention research, Toulouse University Hospital, WHO Collaborating Center for Frailty, and Geriatric Training, Toulouse 31059, France. Berbon.c@chu-toulouse.fr.
**Abstract:**

**Background:** To describe the implementation of the ICOPE program in France using digital tool in order to: 1) describe the characteristics of people completing the screener, identifying differences across assessors (Health Care Professionals (HCP), non-HCPs or self-assessment) 2) describe the characteristics of follow-up and assessments for people with abnormal screening test 3) describe the recommendations in the intervention care plans for people with a decline in intrinsic capacity (IC).

**Methods:** A descriptive study, presenting the results at initial screening, as well as at assessment when needed; and the recommendations issued during Step 3. We compared these results based on whether the participant was enrolled by an HCP, by a non-HCP, or self-assessment.

**Results:** 27,082 participants were enrolled. 67.9% were registered by HCPs. 90.8% participants screened positive at Step 1. Participants who completed the self-assessment were significantly younger (70.9 years versus 76.4 for HCPs or 77.9 for non-HCPs, p<0.01) and less frequently had alerts in Step 1 (83.8% versus 90.8 for HCPs or 94.8 for non-HCPs). Step 2 in-depth assessments were carried out for 8.9% of the participants. In step 2, only the SPPB showed significantly better motor abilities in individuals enrolled through self-assessment (median and IQR: 11(10 – 12) versus 10(8 – 12) for HCPs and 10(7 – 12) for non-HCPs). Prevention care plans were proposed, mainly physical activity (n=833 - 33.7%) and nutrition counseling (n=1,233 - 51.7%).

**Conclusion:** This study highlights the major role of HCPs in the implementation of the ICOPE program. Self-assessment enables the enrollment of more robust seniors, allowing to an early detection and treatment.

**Key Words:** prevention, digital tool, intrinsic capacity, WHO, ICOPE program
Introduction

The World Health Organization's ICOPE program endeavors to promote healthy aging and prevent dependency by fostering self-management¹. ICOPE is aimed at addressing, maintaining or slowing declines in intrinsic capacity (IC)², by assessing and longitudinally monitoring its six core domains (locomotion, vitality/nutrition, vision, hearing, cognition, and psychology). The ICOPE program is composed of five steps: screening of participants for potential declines in one or more of the six domains of IC (Step 1); in-depth assessment of participants in any domains where they are identified by the screening as having deficits (Step 2); developing a personalized care plan to maintain or improve IC (Step 3); following the care plan (Step 4); and engaging communities (Step 5)².

ICOPE is an innovative program designed for autonomous individuals aged 60 and above, regardless of their robustness or frailty status. It detects early declines in IC and makes good use of pre-frailty screening tests such as the Fried phenotype score³ and the FRAIL scale⁴.

ICOPE is a global program accessible to all nations⁵ under the auspices of the WHO.

However, most studies have been conducted with smaller sample sizes and rather than being implemented across a large clinical practice. In China, for instance, the Step 1 screening tool demonstrated efficacy in identifying potential declines in intrinsic capacity and assisting in slowing functional decline in a sample of 376 adults⁶. In Korea, the experimental study ICOOP_Frail evaluated the prevention of functional decline through monthly telephone coaching linked with primary care resources, in comparison with the care usually provided⁷.

In India, a feasibility study demonstrated the program's utility for large-scale identification in a rural population located far from healthcare facilities⁸. Other studies are currently underway, particularly in Belgium, Costa Rica⁵ and Brazil⁹, to test the program in the particular context of each country. Since January 1, 2020 the French Health Ministry and
Regional Health Agencies have supported the nationwide implementation of the ICOPE program to evaluate its large-scale implementation¹⁰.

To support the program and to implement it in routine clinical practice, the Gérontopôle of Toulouse University Hospital (France), a WHO Collaborating Center for Frailty, Clinical and Geroscience Research, and Geriatric Training, created the ICOPE MONITOR platform. This platform includes:

1) Digital tools (the ICOPE MONITOR app and the ICOPEBOT chatbot to conduct Step 1; and a secured database, ICOPE MONITOR, to allow remote health monitoring).

2) A team of trained professionals to maintain the ICOPE pathway for participants, ensuring the dissemination of the program (in terms of its tools and provision of information) and training for healthcare professionals (HCPs)¹¹.

Following our 2022 paper¹⁰, the objective of this new paper is to describe the broader implementation of the ICOPE MONITOR program in clinical practice after three years of practical experience (step 1, step 2 and step 3. At this stage of implementation, data from Step 4 were not being collected, yet. Step 5 involves engaging communities and cannot be included in data collection within the scope of our study).

Specifically, we aimed to:

1) describe the characteristics of people completing the ICOPE screener, identifying differences across assessors (Health Care Professional (HCP), non-HCP or self-assessment) and 2) describe the characteristics of follow-up and assessments visits for people with abnormal screening test and 3) describe the recommendations in the intervention care plans for people with a decline in intrinsic capacity (IC).
Method

This is an ongoing, real-world descriptive study in France. Participants were included in the ICOPE program if they were living in the wider community, aged 60 or older, and independent in basic activities of daily living¹². The Activities of Daily Living (ADL) score assesses independence in the six functions of bathing, dressing, toileting, transferring, continence and eating (score 0 = dependent, score 6 = independent; participants were included if their ADL score was 5 or more). The ADL was conducted by healthcare professionals or estimated based on a general perception of autonomy by the professional or the senior themselves.

