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1/14/2020
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The 4Ms of Geriatrics:What Matters, Medications, Mobility & Mentation
Edmund DuWe, MD; Kathryn Denson, MD;
Steven Denson, MD; Deb Sfmpson, PhD
Winter Refresher
January 29.2020
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AdvocateAuroraHealth ^ ImnA^AnVtKSIf
Financial Disclosures
Edmund Duthie.MD:Disclosure of ABIM Service:! am a member of SEP Committee on Geriatric Medicine,
To protect the integrity of certification, ABIM endorses strict confidentiality andownership of exam content. As a current member of the SEP Committee on Geriatric
Medicine, I agree to keep exam Information confidential. As is true for any ABIM
candidate who has taken an exam for certification, I have certification, I have signed
the Pledge of Honesty in which [ have agreed to keep ABIM exam contentconfidential.No exam questions will be disclosed in my presentation.
No other faculty, presenters, planners, or anyone controlling contenthas any relevant financial relationships to disclose.
Today's Objectives
You will be able to:
1. Explain why considering the 4Ms (What Matters, Medication,Mentation, Mobility) can result in the best care possible forolder adults
2. Apply 3-Step approach to using 4Ms with your patientsA. Identity the 4M's present with the patientB. Prioritize which of the 4Ms needs to be addressed first
C. Utilize Geriatric Fast Facts to address the 4Ms
System to Patient Level Framework
T•_•_
4Ms <fcB5'*~«"|l&l1
AgTlF3Se2 —N-Health Systems
IntroducingThe 4MsFramework foran Age-FriendlyHealth System
* Value is optimizedfor all " patients,families, caregivers,health care
providers & system
• Frameworkfor
organizing care ofevery older adult,every day
Why Care (about the MS) in Primary Care?
• Evidence based
• Easy, simple framework
* Common language for patients and family, care team, and system
• Connects to values of primary care: Continuing, comprehensive andcoordinated health care for individuals and families
- Integrates the biological, clinical, and behavioral sciences.- Encompasses care for all ages, genders, organ systems, and disease entities
o Particularly valuable for geriatrics
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4 Ms Framework for - Age Friendly Care i
•What Matters Most- Know and Act: Align care with each older
adult's specific health outcome goals &care preferences including, but not limitedto, end-of-Iife care, and across settings of
•Medication- Optimize use to reduce harm and burden,
focusing on medications affectingniobility.mentation, and whatm,atters
Thii. Mia'.is
• Mentation- "Preventing, identifying, treating and
managing dementia, depression anddelirium across care settings."
• Mobility- "Ensuringthat older adults move safely
every day to maintain function and doWhat matters to them."
What Matters Most
Ideal time to discuss:
* At Annual wellness visitor Medicare Wellness Visit
• Routine follow-up visit
This may include: Medical or Other
* Living / housing arrangements
Driving
Goals of care & Advance Directives
- Living will. DNR, Power of Attorney for Health Care
£•I-
Clin-IQ: Time efficient strategiesfor initiating AD conversationsJournal for Patient-Centered Research and ReviewsMyers JM, Duthie E Jr, Denson K, Denson S, Simpson D,
What can a primary care physician discuss with olderpatients to improve advance directive completionrates? A Clin-IQ.
J Patient Cent Res Rev. 2017:4:42-5.
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Mentation
Screening for:
's®~5''s'
Cognitive Decline Delirium
- Mini-Cog - CAM (Confusion Assessment Method)- SLUMS (St Louis University Mental Status) - NuDESC (Nursing Delirium Screening Scale)- MoCA (Montreal Cognitive Assessment)
Depression- PHQ-2orPHQ-9- Geriatric Depression Scale (GDS)
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Mobility - Falls
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IFoot or ankle disorders
Home hazards
Medications linked to falls |Medication management
IPoorbalai
Identify Modffl»b]l Fall Rlik Intervention]T^
|Adaptlve devices for walking (cane, walker)lOrthotics
I Home safety evaluation (OT)
IPostural hypotension
Vestibulardisorder
Vision impairment
Vitamin D deficiency
•Exercise
Strength/balance programs (Tai Chi, FT)
Medication managementStrength/balance programs (Tai Chi, PT)Exe,
Strength/balance programs (Tai Chi, FT)Cataract surgery
Corrective eye'Vital D supplementation
Medications
• Review Meds (e.g., Beers List)- Anticholinergics: Sedating antihistamines,
Muscle relaxants
- Anticonvulsants
- Antidepressants
- Anti psych otics
- Benzodiazepines/Sedative Hypnotics
- Blood Pressure Lowering Medications
-Opioids
^y• If >9 meds on list - considerreferral to clinical pharmacist ifavailable
- Stop meds when possible
- Reduce med dosage when applicable
- Switch to safer alternative;
Geriatric Fast Facts (GFFs)www. geri a tricfastfacts.com
• Concise, evidence-based summaries of key health care issues in the careof older adults
•Viewable on all electronic devices
•Searchable by:0 free text
o geriatric topic
o organ system
o ACGME competencyo dise;
0 underlying science
Geriatric Fast Facts
Recent Fast Facts
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Deprescribing Benzodiazepines in Elderly Patients - #73
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Deprescribing Benzodiazepines in Elderly Patients!Quiz-Fast Fact #73
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Let's Try the 4Ms: Case #1
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stop after Gsngko B'tSbao and tafks aboutMemory (2/3s in)
• What 4 Ms are Present(if any)?
