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Redefining Geriatrics Care: The Age-Friendly 4Ms

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Redefining Geriatrics Care: The Age-Friendly 4Ms

Oct 11, 2023

The "4M" approach is an emerging framework for age-friendly care that shifts the focus from treating conditions to treating people. The "4Ms" stand for: What Matters, Medication, Mentation, and Mobility. Timothy Farrell, MD, explains these critical elements of care and how they can be utilized to provide a more holistic and effective medical treatment for older patients.

Episode Transcript

Interviewer: There's a movement in healthcare toward age-friendly health systems. Even though approximately 3,000 hospitals and practices in the United States are age-friendly, you might not ever have heard of this concept, which can provide older adults with better healthcare.

Dr. Timothy Farrell is Associate Chief for Age-Friendly Care at the Division of Geriatrics, Spencer Fox Eccles School of Medicine at the University of Utah.

Dr. Farrell, let's just get right to it here. First of all, what problem does an age-friendly healthcare system solve?

Defining the Problem: Inconsistency in Elderly Care

Dr. Farrell: The main problem that we've been hearing from our patients, from other healthcare professionals, geriatricians, you name it, has really been a lack of consistency in providing a reliable set of evidence-based care that we know works for older people.

So if you go to Hospital A, they may have some of these elements, but not all, and Hospital B will have still others, but there's not really a uniform set of standards, if you will, to provide age-friendly care. But that thankfully is changing.

Interviewer: Okay. I guess I'm a little confused. I thought if I needed to go see my doctor for a condition or for something, I went and saw my doctor and then they just took care of me. But you're saying behind the scenes, there should be some guiding principles to help make sure that the care is . . . what? Consistent? Higher quality? What are we trying to accomplish?

Dr. Farrell: That's correct. Much of the care that's offered in the United States, and elsewhere for that matter, is really focused on addressing a series of diseases, chronic illnesses that sort of accumulate. And that's all well and good.

However, when the focus is simply on providing the best care for each individual chronic condition, it may overlook what matters to the patient. And so the patient ends up getting unneeded care, unwanted care, or care that may frankly harm the management of their other chronic conditions.

So part of this is care coordination, but it really does start with understanding what matters most to the patient.

Paradigm Shift: From Disease-Focused to Patient-Centric Care

Interviewer: Yeah, which is a little bit of a paradigm change in healthcare in general. I think it used to be . . . Like you said, it was treating the disease. So a patient comes in with a condition, you treat that, not really asking the patient, "Well, what's important to you? Is this treatment for this disease worth the side effects that are going to impact you?" Is that kind of what we're talking about? It's thinking more of a person than a disease.

Dr. Farrell: That's absolutely correct. Now, we don't forget about the chronic diseases. We are all trained to address those, and we do. However, when you're dealing with multiple conditions . . . The most common chronic condition for older people is simply having multiple chronic conditions. The management of one may involve trade-offs when you're kind of balancing against the management of another condition, especially in the context of a patient's life goals.

So it's absolutely necessary to manage chronic disease. I want to make sure I'm clear about that. But not considering what matters most to the patient means you're sort of managing these conditions in a bit of a vacuum without really a clear guidepost for where you're kind of going with this management.

Interviewer: And for many older adults, especially those that are becoming older adults right now, they've had a doctor relationship where the doctor really guides everything and there's not a lot of participation. It's like, "All right. What you say, doc, that's what we'll do." But this type of care is really going more towards kind of a team approach to taking care of the patient, to make sure the patient's voice is included. Is that accurate?

Dr. Farrell: That's absolutely correct. And I think one way to think about this is the patient is the expert in what they want, and the healthcare professionals are the experts in how to get them there.

Interviewer: Ah, yes. So instead of telling what to do, there should be communication, which can be a bit of a paradigm change for many older adults.

Dr. Farrell: Correct. When I was in medical school, I was taught to elicit the chief complaint. I still absolutely do that, but increasingly I'm also asking patients what matters most to them. Is it getting to their granddaughter's wedding in six months? Is it being as healthy as possible, living as long as possible? Is it maximizing quality of life? Or some combination of those things?

And so that really is a paradigm shift. It's a very subtle but important shift that actually also makes healthcare much more satisfying for those providing it and, I would venture to say, for the recipients of the care.

The 4M Framework: A Guide to Age-Friendly Care

Interviewer: Let's dive into this notion of the 4M Framework that helps make sure that older adults are getting the care that they should be. And then we'll discuss why some . . . Well, first of all, why should somebody like a patient or somebody who knows an older adult or is an older adult even care about these 4Ms? Shouldn't they just assume this is going on in the background?