* Procedures

Using the Step 1 digital screening tools (smartphone app or chatbot) older adults were enrolled into the ICOPE MONITOR program either through self-assessment (individually or with the assistance of a proxy) or directly with a trained HCP or non-health professional. HCP and non-HCP assist with the registration of participants. Professionals participate in the program on a voluntary basis. Once they decide to join the ICOPE program, they are required to be trained using the e-learning training platform (www.icope-formation.com). All professionals are trained in step 1, only HCP can be trained and carry out step 2. Whenever Step 1 screening indicated a potential decline in one of the six domains of IC, the platform automatically generated an alert (Figure 1). Subsequently, a HCP analyzed the Step 1 results using decision-making algorithms specific to particular IC domains to determine the clinical relevance of the alert (efigure 1; algorithms for HCP). There were two procedures for analyzing Step 1 alerts by HCPs: 1) “Face-to-face analysis” when Step 1 was conducted by the HCP, and 2) “Remote analysis” using the ICOPE MONITOR secured platform database for remote health monitoring when Step 1 was performed by a non-HCP or by self-
assessment. In the remote analysis, if necessary, depending on the alert, HCPs may have
needed to contact the participant by phone to confirm: (1) the veracity of the alert: false alerts
are due to participants' mistakes when performing the Step 1 screening test and (2) the
accuracy of the alert and its clinical relevance based on decision-making algorithms (eFigure
1 - 6; algorithms for HCPs). For cognition, this was about verifying any impact on daily life;
for psychology, a HCP confirmed the risk of depression and assessed the presence of a
suicide risk; for mobility, the algorithm focused on the impact of impairment on the person's
daily life and the recent (or otherwise) onset of the problem; for nutrition, it was necessary to
confirm weight loss and assess the impact of appetite loss; finally, for hearing and vision, it
was important to know if the problem was new and if it was already being managed by a
specialist. If the alert indicated clinical relevance, defined by a potential decline in one or
more IC domains, a HCP proposed and carried out a Step 2 (in-depth assessment) to the
participant so that the decline could be investigated and GPs were systematically informed
of the Step 1 results by either e-mail or letter. Based on the results of Step 2, the HCP
collaborated with the participant's family physician ("general practitioner", or GP) to develop
a personalized care plan with recommendations (Step 3). These recommendations have been
discussed during a consultation meeting between the HCP and the GP where the HCP
presented to GP a summary of the step 2 assessment. Then the personalized care plan was
presented to the participant during a dedicated consultation. An exhaustive list of
recommendations was provided for each domain in the ICOPE MONITOR database,
enabling healthcare professionals to select those they offered to the participant. The selected
recommendations for a participant are based on the WHO guidelines², existing resources
within the territory, and the participants' motivations and wishes. To implement these
procedures, some obstacles have been identified, including: (1) A lack of information
provided to health professionals and older adults about the program, (2) Difficulties
experienced by some HCPs in integrating the program into their daily practice (3) The adoption of new digital tools by HCPs and older adults for self-management. and (4) The establishment of ICOPE pathways in rural areas where healthcare professionals are scarce.

* Data collecting

The ICOPE MONITOR platform database was used for the ICOPE pathway data, adhering to confidentiality and data security standards in compliance with the General Data Protection Regulations of 2017, validated by CNIL, the French national commission for data processing and liberties (registration number 247169284s, reference MMS/OSS/NDT171027). Participants in the database were older adults who were informed about the secure and accredited tool used for managing health data, the potential for anonymous data processing, and their right to withdraw, along with relevant contact information.

* Study variables

Each participant's age and gender were recorded. Data collected during Step 1 included: for cognition, memory complaints, recall of three words and temporal orientation; for nutrition, weight loss and loss of appetite; for vision, vision problems, eye diseases or use of antihypertensive or antidiabetic medications and recent vision loss; for hearing, a whispered voice test and recent hearing loss complaints; for mental health, feelings of depression and loss of interest in activities; and for mobility, the timed 5-chair rise test. Additionally, the described variables included the number of domains potentially affected, the frequency of potential decline per domain, the duration of the 5-chair rise test, and the number of Step 2 assessments performed over the study period (it was recommended that Step 2 be performed within one month following an altered Step 1). When participants discontinued their participation in the program, the reason for discontinuation was noted. In the self-assessment
cohort, alert management was described by the number of calls made to participants and GP.
The numbers of false alerts (errors in the administration of Step 1) and clinically relevant
alerts were collected. Step 2 included the number of comorbidities; the number of different
medications per day (using information collected from the participant and if possible, from
their prescriptions); lifestyle factors (living alone, cohabitation with a proxy); Mini Mental
State Examination<sup>13</sup> for cognitive function; Patient Health Questionnaire-9<sup>14</sup> for mental
health; Short Physical Performance Battery<sup>15</sup>, Fried phenotype score<sup>16</sup> and Instrumental
Activities of Daily Living<sup>17</sup> for mobility; Body Mass Index and Mini Nutritional
Assessment<sup>18</sup> for nutrition; distance and near visual acuity using the WHO eye test and
HHIE-S (Hearing Handicap Inventory for the Elderly) for hearing<sup>19</sup>. The Step 3
recommendations are presented based on their frequency with which they were offered for
each IC domain.

