This study evaluates the implementation of a structured community-based pathway to screen, risk stratify, and prevent decline in intrinsic capacity (IC) among adults aged 60 years and above in Singapore. Using the World Health Organization (WHO) Integrated Care for Older People (ICOPE) framework and digital screening tools, participants will undergo IC domain screening in community settings. Individuals identified with early decline will receive targeted multidomain interventions and/or referral to primary or specialist care as indicated. Participants will be followed longitudinally to assess feasibility, uptake, functional trajectories, and implementation outcomes.
pre-frail or robust older adults who can provide consent and follow instructions
frail or with terminal illness
Recruitment will be conducted from Active Ageing Centre and Community Centres.
Cohort
Prospective
ICOPE-Based Digital Intrinsic Capacity Monitoring and Triggered Follow-up (SPICE Pathway)
Other interventionParticipants will undergo baseline intrinsic capacity (IC) screening using WHO ICOPE-aligned tools in community settings. Follow-up contacts/visits will occur over the study period and include: 1. Scheduled follow-up at predefined intervals (e.g., every 3, 6-12 months) for repeat IC assessment and outcome data collection; and 2. Triggered (non-scheduled) follow-up that is initiated when remote/digital monitoring indicates decline in one or more IC domains, poor adherence, or when major intercurrent clinical events are reported/identified, prompting in-depth assessment, care plan adjustment, and referral to Community Health Posts, primary care, or specialist services as appropriate.
Prevalence of intrinsic capacity decline at baseline (robust / pre-frail)
Proportion of participants (restricted to robust and pre-frail at baseline) with ≥1 impaired IC domain on screening; and proportion impaired by each domain (mobility, cognition, vitality, psychological, sensory).
Uptake of recommended actions (implementation effectiveness)
Proportion of participants who initiate at least one recommended action within a defined window after screening/plan (e.g., enrolment in a prescribed community programme, completion of recommended assessment, or attendance at a referred service).
Identification of (a set of) biomarkers of aging
Both blood biomarkers and digital markers associated with various intrinsic capacity
Feasibility and reach
Proportion of individuals in each community setting complete both Step 1 and Step 2 assessment.
Change in intrinsic capacity and function over time
Change in number of impaired IC domains (0-5) from baseline to follow-up.
Frailty progression
Proportion transitioning from robust → pre-frail/frail; pre-frail → frail
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