Dr. Farrell: And it may very well be. One thing we've found in our sort of anecdotal observations is that very often this care is happening or is happening maybe partly, and people may not realize it. But sometimes it doesn't happen as well as it could if it's not sort of called out and more intentional.

What Matters Most

So really the key aspects of these 4Ms begin with what matters most to the patient. I consider that to be the North Star. And there are three other aspects: medications, mentation, and mobility.

I think one reason that patients should care about these 4Ms, or maybe the most important reason, is that it really can be quite overwhelming to go into a doctor's office with 10 chronic conditions and 10 or more medications sometimes. And if nothing else, this framework really helps to boil down to what's most critical. You may only have 15 or 20 minutes and you really don't want to spend time on things that aren't really a priority.

Interviewer: Yeah. So this could be a guiding framework for a conversation. As was said earlier, if some of these things are missing, then perhaps the patient can make sure that they're calling that out. "Let's have a discussion about one of these Ms that might be missing."

Dr. Farrell: That's correct.

Medications: Ensuring Safe and Effective Drug Regimens

Interviewer: What matters is number one. What else is on the list? And let's go through what they mean. So medication was number two.

Dr. Farrell: Yes, medications. And that's really understanding the medication list and making sure that the medications are not causing side effects, like drowsiness or confusion, that may be interfering with a patient's ability to do what matters or could be causing harmful side effects.

Interviewer: Right. Or even lead to false diagnoses of other conditions, especially when you talk about confusion and mental things. Assumptions could be made it's something else, it's something worse, but it could just be medications.

Dr. Farrell: That's right. It's not uncommon for a very well-intentioned healthcare team to treat a medication side effect as if it were a medical problem. And now what you have are layers of additional medications that are all interacting with each other, sort of making the problem worse instead of better.

Mentation: Addressing Cognitive Health

Interviewer: And then the next one is mentation. What is that?

Dr. Farrell: Yeah, mentation really refers to cognition or mind. And that has to do with things like dementia, delirium, and depression, which are so common among the older adults that we serve.

Interviewer: And is it under-diagnosed, undiagnosed a lot of times? Why is this an important thing to consider for an older adult patient?

Dr. Farrell: It's easy to be fooled as a clinician. Even patients with fairly significant cognitive impairment, even mild dementia, may carry along a very nice conversation, and you may not have really any suspicion that something is amiss. There'd be maybe more subtle clues.

So one of the things that we do or we try to advocate for is really more general screening with things like the mini cog, which is a really quick and easy, two-minute screening in primary care.

Interviewer: So as a patient or somebody who has an older adult in their life, this mentation point really is about making sure that you are screening for those things.

Dr. Farrell: That's correct. And there are other implications as well. One would be thinking about advanced care planning and making your preferences known as early as possible because that becomes a very difficult situation if you have someone who has more advanced cognitive impairment and we don't know what their preferences are for their care.

Mobility: Promoting Safe and Active Living

Interviewer: And then the fourth M is mobility. Talk about that.

Dr. Farrell: This is really the ability to move about safely every day to do what matters. And all of these Ms, including mobility, have a very solid evidence base. So we know studies of deconditioning in hospitals when people are in bed, they can be in bed 75% to 80% of the time in the hospital. And when you do MRIs of the cross-section of their legs and arms, you find that there's significant atrophy. That's not the only place deconditioning occurs, but it's a great example of this.

And there are efforts now to really sort of rethink the way we care for people in hospitals to make sure that they are mobilizing as soon as they can so that their recovery goes as well as it can, and they don't hit the next setting of care being excessively deconditioned.

Interviewer: And I would imagine mobility also applies to, if I have an older adult in my life, making sure that they are mobile, they are able to move around, and that they not only are able to do it, but they do it. I mean, it can impact not only your physical health, but your mental health, can't it?

Dr. Farrell: Sure thing. There's great literature now emerging about social isolation. Very important in terms of the health effects, and adverse effects of being isolated if you're not getting out.

Also, it may seem counterintuitive, but if you're not active and mobile, your fall risk will increase. So you really have to be mobile in order to reduce the risk of falls.

Interviewer: And from personal experience, I can speak from older adults in my life, when that loss of mobility happens, even something as simple as going to the grocery store and being able to shop for yourself really can impact somebody's self-image. It's such a silly thing we don't think about, but I've seen it happen. Is that something you've seen happen as well?

Dr. Farrell: Oh, yes. All the time. There's this concept in geriatrics and gerontology about life space. And so as one's ability to ambulate or drive sort of decreases, then there's this shrinking concentric circles of where they can actually go.

At one point, they go to the grocery store. But then maybe they can't go to the grocery store, so they're limited to their neighborhood. Then they're limited to their house, and it's shrinking.