* Statistical analyses

The categorical variables were presented by their numbers and frequencies (%). Continuous
variables were described by their mean and standard deviation, or by their median and
interquartile range, depending on the distribution of the variable. Comparison between
participants who were enrolled via HCPs, non-health professionals and self-assessment was
conducted using the chi-square test or Fisher's exact test for categorical variables, and
analysis of variance (ANOVA) or the Kruskal-Wallis test for continuous variables based on
their distribution. Subsequently, the comparison between participants with abnormal Step 1
results & those with a normal Step 1 was performed using the chi-square test or Fisher's
exact test for categorical variables, and the Student t-test or Mann-Whitney U test for
continuous variables. Statistical analyses for this study were conducted using the Stata
software package (StataCorp LLC, College Station, TX, USA), version 14.2.
# Results

## 1. ICOPE MONITOR Participants

**- Characteristics of people completing the ICOPE screener:** Between January 1, 2020 and February 20, 2023, 27,082 participants were enrolled in the ICOPE MONITOR program (see flow chart, figure 2). The primary digital tool used was the ICOPE MONITOR smartphone app (N=15,158 - 56.0%). Most of the participants were enrolled by HCPs (18,373 - 67.9%): 36.2% (9,791) by nurses or nursing assistants, and nearly one in five by physiotherapists. To date, most enrollment in the program has come via geriatric care facilities such as day hospital wards and ambulatory healthcare establishments (n = 9,739 - 36.0%), followed by primary care (n=6,815 - 25.2%). Non-health professionals (such as social workers and postmen) enrolled 20.3% of participants (n= 5,512) and finally, 11.8% (n = 3,197) of participants were enrolled following self-assessment. Table 1 presents the results at Step 1. The average age of the population was 76.1 years +/- 8.9 and they were predominantly women. Nine out of ten participants had a positive screening for a potentially altered IC domain, most of them with two IC domains. More than half of the participants screened positive for potential declines in cognition (54.5% - 14,757) and hearing capacity (50.5% - 13,673), generating an alert in the digital system. Among those who screened positive for cognition, 28.1% made a mistake in time orientation and/or recall of 3 words; among those who screened positive for hearing, 29.1% presented a recent decline and 22.5% presented a recent decline in vision. Regarding mobility, 17.7% of older adults had an extended chair-raise time. In this study, 3,266 (12.1%) participants prematurely stopped the ICOPE program within the first year of follow up. The primary reason for leaving the program was a request by the participant, in the case of 1,114 participants (34.1%). Other reasons included a decline in health status (24.2% - n=789); death intervened for 253 participants (7.7%) and "unknown reason" for 321 participants (9.8%).
- *Identifying differences across assessors HCP, non-HCP and self:* Table 1 presents these differences. The participants who completed the self-assessment are significantly younger (70.9 years for self-assessment group versus 76.4 for HCP group or 77.9 for non-HCP group, p<0.01) and less frequently had alerts in Step 1 (83.8% for self-assessment group versus 90.8 for HCP group or 94.8 for non-HCP group, p<0.01), both overall and for each specific domain. The results for people identified by HCP and non-HCP were similar, except in the domains of cognition and mobility, where those identified by non-HCP showed more impairments (61.7% for HCP group versus 54.8% for non-HCP group for cognition and 38.6% for HCP group versus 33.3% for non-HCP group for mobility). Results from Step 2 showed that participants in the self-assessment cohort have fewer medications (mean 3.9+/-3.1 for self-assessment group versus 4.1+/-3.1 for HCP group and 4.6+/-3.3 for non-HCP group, p=0.008) but more comorbidities (median and IQR =3 (2 - 4) for self-assessment group versus 2(1 - 3) for HCP group and 2 (1 - 3) for non-HCP group). The self-assessment group has better physical performances to the SPPB (median and IQR = 11 (10 - 12) for self-assessment group versus 10(8 - 12) for HCP group and 10 (7 - 12) for non-HCP group) compared to participants enrolled by HCPs or non-health professionals.

2. Follow-up and assessments visits for people with abnormal alerts

- Management of alerts: For self-assessment participants (n=3,197 - 11.8%), a total of 2,680 (83.8%) alerts were generated. Based on decision-making algorithms (see eFigure 1), 37.1% of alerts required contact with the participants. Of these alerts, 6.1% (n=194) were false alerts due to participants' mistakes when performing the Step 1 screening test. The areas requiring the most calls to participants were the nutrition (40.1% of nutrition alerts) and cognition (38.4% of cognition alerts) domains, followed by hearing (37.3% of hearing alerts) and psychological (37.0% of psychological alerts). A phone call was made to the GP in addition for 10% (n=268) of alerts. Currently, 2,414 Step 2 (8.9% of the total cohort) assessments are
registered in the ICOPE Monitor database. In most cases, a Step 2 is performed when at least
two IC domains were positive on step 1 screening. The IC domains that most often led to a
Step 2 assessment were cognition and mood. Step 2 assessments were conducted on the same
day as the altered Step 1 in half of the cases.

