J Nutr Health Aging.

2020;
© Serdi and Springer-Verlag International SAS, part of Springer Nature

IN THE QUEST OF A STANDARD INDEX OF INTRINSIC CAPACITY.

A CRITICAL LITERATURE REVIEW
E. GONZALEZ-BAUTISTA1,2, S. ANDRIEU2,3, L.M. GUTIÉRREZ-ROBLEDO4,
R.E. GARCÍA-CHANES4, P. DE SOUTO BARRETO1,2
1. Gerontopole of Toulouse, Institute of Ageing, CHU Toulouse, Toulouse, France; 2. INSERM/UPS UMR 1027, University of Toulouse III, Toulouse, France; 3. Department of
Epidemiology and Public Health, CHU Toulouse, Toulouse, France; 4. National Institute of Geriatrics Mexico, Mexico. Corresponding author: Emmanuel Gonzalez-Bautista, Université
Fédérale Toulouse Midi-Pyrénées, France, emmanuel.scout@gmail.com

Abstract: Objectives: Intrinsic capacity is a composite of five domains that summarizes the physical and mental
capacities of an individual. Intrinsic capacity is increasing in relevance for adapting health systems to population
ageing. Therefore, our objective was to analyse how intrinsic capacity has been assessed in older adults and
if these measurements have been validated, as an initial step towards the construction of a standard intrinsic
capacity index. Design: Narrative review with electronic searches performed in PubMed and Cochrane databases,
including the studies which used the term “intrinsic capacity” in the context of human ageing and health. The
full text was then accessed to select studies with at least one operationalised domain of intrinsic capacity. We
also looked for information on the validity and reliability of the reported measures of intrinsic capacity. Results:
We included ten articles reporting a quantitative measurement of intrinsic capacity. There were two intrinsic
capacity scores which combined retrospective data on the intrinsic capacity domains sub-scores, with low
concordance among tests chosen to measure each domain. Two studies reported on reliability and validity of
the IC scores. The main gaps in the construction and validation process were a) analysis undertaken with each
domain separately rather than for the construct of intrinsic capacity, b) lack of a clear conceptual and operational
definition of the vitality domain, c) summary score that depends upon the distribution of the study sample.
Conclusion: Further validation of the intrinsic capacity concept is needed, together with more robust approaches
to measure it. A standard index of IC has not been validated for translation into clinical or research purposes.

Key words: Healthy ageing, physical function, index validation, intrinsic capacity.

Abbreviations: AD: Alzheimer’s Disease; ADLs: Activities of daily life; FA: Functional ability; IC: Intrinsic
capacity; IHME: Institute for Health Metrics and Evaluation; NCD: Non-communicable disease; QOL: Quality of
life; ROC: Receiver operator characteristic; SEM: Structural equation modelling; SRH: Self-rated health; WHO:
World Health Organization.

Background After undertaking experts’ meetings, consultation with

stakeholders, literature reviews and empirical pilot studies (7),
Intrinsic capacity (IC), as the composite of the physical and the WHO proposed that the IC construct was composed of five
mental capacities of an individual, is one of a few operational domains, namely cognition, locomotion, sensorial (vision and
indicators of health aimed at measuring the capacities –rather hearing), psychology and vitality. Nevertheless, a consensus is
than deficits- of multiple human biological systems based in lacking about a standard manner to operationalise an IC score
the body functions most relevant for healthy ageing (1, 2). in research as well as in clinical settings. There are already
The conceptual roots of the IC can be traced to the health- tests widely used to measure the intrinsic capacity domains
capability concept in line with the capabilities approach (3, 4). separately (8–10), but the way to transform spare functionality
Intrinsic capacity, the environment and the interaction between scores into an IC index deserves further discussion.
them explain the different levels of functional ability in older The construction of a standard measurement scale for IC is
adults, according to the healthy ageing framework of the World incipient (11). With the increase of the older adult population
Health Organisation (WHO) (5). The framework advocates worldwide, in particular regarding people 80 or over who are at
for a change from a disease-centred paradigm to a person- increased risk for care dependency (12), having a standardised,
health-function-centred paradigm. In line with the WHO World valid and simple way of stratifying people according to their
Report on Ageing and Health (5), the IC index should be able to risk of decline in IC (which are linked to body functions) will
discriminate people according to their risk of care dependence, have crucial implications for public health, as recognised by
to detect early declines in IC levels over time and must be researchers in the Geriatrics and Nutrition fields (13, 14). After
sensitive enough to monitor the effects of health interventions. five years of the releasement of the World Report on Ageing
Such tasks are crucial to providing more efficient and integrated and Health (5), obtaining a global view of how IC has been
care for older people (ICOPE) (6). operationalised in contemporary studies is a useful step in the
Received April 17, 2020
Accepted for publication May 3, 2020 1
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IN THE QUEST OF A STANDARD INDEX OF INTRINSIC CAPACITY

