Introduction

With our aging population, general internists play crucial roles caring for older adults in various settings. The Geriatric 5Ms (Mobility, Mind, Medications, Matters Most, and Multicomplexity) were launched in 20171 and are now a ubiquitous framework highlighting the core components of geriatric care. The Age-Friendly Health System initiative promotes a similar 4Ms framework (Mobility, Mentation, Medication, and What Matters) to incorporate evidence-based geriatric principles on a systems level.2

The 5Ms map onto elements of the comprehensive geriatric assessment (CGA), in which an interdisciplinary team assesses and develops a holistic plan for an older adult. CGA leads to improved outcomes, including increased likelihood to be alive and at home following hospitalization, and reduced risk of unplanned hospital admission.3, 4 This evidence provides additional impetus to incorporate the 4/5Ms framework into the general internist’s clinical practice.

The following is an overview of each M focused on relevance to general internists, along with practical tools.

Mobility

Mobility encompasses gait, balance, fall prevention, and function, which greatly impact quality of life and prognosis. While falls are common and can lead to significant morbidity and mortality, patients may hesitate to mention them. Screening is therefore critical. One can ask about a history of falls or feeling unsteady and incorporate the Timed Up and Go, 30-Second Chair Stand, or 4-Stage Balance Test; these and other resources are available on the CDC’s STEADI website. In all clinical settings, we recommend systematically evaluating patients with falls or risk for falls, considering both intrinsic factors (e.g., sensory impairment, pain, incontinence, musculoskeletal conditions, neurological disease, cardiopulmonary conditions) and extrinsic factors (e.g., medications, footwear, home safety). Care plans can then incorporate targeted interventions. Physical and occupational therapists can further enhance evaluation and management.

Mind

Mind/Mentation encompasses cognition and mood. Older adults may experience cognitive decline ranging from age-related cognitive changes to dementia and may have more risk factors for developing delirium. Internists are often the first to notice, evaluate, and manage cognitive changes, whether chronic (e.g., dementia) or acute (e.g., delirium). Cognitive concerns often span care transitions and thus deserve special attention from internists, such as dementia suspected during hospitalization requiring full outpatient evaluation, or subtle delirium lingering after hospital discharge. Internists can use screening tools such as the Mini-Cog for dementia and Confusion Assessment Method for delirium and can refer based on local resources. After a diagnosis, internists are critical in ongoing counseling, caregiver engagement, and future planning.

Older adults often face grief, significant adjustments in function and living situations, and mood disorders. Given the strong relationships PCPs have with their patients, their role in recognition and management is indispensable.

Medications

Biologic changes with aging, medical conditions, and polypharmacy lead to increased risk of medication side effects and adverse events, including falls and delirium. In all settings, internists can avoid potentially inappropriate medications, monitor for adverse effects, deprescribe as appropriate, and simplify regimens. Accurate medication reconciliations are crucial, especially at transitions of care. Clinical pharmacists, if available, can provide recommendations and counseling. Resources include the American Geriatrics Society Beers Criteria, deprescribing.org, and ePrognosis.org’s “time to benefit” decision aid.

Matters Most

Matters Most focuses on patients’ healthcare goals and preferences, no matter their stages of life. Recognizing a patient’s likely trajectory is helpful for these conversations, and ePrognosis.org provides evidence-based calculators to help inform this understanding. Additionally, free, patient-centered tools are available. The Stanford Letter Project and PREPARE for Your Care provide education and tools for advance care planning. Plan Your Lifespan helps patients and families prepare for life-changing events or diagnoses, such as hospitalizations, falls, and dementia. Patient Priorities Care helps emphasize the patient’s voice and align care with what is most meaningful and feasible.

Multicomplexity

Multicomplexity involves the multimorbidity and complex biopsychosocial situations that older adults frequently experience. Older adults are often excluded from clinical trials, limiting applicability, and having multiple chronic conditions can lead to competing medical recommendations. Principles for managing multimorbidity include understanding the patient’s primary concern and preferences, assessing adherence and comfort with the treatment plan, accounting for prognosis, and serially reassessing the plan.5 Patient Priorities Care, noted earlier, incorporates many of these steps. To help navigate complex biopsychosocial situations, interdisciplinary teamwork with case managers and social workers is key. Clinicians can also refer patients and their loved ones to local area agencies on aging or Eldercare Locator to help navigate resources.

Conclusion

The Geriatric 4Ms and 5Ms offer clear frameworks to provide comprehensive, person-centered care for older adults in any general internal medicine care setting. Ideally, these principles are integrated into the comprehensive care internists already provide. If needed, domains can be addressed iteratively—for example, understanding what Matters Most during one visit and focusing on Mobility during the next. Furthermore, this framework can be used to improve communication with patients and healthcare team members, educate trainees on geriatric care, and prioritize Age-Friendly Care in our health systems. We encourage SGIM members to familiarize themselves with the 4/5Ms and incorporate them into practice.

References

  1. Tinetti M, Huang A, Molnar F. The geriatrics 5M’s: A new way of communicating what we do. J Am Geriatr Soc. 2017 Sep;65(9):2115. doi:10.1111/jgs.14979. Epub 2017 Jun 6.
  2. Mate K, et al. Evidence for the 4Ms: Interactions and outcomes across the care continuum. J Aging Health. 2021 Aug-Sep;33 (7-8):469-481. doi:10.1177/0898264321991658. Epub 2021 Feb 8.
  3. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017 Sep 12;9(9):CD006211. doi:10.1002/14651858.CD006211.pub3.
  4. Briggs R, McDonough A, Ellis G, et al. Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people. Cochrane Database Syst Rev. 2022 May 6;5(5):CD012705. doi:10.1002/14651858.CD012705.pub2.
  5. American Geriatrics Society expert panel on the care of older adults with multimorbidity. Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. J Am Geriatr Soc. 2012 Oct;60(10):E1-E25. doi:10.1111/j.1532-5415.2012.04188.x. Epub 2012 Sep 19.

Issue

Topic

Clinical Practice, Featured Article, Geriatrics/Palliative Care, SGIM, Vulnerable Populations

Author Descriptions

Drs. Szymanski (eva.szymanski@pennmedicine.upenn.edu) and Zuo (jessica.zuo@pennmedicine.upenn.edu) are assistant professors of clinical medicine in the Division of Geriatrics at the University of Pennsylvania, where they co-direct the Internal Medicine residency program’s Aging and Transitions curricula.

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