- Step 2: Table 2 summarizes the results from Step 2, providing a deeper assessment. Half of the sample undergoing Step 2 presented a "pre-frail" status based on Fried's criteria (n=1,034 – 49.0%). Nearly half lived alone at home (n=1,081 – 44.8%). Most of the participants were cognitively unimpaired (MMSE, mean: 25.5+/-3.9) but exhibited mild depressive symptoms (PHQ-9, median and IQR: 5(2 – 9)) alongside satisfactory physical performance (SPPB, median and IQR: 10(7 – 12)) and nutritional status (MNA, mean: 25.0+/-3.7). Approximately 20% of the population had impaired distance (n=206 – 16.2%) and/or near vision (n=247 – 19.3%) requiring treatment. Overall, hearing remained intact, with few complaints reported in HHIE-S (median and IQR: 4(0 – 10).

3. Recommendations in the personalized care plan

The recommendations that were issued extended to all six IC domains (see Table 3). In total, at least one recommendation was made in respect of 97% of older adults who reached Step 2 and 3. For cognition, lifestyle advice and cognitive stimulation exercises were recommended in 42.5% of cases, followed by referral for a memory consultation for 23% of participants. Additionally, older adults were encouraged to participate in stimulation and cognitive workshops in 10.4% of cases. Regarding the psychological domain, the main advice given to older adults related to maintaining social ties and preventing loneliness, while a minority of participants (11.2%) were referred to health professionals, especially psychologists. Recommendations for the mobility domain mainly involved doing appropriate physical activity in the case of 33.7% of older adults. Lastly, advice on appropriate nutrition and maintaining physical performance was provided in almost one fifth of cases. In terms of
nutrition, reminders on appropriate nutrition and general advice were included in more than
half of the care plans. Weight monitoring was recommended for 28.6% of older adults, and
8.6% were referred for dental care. Regarding sensory areas, participants were mainly
referred to an ophthalmologist, an Ear, Nose and Throat (ENT) specialist or a hearing aid
adviser.

Discussion

In the aim of describe the characteristics of people completing the ICOPE screener, this study showed that most of participants in ICOPE MONITOR were enrolled by HCPs using smartphone app. Ninety percent of participants had a positive screening. Regarding the differences across assessors (HCP, non-HCP or self-assessment), the participants who completed the self-test were significantly younger and in better health than the others. To describe the characteristics of follow-up and assessments visits for people with abnormal screening test, 37.1% of alerts required contact with participants and a step 2 was carried out when at least 2 IC domains were positive on step 1 screening. Half of the participants presented a pre-frail status at the step 2 assessment. Finally, in the aim of describing the recommendations in the intervention care plans for people with a decline in IC, this study showed that recommendations proposed concerned all IC domains, mainly for mobility and nutrition.

The enrollment of older adults in ICOPE monitor allows for a comprehensive
prevention program against loss of autonomy. The ICOPE program helps identify frail and
pre-frail older individuals living alone who might otherwise not be identified, so they can be
offered preventive measures as well as personalized proposals for care or support. Step 1 is a
screening tool with high sensitivity and requires optimization to minimize false positives
because currently, decision algorithms with additional questions are employed to discern true
positives. Where Step 1 indicates some degree of impairment, these algorithms facilitate alert sorting, achieving a reasonable Step 2 assessment rate in primary care. The IC domains most frequently associated with a Step 2 assessment were cognition and psychology and any decline in these domains often leads to anxiety, and necessitates specific care as they frequently interact with each other³. Conversely, impairments in sensory capacities, such as vision and hearing, typically result in participants being directly referred to a specialist straight after Step 1. Furthermore, prevention advices were provided to participants who did not require an in-depth Step 2 assessment, whether though the ICOPE MONITOR app for self-assessment at Step 1 or face to face by professionals. Regarding personalized care plans, recommendations in Step 3 largely consisted of advices and elements for self-management mainly concerning cognition, psychological function, and mobility, fostering a participatory approach to medicine where older adults take an active role in managing their health.

**This study provides an overview of the initial results from a large-scale real-world implementation.** In France, the substantial number of participants is the result of large-scale initiatives involving multiple stakeholders, including the government, healthcare and non-healthcare professionals, proxies and older adults themselves. Comparing to our previous paper¹⁰, the profile of participants is slowly changing. The proportion of robust individuals at step 2 has increased from 15.8% to 23.6%, aligning with the program's objective of engaging older adults as early as possible, even during the stage when they are still in robust health². Our research is less exhaustive than it might be, because of real-world limitations arising from implementation in clinical practice rather than with a specific research cohort. As the digital tools evolve this should enable better data collection, including data on the implementation of the Step 3 recommendations. Another limitation on this study is the absence of a control group to measure the program's effectiveness in preventing participants from losing their independence. This is explained by our objective of implementing the
program with real-world data in routine clinical practice. By way of response to this, an
interventional randomized clinical comparative trial will be soon conducted, which will
provide comprehensive data and assess the program's effectiveness in preventing entry into
dependency. However, real-world data collection allows for the immediate assessment of
obstacles and potential solutions for implementing the ICOPE program. As a result,
corrective actions can be considered much more quickly. Implementation is gradually
becoming more comprehensive through the ongoing national prevention project, and by
adapting digital tools to the needs of healthcare professionals.

