Identification, Prevention, and Management of Dependence among Frail Older People in Low Resourced Primary Health Care Setting

Student thesis: Doctoral ThesisDoctor of Philosophy


Background: Numbers of dependent older people will increase in low and middleincome countries (LMIC) with population ageing. Healthcare services do not meet their needs, and little attention has been given to developing age-appropriate services. Research described in this thesis is formative to development of World Health Organization WHO-COPE clinical intervention guidelines for prevention/management of dependence among older people in LMIC.

Method: Predictive validity of frailty indicators was tested by analysing 10/66
Dementia Research Group population-based cohort study data from Latin America, China, and India. Field research was conducted in Goa to train Community Health Workers (CHWs) for case-identification and assessment of frail/dependent older people. Case-identification and impairment classifications were compared with local clinician judgment. Clinical intervention guidelines were developed using WHO methodology (scoping questions/systematic reviews/expert consensus). Qualitative interviews in Goa with CHWs, doctors, and dependent older people and their carers assessed implementation issues for WHO-COPE guidelines.

Results: Frailty indicators (weight loss, inactivity, exhaustion, slow gait speed,
undernutrition, cognitive and sensory impairments) are consistent predictors of
dependence and mortality. Goan CHWs accurately identified older people with
multimorbidity, impairments, polymedication, disability and dependence. Agreement
with clinicians for specific impairments was moderate, but the COPE assessment
positive predictive value was high. It identified those with more pronounced disability. Systematic reviews found moderate quality evidence (from developed countries) for effectiveness of interventions for frail/dependent older people; e.g. exercise, nutritional supplementation/dietary advice, and prompted voiding for incontinence. Consensus guidelines are drafted for most intervention domains. Frail/dependent older people receive little attention in Goan primary healthcare. Home-based assessment and management was endorsed by healthcare professionals, but role definitions, referral options, limited knowledge and skills constituted important obstacles.

Discussion: WHO-COPE assessment and multi-component intervention may address the needs of frail/dependent older people. However, feasibility, acceptability, fidelity, and effectiveness should be evaluated when administered by CHWs in the community.

Date of Award2013
Original languageEnglish
Awarding Institution
  • King's College London
SupervisorMartin Prince (Supervisor) & affiliated academic (Supervisor)

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