A Framework for High-Quality Senior Care
The care of older adults can be complex, often involving multiple chronic conditions, numerous medications, and changing physical and cognitive abilities. To address this complexity, the Institute for Healthcare Improvement (IHI) developed the Age-Friendly Health Systems initiative, which is built on a set of four evidence-based elements known as the “4Ms.” This framework serves as a guide for all healthcare settings, helping to focus care on what is most important to the patient and ensuring that every older adult receives the best care possible.
The 4Ms are not a program to be added to existing care, but rather a reorientation of how care is organized and delivered. By systematically applying this framework, health systems can ensure they address the core needs of older adults in a comprehensive and consistent manner.
What are the 4Ms in the care of older adults?
The four components of the 4Ms framework are:
- What Matters: Aligning care with the older adult's health goals and preferences.
- Medication: Managing medications to reduce harm and ensure effectiveness.
- Mentation: Preventing and managing mental health conditions like dementia, delirium, and depression.
- Mobility: Ensuring the older adult can move safely and maintain function.
What Matters: The Patient's North Star
At the heart of the 4Ms is a deep respect for the individual's wishes and life goals. This principle ensures that all medical decisions and care plans are aligned with what the older adult and their family prioritize. It is the "North Star" that guides all other aspects of care.
- Aligning Goals: Clinicians and care teams engage in conversations to understand the patient's personal priorities. For some, this might mean a focus on maintaining independence at home, while for others, it might be about managing pain to enjoy hobbies.
- Shared Decision-Making: By involving the patient in their care planning, healthcare providers empower them to take an active role in their health. This builds trust and ensures that care is both effective and meaningful to the individual.
- Advanced Care Planning: What Matters conversations often include discussions about advanced directives and end-of-life wishes, ensuring the patient's desires are honored throughout their care journey.
Medication: Safe and Effective Prescribing
Older adults are often on multiple medications, increasing the risk of adverse drug events. The Medication 'M' focuses on optimizing prescribing to reduce unnecessary harm and burden.
- Regular Review: Care teams regularly review all medications, including over-the-counter drugs and supplements, to identify any that are no longer necessary or may cause side effects.
- Avoiding High-Risk Medications: The framework encourages clinicians to minimize the use of certain high-risk medications that can negatively impact mentation and mobility in older adults.
- Impact on the other 3Ms: This component considers how medication affects the patient's What Matters, Mentation, and Mobility, ensuring a holistic view of the person's overall health.
Mentation: Protecting Mind and Mood
This 'M' focuses on maintaining cognitive function and addressing common mental health issues such as dementia, depression, and delirium. These conditions can be overlooked or misdiagnosed in older adults, so proactive screening and management are essential.
- Routine Screening: Care teams screen for cognitive changes and risk factors for delirium, especially during transitions of care or hospitalization.
- Managing Cognitive Decline: For individuals with dementia, care is focused on managing symptoms, providing support for caregivers, and creating a safe, familiar environment.
- Addressing Depression: Screening for depression is a crucial part of the Mentation 'M', as depression in older adults is often under-recognized and undertreated.
Mobility: Promoting Safe and Active Living
Maintaining mobility is crucial for an older adult's independence and quality of life. The Mobility 'M' ensures that patients are encouraged to move safely and that risks of falls and functional decline are addressed.
- Early Mobilization: The framework promotes getting older adults up and moving as soon as it is safe to do so, particularly in hospital settings, to prevent functional decline.
- Fall Prevention: Assessment and mitigation of fall risks are standard practice, including reviewing medications, assessing gait, and recommending home safety modifications.
- Physical Activity: Care teams work with patients to set realistic mobility goals that align with their personal priorities, promoting physical activity as a way to maintain strength and function.
The Integration of the 4Ms
The power of the 4Ms lies in their synergistic application. They are not isolated elements but are deeply interconnected. A change in one area can significantly impact the others. For example, a medication adjustment (Medication) could improve an older adult's cognitive clarity (Mentation), allowing them to more effectively communicate their goals and wishes (What Matters) and safely increase their physical activity (Mobility).
The framework provides a structured yet flexible approach that can be tailored to the specific needs of each patient. It shifts the focus from simply treating diseases to optimizing the whole person's health and well-being.
The Age-Friendly Difference: A Comparison
| Aspect | Traditional Care | 4Ms Age-Friendly Care |
|---|---|---|
| Focus | Primarily on treating diseases and symptoms. | Holistic and patient-centered, focusing on wellness and strengths. |
| Priorities | Often driven by the healthcare provider's agenda. | Driven by the older adult's personal goals and preferences (What Matters). |
| Medication Management | Prescribing based on specific conditions, often without a comprehensive view. | Systematic review and optimization to minimize harm and align with patient goals (Medication). |
| Cognitive Health | Often addresses mental health reactively after issues arise. | Proactive screening for dementia, delirium, and depression is integrated into routine care (Mentation). |
| Mobility | Limited focus on mobility, especially during hospital stays. | Actively promotes safe movement to maintain function and prevent decline (Mobility). |
| Coordination | Can be fragmented across different specialists and settings. | Encourages a team-based approach where all 4Ms are considered together across transitions of care. |
Conclusion: A Paradigm Shift in Geriatric Care
Understanding what are the 4Ms in the care of older adults is fundamental for anyone involved in senior health, from family caregivers to healthcare professionals. This evidence-based framework represents a significant paradigm shift from disease-centered to patient-centered care. By prioritizing What Matters, managing Medications wisely, addressing Mentation, and promoting Mobility, the 4Ms empower older adults to live healthier, more independent, and more fulfilling lives.
For more detailed guidance on implementing this framework, organizations can refer to resources from the Institute for Healthcare Improvement (IHI), a leading authority in the field. The Institute for Healthcare Improvement provides comprehensive tools and resources for adopting the 4Ms.