**The implementation of the program must evolve to allow for its broad development in routine clinical practice.** One key feature of the ICOPE Monitor program is its alert management process. However, new strategies are required to enhance efficiency and performance in this alert management process. Several potential approaches could be considered, including revising the decision-making algorithms to reduce the occurrence of false or irrelevant alerts, and providing training to non-HCPs in alert management to address the current shortage of HCPs. A key strength of the ICOPE Monitor program is that it was implemented from the beginning by offering a comprehensive prevention pathway covering all steps of the WHO ICOPE program. In France, the development of the program at national level has resulted in an expansion of the cohort to various territories, enhancing the representation of the general population. To date, more than 50,000 people have been enrolled in the ICOPE MONITOR program in France, attesting to its large-scale development.

All healthcare professionals, from primary care to hospital units, are confronted with the
challenge of integrating IC into their routine practice using digital tools to enable continuous
monitoring over time, thereby having a tangible impact on healthy aging. Step 1 can be
completed in about 10 minutes, making it easy to implement in clinical practice. The
compensation of professionals conducting STEP 1 is a facilitator for the deployment of the program. We recently published a method to establish age-specific and sex-specific reference centiles for IC, enabling HCPs to measure the IC centile of older adults. This method also makes it possible to place older adults in various functional categories based on their own IC centile, and to identify older adults at high risk of adverse outcomes²⁰.

In conclusion, after three years of implementation, we can recommend targeting a population of adults aged 60 years and older who are independent in activities of daily living, ranging from the most robust to those with "frail" status. Given the challenges HCPs face in implementing all the ICOPE steps in their daily clinical practice, we recommend beginning by implementing Step 1 and alert management. If an alert is confirmed, patients should be referred to their GP, to a trained Step 2 HCP, or to a geriatric team for further assessment. Only then it will be easier to implement the entire ICOPE pathway. The ICOPE program, with its element of integrated care²¹, makes it possible to organize formal structured pathways based on the needs identified during the assessments. HCP responsibility is to alert older adults to a potential decline in IC and to assist them in order to regain the step above, or at least prevent further decline. ICOPE Monitor is one of the keys to achieving healthy longevity.
## Funding

This work was performed in the context of the IHU HealthAge, which received funding from the Agence Nationale de la Recherche as part of the France 2030 program (reference number: ANR-23-IAHU-0011). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

The ICOPE-Care program was supported by grants from the Occitanie Regional Health Agency(Region Occitanie and Pyrénées-Méditerranée; reference number 1901175), ICOPE National Experimentation- Article 51 (Ministry of Solidarity and Health - Order of July 19, 2022 - NOR : SPRS2221913A), the European Regional Development Fund (project number MP0022856) and The Interreg Program V-A Spain-France-Andorra (European Union) in the context of the APTITUDE (EFA232/16) and the APTITUDE-PROXI (EFA018/01) projects.

## Acknowledgments

We thank all the health-care professionals who participated in the ICOPE Care program; the members of the Gerontopole of Toulouse especially those of the “Regional Team for Ageing and Prevention of Dependency” (Fanny Paris, Brune Rieunier, Alessia Robert-Millocco) and the “ICOPE remote monitoring platform” (Laure Aldebert, Pascale Baby, Laure Bouchon, Marie Christine Cazes, Florence Da Costa, Magali Poly, Charlene Seguela, Lay-Nien Sephan); all the members of the Occitanie Territorial Teams of Ageing and Prevention of Dependency; and the project leaders of National Experimentation - Article 51 (Mutualité Française PACA, DAC Sante landes, Inter-CPTS Haut-Rhin, CPTS Haute-Corrèze, Perigueux University Hospital, Filieris Sud, Civic Hospitals of Lyon, CPTS Grand Sud Réunion, InterURPS Pay de la Loire, CPTS Cerebellum, DAC 17, DAC 46, Clinique des Augustines, Brest University Hospital, Mutualité Française Bretagne).
**Declaration of interests:** The authors have no conflicts of interests.

Personal data was collected and processed to analyze the results of the research. Toulouse University Hospital signed an undertaking to comply with the baseline methodology MR-004 from CNIL, the French national commission for data processing and liberties. After evaluation and validation by the data protection officer, and in accordance with the General Data Protection Regulation*, this study satisfying all the criteria, it was recorded in the register of data for studies by Toulouse University Hospital (registration no: RnIPH 2023-122) and for the purposes of MR-004 (CNIL number: 2206723 v 0).
Bibliography

1. World Health Organization. Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity [Internet]. Geneva: World Health Organization; 2017. Accessed on March 16th 2022. Available from: https://apps.who.int/iris/handle/10665/258981

2. World Health Organization. Integrated care for older people: guidelines on community-level interventions to manage declines in intrinsic capacity [Internet]. Geneva: World Health Organization; 2017. Accessed on March 16th 2022. Available from: https://apps.who.int/iris/handle/10665/258981

3. Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001;56(3):M146-M157. doi:10.1093/gerona/56.3.M146

4. Gleason LJ, Benton EA, Alvarez-Nebreda ML, Weaver MJ, Harris MB, Javedan H. FRAIL Questionnaire Screening Tool and Short-Term Outcomes in Geriatric Fracture Patients. J Am Med Dir Assoc. 2017;18(12):1082-1086. doi:10.1016/j.jamda.2017.07.005

5. Sum G, Lau LK, Jabbar KA, et al. The World Health Organization (WHO) Integrated Care for Older People (ICOPE) Framework: A Narrative Review on Its Adoption Worldwide and Lessons Learnt. Int J Environ Res Public Health. 2022;20(1):154. doi:10.3390/ijerph20010154

