The learning outcome for this activity: Participants will have increased knowledge of applying the Age-Friendly 4Ms Framework while caring for an older adult patient experiencing elements of Geriatric Syndrome in a convenient care setting.

1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Grand Rounds
PharmD.
NP
Physician
Topic: Age-Friendly Health Systems: Geriatric Syndromes
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2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Providing Age-Friendly Care
The goal is for all care with older adults to be Age-Friendly care, which:
• Follows an essential set of evidence-based practices;
• Causes no harm; and
• Aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each
case scenario. The 4Ms include:
• What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
• Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation,
and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the
older adult, Mobility, or Mentation
• Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
• Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that
older adults move safely in order to maintain function and do What Matters

3. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
How to Integrate 4Ms Care into the Clinic Visit
What Matters: These are some guiding questions or statements to help patients discuss what matters most to them:
• What is most important for you during today’s visit?
• What are you looking forward to this week?
• What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities?
• Consider discussion about advance care planning if appropriate for the visit
• During development of care plan: I would like to individualize your treatment with what matters most to you
Medication
• Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies
• Reconcile medications with electronic health record
• Cross-check for medications that may be on the AGS Beers© Criteria list
Mentation
• Assess patient’s ability to register, use kiosk, follow directions
• Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9©
• Screen for dementia using the Mini-Cog™
• Assess for delirium for any acute change in mental status using the Confusion Assessment Method
Mobility
• Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test
• Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name

4. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Learning Objectives
At the end of this session, providers will be able to:
• Identify conditions associated with geriatric syndromes
• Identify concerns regarding mobility among older adults
• Identify polypharmacy and principles of de-prescribing
• Identify the interrelationship of the 4Ms in the context of an acute or chronic condition
• Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over

5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Geriatric Syndromes
(S) Situation: 84 year old Joseph presents to clinic with his caregiver complaining of fatigue and back pain. These
have occurred off and on for the past year or so but he became concerned recently when a sore was noted on his
buttocks.
(B) Background: PMH: Hypertension, hyperlipidemia, gout, insomnia, COPD, anxiety, benign prostatic
hypertrophy, and urinary incontinence.
PSH: B/L knee replacements 5 years ago
Medications: amlodipine 10 mg PO daily, atorvastatin 20 mg PO daily, allopurinol 200 mg PO daily, finasteride 5
mg PO daily, and hycosamine 0.125 mg PO BID, buspirone 10 mg PO BID, salmeterol 1 puff BID, melatonin 3 mg
PO every night, ginkgo biloba, fish oil capsules, multivitamin.
Smokes 1 PPD and has a history of alcohol abuse
He is inactive due to back pain and fatigue

6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Geriatric Syndromes (Cont.)
(A) Assessment: VS: BP 118/70 mmHg, HR 70/min, RR 18/min, Temp 97.4F, SpO2 93% on room air
Mentation: PHQ-2 = 0 (negative for depression); Mini-Cog = 1 (positive: recalled 1 word; missed 2 words)
Mobility: Get Up and Go test indicates some fall risk with slow walking speed. Unsteady gait.
General: Disheveled with cigarette burns on his clothing, strong odor of urine, flat affect
Skin: Stage 2 pressure injury noted on sacrum 1 X 1 cm with no exudate or eschar
HEENT: Normal
Respiratory: Diminished breath sounds bilaterally with some expiratory wheezes
Cardiac: Regular rate and rhythm, S1, S2, no murmur
Abdomen: Soft & non-distended
(R): Recommendation: Let’s discuss…

7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Geriatric Syndromes
"Geriatric syndromes" is a term that refers to common health conditions experienced by older adults outside
of distinct organ-based disease categories. They often have multifactorial causes and may affect quality of
life and function. Assess and act upon findings for each. Examples:
• Cognitive impairment
• Incontinence
• Malnutrition
• Falls/gait disorders
• Pressure injuries
• Fatigue/sleep disorders
• Sensory impairment

8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Recommendations: Address Geriatric Syndromes
Address geriatric syndromes
• Pressure injury: Treat pressure injury stage per institutional guidelines; treat pain that is leading to
immobility; suggest future pressure injury prevention strategies such as turning and positioning frequently,
assist with bathing, dressing, and skin care
• Function: Consider assistance with activities of daily living bathing, dressing, skin care
• Cognitive impairment: Follow up with primary care provider
• Urinary incontinence: Consider toileting schedule and routine
• Mobility and gait impairment, fall risk: Treat pain; Consider physical therapy; Consider assistive device
Address home safety issues
• Risk of fire related to smoking and burn marks noted on clothing
• Suggest social work referral for home evaluation
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider

9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Get Up and Go Test: Mobility and Gait Assessment
Interpretation Mobility Assessment
No fall risk Well-coordinating movements without difficulty walking
and without walking aid
Low fall risk Controlled, but adjusted movements; may be using
aid/assistive device
Some fall risk Uncoordinated movements
High fall risk Supervision necessary
Very high fall risk Stand by physical support necessary
INSTRUCT the older adult to sit in a straight-backed arm chair, get up (without use of arm rests, if possible),
stand up still momentarily, walk forward 3 meters (10 feet), turn around, walk back to the chair, and sit down.
The older adult should be using usual footwear and any usual assistive device.
OBSERVE sitting balance, transfer from sitting to standing, pace and stability of walking, ability to turn without
staggering

