In 2017, the Institute for Healthcare Improvement (IHI), the John A Hartford Foundation (JAHF), the American Hospital Association (AHA) and the Catholic Health Association (CHA) of the United States attempted to address the development of age-friendly health systems using a clinical framework to improve the complex care of older adults.

These organizations defined and operationalized age-friendly care following the guidelines of beneficence, evidence-based medicine, and patient/family aligned goals and concerns. The 4M Framework was the result: What Matters Most, Mentation, Mobility, and Medication.

What Matters Most: aligns care to what the patient feels is most important in their life.  It provides both an opportunity and tool to communicate this information with family, surrogate decision makers, and the healthcare team. The framework creates a forum for difficult topic discussions such as:

• approaches and limits to care (e.g., DNR, DNI, rehospitalization)
• degree of invasiveness of therapies/treatments (e.g., surgery, chemotherapy, invasive nutrition support) 
• appropriateness of shifting towards palliative care measures or instituting other end of life care.
• Issues of independence (e.g., living arrangements, driving, personal goals).  

When the patient is unable to communicate what matters, this “what matters most” structure creates a forum for surrogates/family to discuss what the patient would have wanted care-wise. This first “M” emphasizes patient autonomy and decision-making.   

Useful tools and resources for defining and documenting what matters most:

• POLST: Physician Orders for Life Sustaining Treatment. Https://polst.org. State specific forms can be found by searching “POLST” and the state or region name.
• Power of attorney for healthcare documents:  These tend to be state specific, and there is no national document that is universally accepted.  Ideally, the search terms should include “Power of attorney for healthcare” and the state / region name. One example is Five Wishes advance directive documents:  Https://fivewishes.org.  

Mentation: is key in determining the level of care and supervision needed by patients, as well as their ability and level of involvement in directing their health care. Dementia testing and documenting of cognitive function allow tracking of neurocognitive changes over time with benchmarking levels and rates of decline for future testing. Delirium is the brain’s response to acute medical stressors and represents a more urgent form of encephalopathy.  It’s identification and management is often considered a medical urgency or emergency. Correct identification of acute changes to brain function are essential to identify and manage delirium, as it can be a symptom of a life-threatening condition or evolving medical problem. Depression impacts both quality of life and comorbid medical problems.  Additionally, symptoms of depression may be misinterpreted as normal aging, dementia, and other medical problems. Tools to assess and document mentation include:

• The St. Louis University Mental Status (SLUMS) Test: https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/assessment-tools/mental-status-exam.php  
• The Mini-Cog:  https://mini-cog.com
• The Confusion Assessment Method (CAM):  https://geriatricstoolkit.missouri.edu/cog/Confusion-Assessment-Method-delirium.pdf
• The Geriatric Depression Scale (GDS):  https://geriatrictoolkit.missouri.edu/cog/GDS_SHORT_FORM.PDF
• Patient Health Questionnaire for Depression (PHQ-9):  www.med.umich.edu/1info/FHP/practiceguides/depress/score.pdf

Mobility: includes gait and balance assessment and fall prevention strategies with an emphasis on safe mobility.  More than a third of adults over 65 years old fall each year. Proactive management of falls can decrease mortality and morbidity issues and decrease overall healthcare costs.

Useful tools and references in mobility assessment
•    The Timed Up and Go test (TUG): https://www.cdc.gov/steadi/pdf/TUG_test-print.pdf

Medication: use in older adults requires a thoughtful approach using medications and doses that interfere least with What Matters Most, Mentation, and Mobility.  All medications should be reviewed and assessed for appropriate prescribing, with potentially inappropriate medications either avoided or deprescribed as necessary.
Useful tools and references:

• American Geriatrics Society Beers Criteria:  https://geriatrictoolkit.missouri.edu/drug/Beers-Criteria-AGS-2019.pdf
• CMS High Risk Medication List for Elderly:  https://www.centerforpatientsafety.org/resource/cms-high=risk-medication-list/