6. Ma L, Chhetri JK, Zhang Y, et al. Integrated Care for Older People Screening Tool for Measuring Intrinsic Capacity: Preliminary Findings From ICOPE Pilot in China. Frontiers in Medicine. 2020;7:852. doi:10.3389/fmed.2020.576079
7. Won CW, Ha E, Jeong E, et al. World Health Organization Integrated Care for Older People (ICOPE) and the Integrated Care of Older Patients with Frailty in Primary Care (ICOOP_Frail) Study in Korea. Ann Geriatr Med Res. 2021;25(1):10-16. doi:10.4235/agmr.21.0025

8. Mathur A, Bhardwaj P, Joshi NK, Jain YK, Singh K. Intrinsic Capacity of Rural Elderly in Thar Desert using WHO ICOPE (Integrated Care for Older Persons) Screening Tool: A Pilot Study. Published online February 5, 2022:2022.02.04.22270231. doi:10.1101/2022.02.04.22270231

9. Ferriolli E, Lourenço RA, Oliveira VP de, Mello RGB de, Ferretti-Rebustini RE de L, Filho WJ. Project ICOPE Brazil: a study on the intrinsic capacity of Brazilian older adults and accuracy of the screening tool proposed by the World Health Organization. Geriatrics, Gerontology and Aging. 2023;17(0):1-3. doi:10.53886/gga.e0230003

10. Tavassoli N, Barreto P de S, Berbon C, et al. Implementation of the WHO integrated care for older people (ICOPE) programme in clinical practice: a prospective study. The Lancet Healthy Longevity. 2022;3(6):e394-e404. doi:10.1016/S2666-7568(22)00097-6

11. Tavassoli N, Piau A, Berbon C, et al. Framework Implementation of the INSPIRE ICOPE-CARE Program in Collaboration with the World Health Organization (WHO) in the Occitania Region. J Frailty Aging. 2021;10(2):103-109. doi:10.14283/jfa.2020.26

12. Katz S, B. Ford A, W. Moskowitz R, A. Jackson B, W. Jaffe M. Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A. & Jaffe, M. W. Studies of illness in the aged. The Index of ADL: a standardized measure of biological and psychosocial function. JAMA 185, 914-919. JAMA. 1963;185:914-919. doi:10.1001/jama.1963.03060120024016
13. KALAFAT M, HUGONOT-DIENER L, POITRENAUD J. Standardisation et étalonnage français du Mini Mental State (MMS) version GRÉCO. Rev neuropsychol (Marseille). 2003;13(2):209-236.

14. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x

15. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2):M85-94.

16. Fried LP, Tangen CM, Walston J, et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2001;56(3):M146-M157. doi:10.1093/gerona/56.3.M146

17. Graf C. The Lawton instrumental activities of daily living scale. Am J Nurs. 2008;108(4):52-62; quiz 62-63. doi:10.1097/01.NAJ.0000314810.46029.74

18. Lilamand M, Kelaiditi E, Cesari M, et al. Validation of the Mini Nutritional Assessment-Short Form in a Population of Frail Elders without Disability. Analysis of the Toulouse Frailty Platform Population in 2013. J Nutr Health Aging. 2015;19(5):570-574. doi:10.1007/s12603-015-0457-4

19. Duchêne J, Billiet L, Franco V, Bonnard D. Validation de la version française du questionnaire HHIE-S (Hearing Handicap Inventory for the Elderly – Screening) chez l'adulte de plus de 60 ans. Annales françaises d'Oto-rhino-laryngologie et de Pathologie Cervico-faciale. 2022;139(4):198-202. doi:10.1016/j.aforl.2020.11.012
20. Lu WH, Rolland Y, Guyonnet S, de Souto Barreto P, Vellas B. Reference centiles for intrinsic capacity throughout adulthood and their association with clinical outcomes: a cross-sectional analysis from the INSPIRE-T cohort. Nat Aging. 2023;3(12):1521-1528. doi:10.1038/s43587-023-00522-x