10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Timed Up & Go (TUG) Test: Another type of mobility assessment
Mobility Rating Seconds to Complete
Freely mobile Less than 10 seconds
Mostly independent 10-19 seconds
Variable mobility 20-29 seconds
Impaired mobility Greater than 29 seconds
The Timed Up & Go (TUG) test measures the time in seconds it takes a person to stand up
from a standard arm chair, walk 3 meters (10 feet), turn, walk back to the chair, sit down again
using usual footwear and usual assistive device.
Source: Podsiadlo, D., & Richardson, S. (1991). The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142-148.
CDC. Timed Up and Go Test: https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf

11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Polypharmacy Affects Older Adults in Multiple Ways
• Greater risk for adverse drug events (ADE) due to metabolic changes and decreased drug clearance
associated with aging; risk compounded by increasing number of drugs used
• Increased risk for drug-drug, drug-nutrient and drug-disease interactions
• Increased risk for prescription of potentially inappropriate medications
• Increased possibility of “prescribing cascades” which may occur when an ADE is misinterpreted as a new
medical condition thereby leading to additional drug therapy to treat that condition
• Risk of adherence issues related to medication regimen, especially complex medication regimen

12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Appropriate Prescribing in Older Adults
• Is there an indication for the drug?
• Is the medication effective for the condition?
• Is the dosage correct?
• Are the directions correct?
• Are the directions practical?
• Are there clinically significant drug-drug, drug-disease/condition, drug-nutrient interactions?
• Is there unnecessary duplication with other drugs?
• Is the duration of therapy acceptable?
• Is this drug the least expensive alternative compared with others of equal usefulness?

13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
AGS Beers Criteria© 2019: Highlights
Avoid the concurrent use of opioids with either benzodiazepines or gabapentinoids due to increased risk of
overdose and severe sedation-related adverse events such as respiratory depression and death
Use caution when prescribing trimethoprim-sulfamethoxazole in patients who are taking an angiotensin-converting
enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB), and who have decreased creatinine clearance, to avoid hyperkalemia
Use caution when prescribing H2-receptor antagonists and avoid in patients with delirium
Use caution when recommending aspirin for primary prevention of cardiovascular disease or colorectal cancer in patients age 70
or older (down from previous threshold of 80 years or older), due to increased risk of bleeding
Avoid the use of serotonin-norepinephrine reuptake inhibitors (SNRIs) in patients with a history of falls or fractures
Avoid the use of sliding-scale insulin regimens due to the risk of hypoglycemia without benefit of improvement in hyperglycemic
management, unless patients are also on basal or long-acting insulin
The 2019 American Geriatrics Society (AGS) Beers Criteria® Update Expert Panel (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria®
for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society, 67(4), 674-694. doi: 10.1111/jgs.15767.
Available online at geriatricscareonline.org/ProductAbstract/american-geriatrics-society-updated-beers-criteria/CL001

14. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Start Low and Go Slow
Obtain a comprehensive history/review of ALL medications. Ask: "What prescription medications, over-the-counter
medicines, vitamins, laxatives, herbal remedies, and/or supplements do you use?"
De-prescribe. Discontinue unnecessary therapy. Clinicians may be reluctant to stop medications, especially if they did not
initiate the treatment and the patient seems to be tolerating the therapy. This may increase risk for an adverse event with limited therapeutic
benefit. Medication continuation or discontinuation decisions should be based upon the goals of care and risk of ADEs.
Targets for treatment may vary based on age and comorbidities. Note that some targets for treatment are based on
outcomes evidence from studies with younger adults and, hence, may not be appropriate for older adults.
Clinical guidelines may not be tailored to the older adult. This may lead to overly aggressive goals for management of
hypertension, diabetes or other common conditions among older adults.
Many ADEs are dose-related; use the minimal dose required to obtain the clinical benefit
Start with lowest dose and frequency; titrate up slowly as indicated

15. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Back to the case…
Summary: ASSESS and ACT ON the 4Ms as a set
What Matters: Know and act on each patient’s specific health outcome goals and care preferences
• Treat pain; Treat pressure injury per guidelines and institute pressure injury prevention measures; educate patient and
caregiver about toileting schedule
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and
what matters
• Address polypharmacy; Reconcile medications to fewest necessary drugs: Consider deprescribing
https://deprescribing.org (e.g. ginkgo biloba, fish oil)
Mentation: Focus on dementia and depression and delirium
• Screen for dementia and depression; Consider social worker for home safety evaluation and follow up
Mobility: Maintain mobility and function and prevent/treat complications of immobility
• Walk multiple times daily; Consider assistive device; Physical therapy if needed to promote mobility
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider

16. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Interprofessional Team Discussion…

17. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Acknowledgements
Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare
Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health
Association of the United States (CHA).
MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A.
Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.

18. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Thank You