quest for an IC index. Therefore, the objective of the present instruments were not designed to measure IC a priori. We did
work is to analyse how intrinsic capacity (IC) has been assessed not find any standardised IC index for validated for research or
and measured in older adults, as an initial step towards the clinical use.
construction of a standard IC index. Four studies operationalised a global IC score (11, 21,
23, 27): they used a combination of scores from different IC
Methods domains to create a global IC index, half of which reported their
psychometric properties (11, 23) (n=2). One out of four original
We performed a critical review (15) of the literature investigations used data from a multi-country population (27).
published in PubMed and Cochrane about the measurement (Supplemental Table 1).
of “intrinsic capacity” with the following strategy: The authors coming up with an IC score used any of two
(((«measurement»[All Fields] OR «index»[All Fields]) OR approaches: 1) Factor analysis (with single factor) (27)/
«metric»[All Fields]) OR «quantitative»[All Fields]) AND structural equation modelling bi-factor model (IC and the
intrinsic capacity[Title/Abstract]. We included those articles five domains as factors) (11); 2) Obtained sub-scores for each
whose abstracts included the term intrinsic capacity in the domain based on the distribution of the sample; one study used
context of human ageing and health. Full text was then accessed z-scores (21) and the other used a combination of quartiles and
to select studies with at least one operationalised domain of categories (23). Then the domain sub-scores were combined
intrinsic capacity. either by arithmetic sum or average.
The information, extracted by one author, was: first The earliest mention to IC was published in 1972 in the
author, year of publication, description of the study, domains context of plant physiology (28). The term has been used
of IC operationalised, metrical approach, variables used to in scientific publications of the biomedical sciences at the
operationalise IC, health events or exposures associated with IC molecular, cell, organ and system organisational scales. Also,
and psychometric properties reported. IC appears in publications from medical disciplines such as
Given that “validation efforts are integrative, subjective, and haematology, traumatology, surgery and endocrinology, among
can be based on different sources of evidence such as theory, others. The term “intrinsic capacity” was mentioned in the
logical argument, and empirical evidence”(16), we concentrated Gerontology and Geriatrics literature in articles from Geriatric
our review on the following aspects of validity and reliability surgery and trauma, HIV services for older adults, Geriatric
(15, 17): nutrition, clinical trials, as well as Epidemiology of ageing and
• Construct/content validity: how people classified with very public health/health policy.
high or very low IC differ from others with antagonistic or
agonistic traits (i.e. frailty, physiological reserve, resilience)? Methodological issues and gaps
How were the five WHO domains represented? Should
any weights be used according to the importance of each Construct/Content validity
domain? One relevant constraint of the validation process undertaken
• Criterion validity: a) concurrent: how well the measurement from the included studies is the incompleteness of the domains
correlates with a gold standard? b) predictive: how well the (five out of ten studies), with sensorial and psychological being
score agrees with the prediction of adverse health outcomes? the most frequently omitted; and the absence of an integrated
(i.e. frailty and care dependence, healthy ageing). measurement of IC.
• Target population: can we expect similar results in different Two out of ten studies mentioned if their IC score displayed
populations of different geographical, social or health status? significant differences between sex, age, disease or functional
For instance, are we able to generate normative data on IC status (11, 23). Nevertheless, none of the studies reported data
across the life course? to answer questions like how higher/lower is the average IC
• Other properties: ability to detect minimal clinically relevant score in men compared to women? Or how much IC does one
differences; floor and ceiling effects; interpretability as the lose with advancing age?
degree to which it is possible to assign qualitative meaning
to quantitative scores and replicability as the feasibility to Criterion validity
translate the application of the IC measurement from the We found a lack of a clear conceptual and operational
research to the clinical settings. definition of the vitality domain. A gold standard to measure
intrinsic capacity is not yet available, but Giudici et al.
Results (22) found no significant differences between alternative
definitions of vitality in terms of their ability to predict
From the ten original articles with at least one domain of declines in instrumental activities of daily living (IADL)
IC operationalised, 9 were observational studies (18–25), and and worsening frailty. The definitions tested were: a) mental
one was a randomised controlled trial (26). All the studies state of willingness (based on three items from the Geriatric
use a retrospective approach, which means that the research Depression Scale (GDS-15) (9)), b) physiological reserve