So the idea here is let's do what we can to slow down that process and let's also make age-friendly neighborhoods and communities so that it's easier for older people to maintain their activity in sort of an age-friendly space.

How the 4Ms Interact with Each Other

Interviewer: I think with the mobility, what I wasn't saying very well is that I've witnessed the lack of mobility translate into a feeling of a lack of independence, which can impact older Americans pretty significantly, I feel.

Dr. Farrell: Yes. And this is how the Ms will interact. So you have somebody with poor mobility, it's important to think about the mentation M and to screen for depression, for example.

Interviewer: Yeah. And that's a great point that you brought up about the Ms interacting. These 4Ms don't live alone. They all completely interact. Explain that a little bit more. Maybe an example could help us understand how they interact a little bit better.

Dr. Farrell: That's correct. Let me give you a great example that I'm aware of. So when we're contacting older patients to schedule appointments, something as simple as that, you might not think that the staff scheduling appointments needs to know about the 4Ms, but they actually do.

So the example here is if we're scheduling appointments for older people and calling them, and we hang up on the second ring, that overlooks that an older person may need to have several rings of the phone before they can get to the phone because they may have impaired mobility.

Another example of the Ms interacting would be when our clinical pharmacist does a medication review. The reason why she's an outstanding geriatric pharmacist is she also considers what matters most in terms of why people are taking medications and how are the other Ms interacting.

So it really has to be a bundle for it to be most effective.

Interviewer: And you've spoken about how the 4Ms are evidence-based. Is that insofar as you have learned through research that if providers and patients concentrate on these 4Ms, generally their health will be better?

Dr. Farrell: Correct. So this goes back to decades of research in geriatrics. For example, we know that if you have someone who's hospitalized, who's an older person, they are at high risk for delirium. We have evidence-based protocols to reduce the risk of delirium substantially. There are evidence-based guidelines for what's called de-prescribing medications.

And these are great evidence-based activities. The problem is there just has not, until now, been a very nice, straightforward way to bring all this great evidence to bear in a consistent, reliable manner.

Interviewer: I guess what my question comes down to is why these four things? Why not something else? Why were these the four? I mean, coming up with a list of anything can be tough, right?

Dr. Farrell: I think this is what sort of fell out. When there was an expert group that looked at about 20 or 30 or so evidence-based care models, they went through a sort of exhaustive session to see, "What were the common features among all of these evidence-based models?" And this is sort of what fell out.

Now, there very well could be more Ms. So some people would say, "There are actually five Ms. There should be a fifth M of multi-complexity." Some of my dentistry colleagues have said mouth should be another M. Some have said malnutrition should be an M.

And really, when I've talked to the leaders of the 4Ms movement, if you will, what they say is, "Add on as many other Ms as you want, but do the first four. Those are the most critical."

Building Age-Friendly Communities Beyond Healthcare

Interviewer: I've heard it said that patients should go so far that if they don't feel as though they're getting these 4Ms where they go, they should demand them. That seems kind of strong. Do you agree with that?

Dr. Farrell: It is a bit strong, but I do agree. I really feel that the way that we're going to get increasing penetration of age-friendly care in the United States and also internationally is for patients to really demand this from the grassroots.

It may be somewhat uncomfortable, but sometimes some of the best changes we've had in healthcare have come from listening to what our patients are telling us and not just being top-down. It really needs to come from both the clinicians and from the patients themselves.

Interviewer: That's right. So by asking for the f4Ms, you're not only advocating for yourself, but we're at a point in the movement where you're advocating for patients that will come in after you.

Dr. Farrell: That's correct. This is a bit of a ripple effect that we're seeing. And it's been great progress. There are about 3,000 hospitals and clinics in the country that have the basic Level 1 participant designation. At University of Utah Health, we have Level 2 committed to care excellence designation, but that's still sort of a floor, not a ceiling. So we really are looking to the next phase for our patients to help us design the health system that they want as they age.

Interviewer: As we wrap this up, you've done a wonderful job, I think, of explaining the 4Ms, why they matter to a patient, why you should ask for them, maybe even demand them. Are there any additional ways that patients could use the information they obtain today to improve the healthcare that they're receiving?

Dr. Farrell: So I think one of the things that we're learning from our patients and their caregivers is the importance of caregiving. And that really gets back to the what matters and mentation Ms in particular.

So we have some innovative projects going on where we're sort of working on caregiver proxy access through MyChart and other ways to make sure that we're communicating optimally with sort of the dyad or the triad, the number of people that are supporting the patient.

And so this is back to an earlier comment you made about teams. Really, it's not just a healthcare team. It's the team that involves the patient and the caregiver as well. And when it functions well, it's a really wonderful thing that makes sure that you're getting at that North Star of what matters most.