Optimizing INtrinsic Capacity for Functional INdependence and to Impede FrailTY in Older Adults: Adaptation of the WHO-ICOPE for Healthy Ageing in Singapore

Optimizing INtrinsic Capacity for Functional INdependence and to Impede FrailTY in Older Adults: Adaptation of the WHO-ICOPE for Healthy Ageing in Singapore

The goal of this intervention study is to screen and identify frailty and decline in intrinsic capacity (physical and mental capacities) in community-dwelling older adults in Singapore, and to evaluate whether early identification and targeted interventions can improve health outcomes and support healthy ageing. The main questions it aims to answer are:

• Can combined frailty and intrinsic capacity screening with targeted interventions prevent or reduce functional decline in older adults, as measured by changes in life space mobility?
• Will at least 80% of screened older adults adhere to recommended care pathways and interventions?
• Can this screening and intervention programme demonstrate sustainability through continued community participation and recruitment of new partner organizations beyond the initial implementation phase? The investigators will compare an intervention group (receiving immediate assessment and clinical referrals based on identified needs) to a wait-list control group (receiving the same interventions 12 months later) to see if early intervention leads to better health outcomes and quality of life.

Participants will:

• Attend 4 study visits over 2 years (at 6-monthly intervals in the first year, with final assessment at end of year 2), each lasting up to 2 hours.
• Undergo comprehensive screening assessments including mobility, cognition, mental health, hearing, vision, and nutritional status.
• Receive 2 follow-up phone calls at 3-month and 9-month intervals to monitor progress.
• If in the intervention group: receive personalized referrals for further care (which may include comprehensive geriatric assessment, primary care reviews, rehabilitation, or dietitian consultations) and guidance on using a mobile health monitoring application.
• If in the wait-list control group: receive the same interventions after their 3rd study visit (12 months later).

The INFINITY-ICOPE programme integrates the concepts of frailty and intrinsic capacity - a person's physical and mental abilities essential for maintaining overall health and well-being. Since intrinsic capacity represents the physiological reserves whose decline can lead to frailty, monitoring intrinsic capacity trajectories enables timely intervention to address deteriorating physical and mental capacities. The programmme employs a tiered approach to provide comprehensive geriatric assessment for frail older adults, utilizing technology-enabled tools including the SCREENii algorithmic approach for objective physical frailty assessment and the ENGAGE app to empower older individuals through self-screening, remote intrinsic capacity monitoring, and behavioural nudges.

The investigators primary aim is maintaining older adults' independence and community engagement, measured through life-space mobility. Secondary aims encompass promoting regular screening for frailty and intrinsic capacity decline, implementing early intervention strategies, enhancing quality of life, and developing a cost-effective healthcare delivery model. INFINITY-ICOPE follows the implementation research logic model to ensure rigorous and replicable research. The study comprises 4 phases:

1. Phase 1 (Proof-of-Concept) - 12 months. This preparatory phase focuses on 3 key areas: technology readiness, care pathway development, and stakeholder readiness assessment.

   • Technology development: The SCREENii platform will be enhanced to provide automated frailty screening through grip strength and gait speed measurements. The ENGAGE app will incorporate WHO-ICOPE Step 1 screening and deliver personalized care plans adapted for local needs.
   • Care pathway development: Personalized pathways will be developed for frailty management through regional hospital networks and intrinsic capacity domain-specific interventions based on WHO-ICOPE guidelines. Community assessors will receive training in Step 1 screening and individualized care planning, with 400 older adults recruited to test feasibility and assess intrinsic capacity decline prevalence.
   • Readiness assessment: Surveys and focus group discussions will evaluate attitudes and expectations of multidisciplinary care providers (eldercare staff, community nurses, family physicians, social workers) towards INFINITY-ICOPE implementation. Additional focus groups with 30 trained community assessors will capture their screening experiences. Usability testing with 15 older adults will assess SCREENii completion times and ENGAGE app quality using the mobile app rating scale. This phase will inform resource planning for Phase 2 and refine implementation strategies based on identified barriers and enablers.

2. Phase 2 (Proof-of-Value) - 12 months. This single-arm pre-post pilot study will evaluate INFINITY-ICOPE's potential impact by recruiting 60 older adults (aged 60 and above) from an existing mobile frailty screening platform, termed Individual Physical Performance Test for Seniors (IPPT-S). The multi-domain geriatric screening and comprehensive fitness battery will validate SCREENii plus ICOPE Step 1 for stratifying participants by frailty and intrinsic capacity decline.

3. Phase 3 (Testing-bed) - 30 months. This study employs a pragmatic controlled design with 540 older adults across 8 eldercare and/or active ageing centres within SingHealth zones. Intervention design: The INFINITY-ICOPE programme includes integrated frailty and intrinsic capacity screening, targeted referrals based on stratification, and 6-monthly self-monitoring via ENGAGE app and SCREENii. Participants are stratified into 3 groups post-screening: (a) Frail (regardless of intrinsic capacity status); (b) Non-frail with declining intrinsic capacity; and (c) Non-frail with intact intrinsic capacity.

   Targeted interventions: Frail participants (Fried score of 3 and above) receive comprehensive geriatric assessment at geriatric specialty hubs, whilst non-frail participants with intrinsic capacity decline undergo Steps 2 to 3 assessments at Community Health Posts with personalized interventions. All intervention participants receive ENGAGE app notifications including appointment reminders, lifestyle nudges, and screening prompts. Additional cognitive assessment via Cognify (30-minute automated battery) validated cognitive screening for enhanced stratification. Control group: Continues usual activities with wait-list access to INFINITYICOPE after 12-month outcomes assessment, enabling centres to scale the programme as standard care. Data collection: Comprehensive measures collected at 6-monthly intervals include socio-demographics, frailty / sarcopenia / intrinsic capacity status, medical comorbidities, functional performance, cognitive / mood assessments, quality of life, and intervention adherence, emphasizing both clinical and implementation effectiveness for sustainability evaluation.

4. Phase 4 (Scale-up) - 6 months. This phase focuses on programme evaluation and scaling preparation without recruiting new participants. Activities centre on completing Phase 3 follow-ups, comprehensive data analysis, and sustainability assessment.

Inclusion Criteria: (in Phases 1, 2 and 3):

• Any Singaporean or Permanent Resident (PR) aged 60 years and above
• Able to provide informed consent (or legally acceptable representative available)

Exclusion Criteria (in Phases 1, 2 and 3):

• Non-Singaporeans or non-PRs under 60 years of age
• Residents of sheltered or nursing homes