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Figure 1
Types of operationalisation of the five IC domains proposed by WHO in the studies included for reviewed (% based on n=10)

(excellent physical and cognitive performance measured with to predict care dependence and mortality (11, 23). None of the
the Short Physical Performance Battery SPPB, Mini-Mental studies used an outcome that could be closer in time to early
State Examination MMSE and Clinical Dementia Rating CDR declines in functional capacity, i.e., pre-frailty/frailty.
(8, 29, 30)), c) grip strength.
Moreover, Beard et al. (11) concluded that part of Target population
the contribution of the vitality domain to the construct of Three studies used a composite IC score using nationally
IC is through the other four domains (“overt expressions of representative data. The countries represented are England
capacity”) but also directly to IC. (ELSA) (11), Costa Rica (CRELES) (23), South Africa, Ghana,
Two studies used longitudinal data to test their score’s ability China, Russia, India and Mexico (SAGE) (27), although, no

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Table 1
Considerations to have in mind in the process of developing a composite score of IC according to our review results

Validity
• The score should provide a summary measure of IC besides domain-specific scores.
• Reach consensus about a clear conceptual and operational definition for the vitality domain
• Consider the use of weights for each domain.
• Explore different arithmetical ways of arriving at a summary measure (i.e. geometric mean, arithmetic mean, the addition of sub-scores)
that does not depends upon the distribution of the study sample (i.e. Z-scores)
• Use complete validated scales whenever possible, but do not make it too complicated for usage in clinical settings
Reliability and implementation
• Test for floor and ceiling effects
• Asses the sensitivity to detect changes
• Consider the feasibility to measure IC through the life course and to produce normative data and nomograms