• Top priority 4M?
4M: Mentation & GFFs
^ssessfKnt
*53 - Ina&prop'lflte Sexual Benav'ior (IS8) and3eme."tia Patien:M6 • AssesSTieit and P'evention of Qelirumcut34 - Ncrmg' P.'es5t<re Hvdrcce^ha.us»14 - Asiess;'ig Deiiriumtil - Dfaeiosfng Demtntia in AcLrteiy lit
Oepfession •."•-(t78 - FAQs ano Resources for Oemcntw PatientsCa'eB;versff75 - Eva.uatian & "'reatrr.crtt ot Mania in
Gefiatn; Pat.eits)t72 - Asses^-neA; of Deffien^ia P3t;e»ts •n the
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Case #2
Clifford Square: video 36Age98reflectonlife [Play all]
• What 4 Ms are Present(if any)?
• Top priority 4M?
4M: What Matters Most & GFFs
I »76 -Artificial Nutrition In Ad»anced Dementia|Pat<ents
#70 - Senior Hausing Optioiisi?62- Pov/e' ofAttomev tcr Health CareIftSl-AdvaiceDj'-e^ives|»59 - Tips ccr Leading Oimcu't FanilY Mee:iies
B36 - Should your patxnt have that oncolowinterver-tion
»33 - Per;-op?ra^e Manata'n<r': sf oo-Not-Resus:!iatc Orders i :hc State of w iconsin
»25 - Hone Care Sfrv-cts»22 - Hor'e Sa'ety Evaii-s: 01 Can I swd this
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Case #3
Mobility: video 2-4 Tang Square [Iftime, can cut hip pain then after meds
mentioned]
• What 4 Ms are Present(if any)?
• Top priority 4M?
4M: Mobility & GFFs
|4- Norms! Pressure HydrocephalusF2 - Perioperat've nerve injury prevention16 - Falls Rs< Factors & 1-te-ve-tions
.5 - Fall Etioloff,/ and Assessment-Assessing Ga t- Sircke Ir-psirment & Corn plications
thabilitation
.-Assessment of Fall Risk Etiology
4M: Medication & GFFs
^73 - Deprescribing Beniodiateftines in Etdtff^rpatwnts f.
|t68 - Dtforc&cn&ing Medcatior's i"- Eide'iv
patients
f>56 • OsteopcrosfsTfffatment
|i37 - Chemothfr'apv tox'c'tv
t29 - SystcfriiC Ejects of Ocular Mea:cations t;
pfaucoma and PL,p;''arv Dilation
(28 - Systems Ejects of Ocular Medications tL
l^gff-'-friatea Macular Degeneration
' - Med cations in Ge'fatric Otolarvr'gologyHvpcrtension
; - Caution; Per:oaerat've Sui^ery ^edicati'IA'0 - Antfcoagu'ation in tie Ge-iaTr'c SurgicalPfnt<& - Marajine Pain in Elder y S o =''actureNtiCTb 1>65 years!IBI- Pharmgcoloeic Aspects of Rentt Drut
knou'tcdp' ttiaapnK
Take - Away: Considering the 4MsBesides the fact that it will be coming your way via Health Care System
What Matters, M^edication, M.entation, Mobility can result in thebest care possible for older adults
1. Identity the 4Ms present with the patient
2. Prioritize which of the 4Ms needs to be addressed first
3. Utilize Geriatric Fast Facts to address the 4Ms
Questions? Think 4 Ms!
Geriatric Fast Facts (GFFs) - TwitterFollow us on Twitter
Re-Tweet w #GerFastFacts
Complete the Evaluation Please^@GerFastFacts
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BibliographyA. Hartford Foundation: Mate. K and Pallon. L. The Instlluts for Healthcareiystems: the 4Ms. Tfy This. 2019:35 httpsy/consultgeri.org/try-this/genaral-
Fulmar, T and Berman. A. TheImprovement Age-Friandlyassessment/issue-35.pdf
Richardson S. Making the 4Ms Practical in Primary Care - March 201B http3//www.stvincanl.ora/-/media/Files/lNIND/Servii:as/Ssniof-SBrvices/GHA/Mal(ing-th9-4Ms-Pfactica!-in-Primary-Care—Wlbrieht.pdffl3=en&hash=E68C60974303D474371DBBD94FBS4F2EF43FB6Da
MyerE. J. Duthie. E Jr, Denson. K.. Denson. S.. & Simpson. D. (2017). What can a primary care physician coldsr patients to Improva advanca directive completion ratss? ACIin-IQ. Journal of Pa'tisnt-Centered Resa.
4(1). 42-45.
Mini-CogTM. Retrisvsd V28/18.011916pdf
SLUMS. RetriGvedV28/18 from https-^/www.sucessfuJly/pd fs/menial-status-exam.pdf
Tanzi. Maria. (2012) Beers Revised: Meds not to use in olderhttp^/wwiM.pharmacist. com/beers-rensed-dfu^s-not-u se-older-a d l
r[py/mm wog. com/wp-con tent/upload^'2015/12/Un iversa t-Wmi-Cog-Fi.
I u/medicine/in ternal-medicin e/gerta tric-ivedicin e/aging-
rieved V23/18 from
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