A global gap in autonomy assessment among older adults: a COSMIN systematic review

Autonomy is increasingly recognised as the basis of healthy ageing and person-centred care; however, it remains under-represented in clinical assessments and policy. We systematically reviewed patient-reported outcome measures and clinician-reported outcome measures of autonomy in adults aged 60 years and older (older adults), following the consensus-based standards for the selection of health measurement instruments (COSMIN) methodology (PROSPERO CRD42025640772). Across 116 studies involving 861 338 older adults in 42 countries, 50 instruments were evaluated for structural validity, reliability, internal consistency, cross-cultural validity, and responsiveness. High-quality evidence supported structural validity in 29 instruments, internal consistency in 33, and test-retest reliability in 17, whereas content validity and responsiveness were often insufficient. 14 instruments met the COSMIN category A criteria (ie, instruments with sufficient content validity and at least low-quality evidence for sufficient internal consistency, indicating that they are reliable and suitable for recommendation) and were recommended for research and clinical use. Substantial gaps remain, particularly in cross-cultural validity and responsiveness of the tested instruments, highlighting the need for internationally aligned, culturally robust, and co-created tools. Health authorities should adopt validated measures to assess autonomy, guide policy, and ensure equitable resource allocation.