tabulations of IC were presented for the latter. Improving validity

The validity of an IC global score could be improved by
Other properties: minimal clinically relevant differences; a) using a prospective approach with validated functional
floor and ceiling effects; interpretability as the degree to which scales and performance-based tests weighted according to each
it is possible to assign qualitative meaning to quantitative scores domain’s risk to develop functional decline, b) using a concrete
and replicability as the feasibility to apply the same score in operational definition of vitality, i.e., nutrition, c) expressing IC
different contexts even by different research teams (31). in terms of a continuous scale that allow for group comparisons,
None of the studies has so far assessed their IC scores for d) using an event upstream in the natural history of functional
sensitivity to detect clinically significant changes neither for the decline, i.e., frailty or other geriatric syndromes.
ceiling and floor effects. Using an integrative approach, rather than domain-by-
The interpretation of the reviewed scores in the clinical domain, to summarising the IC levels strengthens its validity
context is not straightforward, except for one using categories because the construct of IC is integrative by nature; such a
of IC based on the score (23). global score would have important implications in a preventive
Overall, there is a low level of concordance among the perspective. Studying domain-by-domain associations is
tests used to operationalise the domains. No score/biomarker essential for contexts. Although, the use of valid combined
was used by more than 30% of the original studies. Also, scores of IC can be a better way to measure the integrated
self-reported and separate items of scales were used for all the construct of IC.
domains at least once. See Figure 1. Having a clear definition of the vitality domain might
increase consistency in the operationalisation of variables and
Discussion eventually, a decrease in the measurement error. Without a clear
definition, vitality could be interpreted as an “umbrella” term
In the context of healthy ageing, IC has been measured using encompassing physiological reserve, resilience and biological
self-reported variables, performance-based tests, biomarkers, age. Recent publications distinguish physiological reserve
or a combination of them. However, further validation of the and physical resilience, as might be the case for robust older
intrinsic capacity concept is needed, together with more robust adults with low resilience (32). If a non-hierarchical model
approaches to measure it. A standard IC score has not been is to be used as Beard et al. (11) suggest, the vitality domain
operationalised for clinical or community-based use. should focus on the process of nutrition which holds a closer
All the studies were retrospective, and methodological taxonomical place to that of cognition or mobility than vitality
limitations might answer to the fact that their original aim (considering the latter as an “umbrella term”). In the ICOPE
different from measuring IC. We found four published handbook (33), the term “malnutrition” is employed to address
IC global scores, from which two have reported some declines in the vitality domain. We support this approach and
psychometric properties. There is not a study using only recognise the MNA (20) as a potential instrument to harmonise
biomarkers or validated scales and performance-based tests for the operationalisation of vitality in older adults, given it is
the five IC domains as defined by WHO. The IC index has been widely used in clinical settings. Experts in the topic should soon
associated with incident disability (11). reach consensus about the concept and operationalisation of the
vitality domain (i.e. should biomarkers like grip strength and

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lung capacity be used?). The two main techniques to calculate the IC score were
Another question related to validity is: should different factor analysis and z-scores. The results from both are subjected
weights be used for different IC domains within the composite to the distribution of the variables of interest within the study
index? The impact of weights is higher when one deals with sample. None of the studies showed a numerical equation or
a score with a) few items, b) high correlation between items, algorithm to calculate the IC score proposed; therefore, it is
and c) the range of the weights used is higher (15). None of the hard to be replicable in clinical settings. Especially for the
studies using a combined score reported the weights used for z-score, it relies on the distribution of the IC score within the
the estimation (if any used). study sample. We would need to replicate these findings in
other populations, or with representative samples to advance in
Improving reliability the construction of a standard IC score, and eventually obtain
The use of self-reported measures opens the door to biases normative cut-offs for it.
in responding. However, scales based on self-reported items We foresee that replicability will work as a validation
might be the only option to measure the psychological domain. method through time. For example, with data from different
From the studies with all five domains measured, at least geographical and cultural backgrounds, one could use diverse
one of the domains was operationalised using self-reported methodological approaches such as graphic networks whose
measurements. Measurement error could be reduced by using nodes probabilistic networks to produce maps of the emerging
only the complete validated scales, performance-based tests clusters of biomarkers that should relate to the five domains of
and biomarkers in the construction of the IC score, though IC (35).
feasibility in clinical settings should be privileged.
The scaling technique of an IC score should consider that Emerging properties and perspectives
the same amount of change in IC for a chronologically- or The levels of inter-relation among the five domains might
biologically older person might exert a more significant impact be informative about physical resilience, a characteristic which
on the risk of functional decline than for a younger person. determines one’s ability to resist or recover from functional
Using flexible thresholds (maximums and minimums) for each decline following health stressor(s) (36). As physiological
domain and estimating the critical difference and individuality, reserves deplete, it is expected that variables of the
the index could be of help in this regard and also in dealing with physiological systems become more correlated and dependent
ceiling and floor effects (34). Also, interventional studies are from each other as they approach a critical turning point that
needed to assess the sensitivity to detect clinically meaningful increases the risk of adverse health events (32, 37). According
changes. to Gijzel et al. (38), a higher level of correlation within the
IC domains during an external insult might be a signal of
Improving implementation lower resilience. High IC not necessarily implies high physical
Ideally, after standardising and measuring IC throughout resilience in older adults. Therefore, the emerging question
different populations, we should be able to come up with is: could resilience be measured from the interaction of the
nomograms for IC levels like the ones currently used to follow- previously defined five domains of IC?
up the children’s physical development. Emerging studies aimed at measuring IC at a population-
A simplified IC measure obtained at the community-level, scale might benefit from this review when designing their
such as the Step1 (screening tool) as defined in the WHO research instruments. For example, the INSPIRE / ICOPE
ICOPE program, could flag declines in IC in the community- geroscience program aims to bring more data about IC and
level (33), and guide timely interventions accordingly. Such Gerosciences both from the Inspire Translational cohort and the
tool recommends separated items selected from validated scales INSPIRE ICOPE Care Cohort (39–43).
to identify older adults at higher risk of decline, but we did In the meantime, we are restless pushing for health care
not find any studies that applied the screening tool in any systems to adapt to ageing populations. Adding frailty to the
population. International Classification of Disease (ICD) would be very
The measurement of IC will have to report domain-specific helpful, given that frailty and IC are moving the field towards
scores but also a global IC index. Clustering the domains better prevention of disability in older adults by maintaining
affected will allow creating profiles of patients, useful when functionality. Implementing ICOPE in clinical practice is one
designing personalised care plans, or when delivering a pre- top priority. We learn when while we advance on this (44, 45).
surgery risk assessment. That way, we will also advance in our Finally, we think the next step in the quest of a standard
understanding about how multi-domain interventions targeted index of IC is to test different metrical approaches that enhance
at specific domains or combination of domains will exert validity, reliability and implementation in different clinical
effects in the overall level of IC. Also, the trajectories of the settings. Overall, we think that a standard quantification
IC domains are to be explored. Which domains are affected procedure of IC will pave the way to its epidemiological and
first? Is there a universal or more frequent pattern of losses? clinical application. Accurately measuring intrinsic capacity
Furthermore, can the metric be valid across the life course? is fundamental to gain in-depth knowledge about how

