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 addressed 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.  A 5^th M is sometimes incorporated to include Multi-Morbidity, which calls attention to the multiple, often inter-related, health problems that many older adults face.

The domain of “Mentation” encompasses both cognitive and psychiatric health.  Incorporating mentation into the 4M framework assists the provider to:

• Identify the presence of a cognitive, mood or psychiatric disorder
• Better define the prognosis of a cognitive or psychiatric illness or disorder
• Identify and discuss potential treatment and care options
• Assist with caregiver support services
• Identify factors that could impact other facets of the individual’s care ( for example, changes in what matters most, medication choices, mobility and functional issues, and the impact of mentation on the management of multi-morbidity conditions)

• Better enable anticipatory guidance for safety and well-being

Cognitive health:

Changes in mentation and cognitive decline represent a complex continuum in older adults, and often represent a multifactorial progression over time.  The rate of cognitive change often indicates the nature of the underlying pathology, whether it is a slow or rapidly progressive dementia, or whether it is more likely to be an acutely presenting delirium.  To better define cognitive baseline and  the trajectory of change, it is important to thoughtfully assess cognitive function regularly.  Several tools are helpful in quantifying cognitive function, but it is important to remember that scores between different tools are not equivalent, and it is helpful to document the subcomponents and scores of a test to be able to compare between tests.

The current iteration of the DSM-5 uses the term neurocognitive disorder (NCD) to classify a change in cognitive function and replaces the term dementia with a more flexible framework. Minor NCDs comprise subjective and objective declines in cognitive performance that do not impact an individual’s ability to function at home or work, as benchmarked against an individual’s prior, baseline ability to complete basic and instrumental activities of daily living. Minor NCDs encompass preclinical asymptomatic cognitive changes and a mid-stage of mild cognitive impairment (MCI).  A percentage of individuals with MCI will progress into advanced NCD, termed major NCD, which correlates clinically with dementia, although not exclusively of the Alzheimer’s type. 

It is important to note that early cognitive decline can be undiagnosed in many individuals who still can maintain a semblance of their normal function.  Screening, corroborative histories from families, and monitoring for changes compared to prior baselines are important tools in identifying a cognitive disorder.  While there are rarely cures to cognitive decline, most dementing disorders represent a chronic degenerative disease that is terminal on its own trajectory, separate from other comorbidities.  Diagnosis allows for optimization of safety and function, and allows more resources to be made available to caregivers and families. 

Please reference Geriatric Fast Facts #11, 14, 63, 72, 77, 95, 96, 97 as related to dementia assessment and management.  GFF #14 addresses delirium.

Tools for assessing cognitive health include:

• The Montreal Cognitive Assessment (MoCA).  | MoCA Test (mocacognition.com)
• St Louis University Mental Status (SLUMS) Exam.  slums form.pdf
• The Mini-Cog quick screen for dementia.  Mini-Cog© – Quick Screening for Early Dementia Detection

Rapid changes in cognitive performance or mood may constitute an acute encephalopathy or delirium, which could be a manifestation of an urgent or emergent medical condition.  Early identification of delirium, and intervention towards the precipitating causes, may decrease morbidity and mortality, and may limit secondary complications. 

Mentation assessment (both cognitive and psychiatric) may help identify potentially reversible or contributing pathologies affecting cognition, (e.g., thyroid disease, depression, anxiety, nutritional deficiencies, liver or renal disease causing hepatic and uremic encephalopathy, sleep apnea compromising cognitive function, or cardiac disease affecting CNS perfusion).

Psychiatric health:

Depression occurs in 7% of the general older population (2), and is often an underdiagnosed and undertreated problem, particularly when superimposed against multiple comorbidities and concurrent cognitive disorders.  Often, it is a linked comorbidity with dementia, and many of the manifestations of depression and anxiety can worsen performance on cognitive testing.  Diagnosis and treatment can greatly improve quality of life, and potentially improve cognitive components of these diagnoses.  Depression has also been linked as an independent risk factor for developing dementia.  Similarly, anxiety is a common psychiatric diagnosis in elderly patients. 

Please reference Geriatric Fast Facts #2, 40, 73, 75, 82, 94, 98 as related to depression and psychiatric topics in the elderly.

Tools for assessing psychiatric health include:

• PHQ2: PHQ-2 (English) (aidsetc.org)
• GDS: Microsoft Word - ML_07_gds.doc (missouri.edu)
• GAD: GAD-7_Anxiety-updated_0.pdf (adaa.org)