The impact of intrinsic capacity and physical resilience on health outcomes: a case report

O impacto da capacidade intrínseca e da resiliência física em desfechos de saúde: um relato de caso

Mariangela Perez mariangela.perez@hotmail.com

Universidade do Estado do Rio de Janeiro, Brazil

Bruno Goulart

Hospital Copa D’Or, Rio de Janeiro, Brazil

Flavia Zuchen

Hospital Copa D’Or, Rio de Janeiro, Brazil

Flávia Lopes Fonseca

Hospital Placi Cuidados Extensivos, Brazil

Roberto Alves Lourenço

Universidade do Estado do Rio de Janeiro, Brazil

Conceptually, health is defined as a complex interaction between physical, mental, and social well-being.1,2 Physiological changes that result in impaired functional reserve and accompany chronological aging increase the risk of morbid conditions and dependence,1 Therefore, the traditional disease-oriented model of health care has proven inadequate for the growing older adult population,3 ie, care must go beyond diagnosing specific diseases and assess the impact of these conditions on functional capacity.4

As they age, individuals follow different functional trajectories which, in turn, result from an interaction between their intrinsic capacity and their environment.4,5 Thus, the concepts of intrinsic capacity and physical resilience provide us with a theoretical basis for explaining the varied health outcomes that result from catastrophic health events in older patients.3,6

The World Health Organization originally conceived of intrinsic capacity as a combination of all of an individual’s physical and mental capabilities at any given time, assessed in 5 domains: locomotion, vitality, sensory, cognition, and psychological well-being.5 The concept of physical resilience concerns the ability to resist decline or to functionally recover from a traumatic health event.6 Another important concept in understanding this case is functional ability, defined as health-related attributes that allow individuals to be and do what they value.1

The case presented below illustrates the positive impact of intrinsic capacity, physical resilience, and functional skills, together with external resources, on the prognosis of an older patient.

This case report follows the CARE guidelines,7 and the patient provided written informed consent.

After six days without contacting his family, a 91-year-old widower who lived alone was found disoriented, lying on the floor, trapped between the bed and another piece of furniture, and covered in his own waste. He was immediately taken to a general hospital.

In the hospital emergency department, severe dehydration, mental confusion, pneumonia, and a grade IV pressure lesion in the sacral region were diagnosed. Complementary tests ruled out cardiac arrhythmia or fractures; bilateral pneumonia was found in chest computed tomography (Figure 1).

FIGURE 1
Computed tomography image of the patient’s chest upon hospital admission.

Blood tests showed kidney failure, hypernatremia, and hypothyroidism (Table 1). A family member reported that the patient, except for previous hypothyroidism, was independent, autonomous, active and healthy; he was using a single medication, levothyroxine (188 mcg per day).

TABLE 1
Results of the laboratory tests performed upon hospital admission.

Treatment was begun with amoxicillin, clavulanate, azithromycin and vigorous intravenous hydration. After the pneumonia and electrolyte disorders were resolved, the patient underwent 3 surgeries for the sacral injury.

Near hospital discharge, the patient was diagnosed with COVID-19, with less than 25% lung involvement, which did not require invasive procedures. He remained a further 14 days in a unit for patients with COVID-19.

The patient’s total hospital stay was 62 days and, due to mobility impairment, he was referred to a transitional care unit for rehabilitation. By the time he reached this new unit, he had lost 13% of his usual weight, had global muscle weakness, handgrip strength of 10 kgf, imbalance, and sarcopenia, in addition to a postoperative wound in the sacral region (Figure 2). After 25 days, he was discharged lucid and alert, having gained 5.2 kg, with good sphincter control and walking with little unilateral assistance.

FIGURE 2
Postoperative wound in the sacral region upon admission to the care transition unit.

While hospitalized, the patient had a positive emotional attitude, remaining calm and confident, despite the severity of his clinical condition.

The main point of this case is that a positive outcome occurred after a dramatic and serious clinical condition in an individual of advanced age who had led an active life but was in a risky environment. His social network was large and close from an emotional point of view but had little power to intervene in emergency situations. We proposed to analyze the patient’s trajectory from the point of view of physiological reserve through the concepts of intrinsic capacity and physical resilience.

In addition to genetic inheritance, the World Health Organization considers personality characteristics, disease burden, behaviors, health care skills, and lifestyle habits determinants of intrinsic capacity.1 According to the patient’s report, which was confirmed by his family, it can be inferred that, prior to hospitalization, he had high intrinsic capacity according to the World Health Organization’s 5 domains,5 ie, preserved mobility, good sensory function, and excellent cognition and vitality, in addition to optimistic and participatory behavior.

When asked about things that, over the course of his life, positively influenced his intrinsic capacity, he highlighted regular jiu-jitsu training and aerobic exercise, such as running and walking, in addition to low alcohol consumption, good sleep patterns, a successful romantic life, good mood, high intellectual activity and low disease burden.

According to Chhetri et al.,6 physical resilience can only be defined without ambiguity when the “system, state, and stressor” triad is specified. According to this approach, considering the individual as the system, the state as survival, and the stressor as a fall and its complications, it is clear that the patient in question was extremely resilient. However, the same conclusion can be reached if the muscular system is considered the “state”, since its function has almost completely recovered.

In summary, the patient’s trajectory can be understood as resulting from high intrinsic capacity prior to the stressful event, undoubtedly a measure of adequate physiological reserve.3,6 Likewise, the positive response to therapeutic interventions, especially functionality recovery after a long hospital stay, indicates a high level of physical resilience.3,6

This clinical case helps us visualize the concepts of intrinsic capacity and physical resilience descriptively and factually. Although such concepts can reconfigure discussion about older adult health, approaching it through an individual’s strength reserves against natural physiological wear and tear, its operationalization still lacks adequate instruments that can objectively describe such forces.8,9