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intrinsic capacity is “built” through the life course and how 18. Carvalho IA de, Epping-Jordan J, Pot AM, et al. Organizing integrated health-care
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Acknowledgements: The present work was performed in the context of the Inspire
home residents according to intrinsic capacity proposed by the World Health
Program, a research platform supported by grants from the Region Occitanie/Pyrénées-
Méditerranée (Reference number: 1901175) and the European Regional Development Fund Organization. J Gerontol A Biol Sci Med Sci. 2019. doi:10.1093/gerona/glz218.
(ERDF) (Project number: MP0022856). 21. Giudici KV, de Souto Barreto P, Guerville F, et al. Associations of C-reactive protein
and homocysteine concentrations with the impairment of intrinsic capacity domains
Author’s contribution: EG performed the search, reviewed the documents, extracted over a 5-year follow-up among community-dwelling older adults at risk of cognitive
the data and prepared the first draft. SA, and PB made significant contributions to the decline (MAPT Study). Exp Gerontol. 2019;127(August):110716. doi:10.1016/j.
manuscript, including format and content corrections mainly with an epidemiological exger.2019.110716.
focus. LG, RG and BV made significant contributions focused in the clinical implications 22. Giudici KV, de Souto Barreto P, Soriano G, Rolland Y, Vellas B. Defining Vitality:
and also suggested additional references to improve the discussion. Associations of Three Operational Definitions of Vitality with Disability in
Instrumental Activities of Daily Living and Frailty among Elderly Over a 3-Year
Conflicts of interest: The authors declare no competing interests. Follow-Up (MAPT Study). J Nutr Heal Aging. 2019;23(4):386-392. doi:10.1007/
s12603-019-1175-0.
Ethical Standards: This study did not include any experiments involving humans or 23. Gutiérrez-Robledo LM, García-Chanes RE, Pérez-Zepeda MU. Allostatic Load as a
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THE JOURNAL OF NUTRITION, HEALTH & AGING

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