21. Goodwin N. Understanding Integrated Care. International Journal of Integrated Care. 2016;16(4):6. doi:10.5334/ijic.2530
<table><caption>Table 1: Description of Step 1 ICOPE (N=27,082) and comparison of results between participants enrolled by HCPs, non-health professionals and self-assessment</caption><thead><tr><th></th><th>All<br>participants<br>(N=27,082)</th><th>HCP<br>registered<br>(N=18,373)</th><th>Non-health<br>professional<br>(N=5,512)</th><th>Self-<br>assessment<br>(N=3,197)</th><th>p</th></tr></thead><tbody><tr><td>Age in years*</td><td>76.1 ± 8.9</td><td>76.4 ± 9.0</td><td>77.9 ± 8.5</td><td>70.9 ± 7.3</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Female</td><td><strong>16,746 (61.8)</strong></td><td>11,465 (62.4)</td><td>3,421 (62.1)</td><td>1,860 (58.2)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Step 1 positive screening, yes</td><td><strong>24,586 (90.8)</strong></td><td>16,680 (90.8)</td><td>5,226 (94.8)</td><td>2,680 (83.8)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Number of alerts per subject**</td><td><strong>2 (1 - 3)</strong></td><td>2 (1 - 4)</td><td>3 (2 - 4)</td><td>2 (1 - 3)</td><td><strong>0.0001</strong></td></tr><tr><td>Cognitive alert, yes</td><td><strong>14,757 (54.5)</strong></td><td>10,073 (54.8)</td><td>3,400 (61.7)</td><td>1,284 (40.2)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Cognitive alerts defined by a mistake<br>in time and/or recall of the 3 words</td><td><strong>7,623 (28.1)</strong></td><td>5,335 (29.0)</td><td>1,698 (30.8)</td><td>590 (18.5)</td><td></td></tr><tr><td>Step 1</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Psychological alert, yes</td><td><strong>10,465 (38.6)</strong></td><td>7,220 (39.3)</td><td>2,257 (41.0)</td><td>988 (30.9)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Mobility alert, yes</td><td><strong>8,873 (32.8)</strong></td><td>6,112 (33.3)</td><td>2,129 (38.6)</td><td>632 (19.8)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Nutritional alert, yes</td><td><strong>5,403 (20.0)</strong></td><td>3,928 (21.4)</td><td>1,193 (21.6)</td><td>282 (8.8)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Vision alert, yes</td><td><strong>13,238 (48.9)</strong></td><td>8,751 (47.6)</td><td>2,891 (52.5)</td><td>1,596 (49.9)</td><td><strong>&lt;0.01</strong></td></tr></tbody></table>
<table><tbody><tr><td>Visual alerts with recent decrease</td><td><strong>6,096 (22.5)</strong></td><td>4,150 (22.6)</td><td>968 (17.6)</td><td>978 (30.6)</td></tr><tr><td>(1)</td><td></td><td></td><td></td><td></td></tr><tr><td>Hearing alert, yes</td><td><strong>13,673 (50.5)</strong></td><td>9,575 (52.1)</td><td>2,977 (54.0)</td><td>1,121 (35.1)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Hearing alerts with recent decrease</td><td><strong>7,884 (29.1)</strong></td><td>5,573 (30.3)</td><td>1,194 (21.7)</td><td>1,117 (34.9)</td></tr><tr><td>(1)</td><td></td><td></td><td></td><td></td></tr><tr><td>5-Chair rise test in seconds (Mean time) *</td><td><strong>12.8 ± 5.6</strong></td><td>12.9 ± 5.9</td><td>13.0 ± 5.5</td><td>11.9 ± 3.6</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Slow chair rise (2), yes</td><td><strong>4,793 (17.7)</strong></td><td>3,334 (18.1)</td><td>576 (17.8)</td><td>480 (15.0)</td></tr></tbody></table>

*Data is presented by mean +/-SD; ** median (p25-p75) otherwise n (%),

(1) recent decrease means occurring within the last 6 months

(2) increased chair rise means that the completion time is over 14 seconds for participants under 80 years old and over 16 seconds for participants over 80 years old

Positive alerts are defined in Figure 1

Table 1
<table><caption>Table 2: Description of Step 2 ICOPE (N=2,414)
and comparison of Step 2 results according to their mode of enrollment (by HCP, non-health professional and self-assessment)</caption><thead><tr><th></th><th></th><th>All<br>participants<br>(N=2,414)</th><th>HCP<br>registered<br>(N=1,933)</th><th>Non-health<br>professional<br>(N=446)</th><th>Self-<br>assessment<br>(N=35)</th><th>P</th></tr></thead><tbody><tr><td>Number of comorbidities</td><td></td><td>2 (1-3)</td><td>2 (1-3)</td><td>2 (1-3)</td><td>3 (2-4)</td><td><strong>0.0001</strong></td></tr><tr><td>Number of medications</td><td></td><td>4.2 ± 3.2</td><td>4.1+/-3.1</td><td>4.6+/-3.3</td><td>3.9+/-3.1</td><td><strong>0.008</strong></td></tr><tr><td>Living alone</td><td></td><td>1,081 (44.8)</td><td>857 (44.3)</td><td>207 (46.4)</td><td>17 (48.6)</td><td>0.7</td></tr><tr><td>Presence of home caregivers, yes</td><td></td><td>1,029 (42.6)</td><td>781 (41.0)</td><td>232 (52.4)</td><td>16 (47.1)</td><td><strong>&lt;0.01</strong></td></tr><tr><td>Cognition</td><td>MMSE N= 1,879</td><td>25.5 ± 3.9</td><td>25.3 ± 3.9</td><td>25.9 ± 3.9</td><td>27.3 ± 3.2</td><td>0.3</td></tr><tr><td>Psychology</td><td>PHQ-9 N=1,306</td><td>5 (2-9)</td><td>5 (2-9)</td><td>4 (1-8)</td><td>6 (2-10)</td><td><strong>0.01</strong></td></tr><tr><td></td><td>SPPB N=2,071</td><td>10 (7-12)</td><td>10 (8-12)</td><td>10 (7-12)</td><td>11 (10-12)</td><td><strong>0.02</strong></td></tr><tr><td></td><td>Fried score N= 2,110</td><td>2 (1-3)</td><td>2 (1-3)</td><td>2 (1-3)</td><td>1 (0-2)</td><td>0.08</td></tr><tr><td rowspan="3">Mobility</td><td>Fried score status<br>N=2,110</td><td>robust</td><td>498 (23.6)</td><td>393 (28.9)</td><td>95 (21.9)</td><td>10 (33.3)</td><td rowspan="3">0.09</td></tr><tr><td>pre-frail</td><td>1,034 (49.0)</td><td>789 (47.9)</td><td>228 (52.7)</td><td>17 (56.7)</td></tr><tr><td>Frail</td><td>578 (27.4)</td><td>465 (28.2)</td><td>110 (25.4)</td><td>3 (10.0)</td></tr></tbody></table>
<table><thead><tr><th></th><th>IADL</th><th>8 (6-8)</th><th>8 (6-8)</th><th>8 (6-8)</th><th>8 (8-8)</th><th>0.02</th></tr></thead><tbody><tr><td></td><td>BMI in kg/m²</td><td>26.0 ± 5.0</td><td>26.1 ± 5.0</td><td>25.8 ± 4.9</td><td>24.7 ± 3.8</td><td>0.1</td></tr><tr><td></td><td>MNA</td><td>25.0 ± 3.7</td><td>24.9 ± 3.9</td><td>25.1 ± 3.3</td><td>25.2 ± 3.0</td><td>0.9</td></tr><tr><td rowspan="3">Nutrition</td><td>normal</td><td>1,388 (71.7)</td><td>1,046 (70.6)</td><td>325 (76.3)</td><td>17 (60.7)</td><td rowspan="3">0.006</td></tr><tr><td>at risk</td><td>472 (24.4)</td><td>367 (24.7)</td><td>94 (22.1)</td><td>11 (39.3)</td></tr><tr><td>malnutrition</td><td>76 (3.9)</td><td>69 (4.7)</td><td>7 (1.6)</td><td>0</td></tr><tr><td rowspan="2">Vision</td><td>Distant vision, abnormal N=1,271</td><td>206 (16.2)</td><td>179 (17.2)</td><td>26 (12.0)</td><td>1 (6.3)</td><td>0.1</td></tr><tr><td>Near vision, abnormal N=1,277</td><td>247 (19.3)</td><td>218 (20.9)</td><td>27 (12.5)</td><td>2 (12.5)</td><td>0.01</td></tr><tr><td>Hearing</td><td>HHIE-S N= 1,122</td><td>4 (0-10)</td><td>4 (0-12)</td><td>2 (0-8)</td><td>4 (0-12)</td><td>0.001</td></tr></tbody></table>

