Geriatrics is a specialized field of medicine that focuses on the health care of older adults. Unlike general medicine, which may prioritize disease treatment, geriatrics takes a holistic approach, considering the complex interplay of physical, mental, and social factors that influence an older person's well-being. At the heart of this patient-centered approach is the 4Ms Framework, developed by the Institute for Healthcare Improvement (IHI) and the John A. Hartford Foundation to standardize and improve care for older adults across all settings. These four pillars—What Matters, Medication, Mentation, and Mobility—serve as a roadmap for clinicians and caregivers to deliver high-quality, person-centered care.
What Matters: Centering Care on the Patient's Values
The first and most important pillar of the 4Ms framework is "What Matters." This component emphasizes that the priorities and goals of the older adult must be the central focus of all care decisions. This goes beyond a simple medical history and requires a deeper understanding of the patient's personal preferences, values, health outcome goals, and life priorities. For a geriatrician, this means asking questions and truly listening to the patient's answers to understand their perspective on quality of life. For example, an older patient with arthritis may value being able to walk in their garden more than a specific medication, so the care plan should reflect that priority by focusing on mobility rather than just medication. What Matters also involves understanding and respecting a patient’s preferences for end-of-life care, ensuring their final wishes are honored.
Key considerations for implementing "What Matters":
- Goal-oriented conversations: Clinicians must regularly engage in discussions with patients and their families about what is most important to them regarding their health and daily activities.
- Documentation: Patient goals and preferences should be clearly documented in the medical record to ensure all members of the care team are aligned.
- Aligning treatment plans: Medical interventions and care plans should be crafted to support and align with the patient’s expressed goals, not just to treat a diagnosis.
Medication: Managing Complex Drug Regimens
Older adults often take multiple medications for various chronic conditions, a practice known as polypharmacy. The Medication pillar focuses on ensuring that all prescriptions and over-the-counter drugs are age-friendly, necessary, and do not interfere with what matters to the patient, their mentation, or their mobility. Geriatricians use specific criteria, such as the American Geriatrics Society's (AGS) Beers Criteria, to identify potentially inappropriate medications for older adults.
Effective medication management involves:
- Comprehensive medication review: A regular, thorough review of all medications to identify and reduce potentially harmful drugs.
- Deprescribing: Safely and systematically stopping or reducing medications that are no longer beneficial or are causing harm.
- Addressing polypharmacy: Minimizing the number of medications to reduce the risk of adverse drug events and dangerous drug interactions.
- Patient education: Informing patients and caregivers about why and how to take their medications safely, and what potential side effects to look for.
Mentation: Supporting Mental and Cognitive Health
The Mentation pillar addresses the mental health and cognitive function of older adults, including the prevention, identification, and management of dementia, depression, and delirium. These conditions are common among older adults and can significantly impact their independence and quality of life. An age-friendly approach ensures regular screening and appropriate care for these cognitive and mood disorders.
Components of the Mentation pillar include:
- Screening for cognitive impairment: Using tools like the Mini-Cog or Montreal Cognitive Assessment (MoCA) to regularly check for signs of dementia.
- Preventing and managing delirium: Implementing strategies in hospital settings and long-term care facilities to prevent and quickly identify delirium, a sudden state of confusion that often indicates an underlying medical issue.
- Addressing depression and anxiety: Utilizing validated screening tools like the Patient Health Questionnaire-2 (PHQ-2) or Geriatric Depression Scale (GDS) to identify and manage mood disorders.
- Referrals to specialists: Connecting patients and caregivers with resources, such as the Alzheimer's Association or mental health providers, for specialized support.
Mobility: Maintaining Functional Independence
The Mobility pillar focuses on ensuring that older adults move safely every day to maintain their functional independence and do what matters to them. Mobility challenges, including gait and balance issues, are major risk factors for falls, which can lead to serious injuries and a significant decline in quality of life. This pillar emphasizes proactive measures and interventions to improve physical function and prevent falls.
Key strategies for promoting mobility:
- Regular physical activity: Encouraging daily, safe movement, potentially with the help of physical therapy.
- Fall risk assessment: Regularly assessing patients' balance and gait using tools like the Timed Up and Go (TUG) test.
- Managing impairments: Addressing conditions that limit mobility, such as pain, arthritis, and gait imbalances.
- Creating a safe environment: Recommending home modifications to reduce fall hazards, such as removing throw rugs and adding grab bars.
Comparison of 4Ms vs. Traditional Geriatric Assessment
| Feature | 4Ms Framework (Age-Friendly Care) | Traditional Geriatric Assessment (CGA) |
|---|---|---|
| Focus | Prioritizes four key, interconnected elements: What Matters, Medication, Mentation, Mobility. | Comprehensive evaluation covering multiple domains like physical health, mental health, functional status, and social circumstances. |
| Application | Designed for reliable, evidence-based care in all healthcare settings and across all transitions of care. | Often used in specialized geriatric clinics or inpatient settings to create a detailed care plan. |
| Patient Involvement | Patient's goals and preferences ("What Matters") are the starting point and central guiding principle of care. | Patient input is a component, but the framework is not explicitly centered on patient priorities in the same way. |
| Efficiency | Helps streamline complex care decisions by focusing on the most critical, high-impact areas for older adults. | Can be a lengthy and resource-intensive process, potentially leading to treatment fragmentation if not properly coordinated. |
| Goal | To organize and simplify care delivery for older adults, improving consistency and quality across an entire health system. | To create a detailed, multidisciplinary care plan to address all identified problems in an individual patient. |
The Interconnectedness of the 4Ms
The strength of the 4Ms lies in their interconnected nature. A change in one pillar can significantly impact the others. For example, a new medication (Medication) could cause dizziness, leading to a fall (Mobility) and increased fear of falling, which could contribute to depression (Mentation). Conversely, addressing mobility issues through physical therapy might improve physical function, which in turn could reduce depressive symptoms and help the patient achieve their personal goals (What Matters). Geriatric care uses this integrated perspective to create a more comprehensive and effective treatment plan. The 4Ms work synergistically to address the complex needs of older adults, helping them maintain their independence and enhance their overall quality of life.
Conclusion
The 4Ms—What Matters, Medication, Mentation, and Mobility—represent a foundational shift towards person-centered care in geriatrics. This framework provides a standardized yet personalized approach for healthcare professionals to assess, manage, and optimize the health of older adults. By deliberately focusing on what is most important to the patient, carefully managing medications, addressing mental and cognitive health, and promoting safe mobility, healthcare systems can reliably deliver high-quality, age-friendly care. This structured approach helps ensure that older adults are not merely surviving, but thriving in their later years, with their dignity and well-being at the forefront of every care decision.
Sources:
- Fulmer, T., Mate, K. S., & McKay, M. (2021). Evidence for the 4Ms: Interactions and Outcomes across the Continuum of Care. Geriatric Nursing, 42(3), 850–858. https://pmc.ncbi.nlm.nih.gov/articles/PMC8236661/