Data is presented by mean +/-SD or n(%) or median (p25-p75)

MMSE: Mini-Mental Status Examination (from 0 to 30), Phq-9: Patient Health Questionnaire-9 (from 0 to 27), SPPB: Short Physical Performance Battery (from 0 to 12), Fried score from 0 to 5 (0 = not frail; 1 – 2 pre-frail; 3 or more frail), IADL: Lawton Instrumental Activity of Daily Living score (from 0 to 8), MNA: Mini Nutritional Assessment (from 0 to 30. Normal status from 24 to 30; at risk from 17 to 23.5; and malnutrition for MNA under 17), BMI: Body Mass Index, HHIE-S: Hearing Handicap Inventory for the Elderly (from 0 to 40)

<caption>Table 2</caption>
<table><caption>Table 3: Recommendations at Step 3 (N=2,414)</caption><thead><tr><th></th><th></th><th>N (%)</th></tr></thead><tbody><tr><td rowspan="3">Cognition</td><td>Advice/cognitive stimulation</td><td>1,025 (42.5)</td></tr><tr><td>Referral for memory consultation</td><td>554 (23.0)</td></tr><tr><td>Memory workshops</td><td>250 (10.4)</td></tr><tr><td rowspan="2">Psychology</td><td>Advice /information on social ties</td><td>668 (27.6)</td></tr><tr><td>Psychologist</td><td>271 (11.2)</td></tr><tr><td rowspan="3">Mobility</td><td>Physical activity</td><td>813 (33.7)</td></tr><tr><td>Physiotherapy</td><td>717 (29.7)</td></tr><tr><td>Specific nutritional advice to maintain mobility: protein intake</td><td>584 (24.2)</td></tr><tr><td rowspan="3">Nutrition</td><td>Advices / reminders on recommendations</td><td>1,233 (51.2)</td></tr><tr><td>Weight monitoring</td><td>666 (27.6)</td></tr><tr><td>Dental care</td><td>207 (8.6)</td></tr><tr><td rowspan="2">Vision</td><td>Ophthalmologist</td><td>666 (27.6)</td></tr><tr><td>Eye care</td><td>196 (8.1)</td></tr><tr><td rowspan="3">Audition</td><td>ENT (Ear Nose and Throat) specialist</td><td>503 (20.8)</td></tr><tr><td>Hearing aid adviser</td><td>261 (10.8)</td></tr><tr><td>Ear care</td><td>253 (10.5)</td></tr></tbody></table>

<caption>Table 3</caption>
Figure 1: ICOPE Monitor Step 1 algorithm leading to automatic alert generation in the ICOPE data base

Figure 2: Flowchart of the study population
<figure><img src="image_3.png" /><figcaption>Figure 1: ICOPE Monitor Step1 algorithm leading to an automatic alert generation in the ICOPE data base</figcaption></figure>

<figure><img src="image_4.png" /></figure>
<figure><img src="image_5.png" /><figcaption>Figure 2: Flowchart of the studied population</figcaption></figure>

<figure><img src="image_6.png" /></figure>