The 4 M’s Framework: Case History and Physical Examination of Older Adults

The population of older adults, or persons aged 65 and older, is rapidly increasing nationally and globally. Regardless of the area of practice entered, to optimize the care of patients, it is critical to be aware of unique considerations for this population. To optimize the care of older adults, the John A. Hartford Foundation and The Institute for Healthcare Improvement have partnered to create the Age-Friendly Health System initiative. This initiative aims to disseminate evidence-based care models and frameworks of decision-making that embody the 4 M's of Geriatric Medicine (What Matters, Mobility, Medications, and Mentation). Here, details of specific considerations in the older adult with reference to the 4 M's will be demonstrated. While a comprehensive evaluation of the older adult includes physical exam considerations in each of the 4 M's below, each visit does not need to include every portion of the below protocol. 

What Matters: Studies have shown that older adults vary in the health outcomes (preserving function, managing symptoms, or maximizing longevity) that matter most to them and the interventions they will accept to achieve them. As part of a comprehensive evaluation of the older adult, help the patient identify the health outcomes they most want to achieve. Focused evaluation of their health conditions and physical examination can help guide patients on what outcomes are realistic and achievable. This information can assist decision-making over time. To ensure that patients, including older adults, receive the care that best aligns with their individual goals and healthcare preferences, they should consider their goals and values, identify a healthcare surrogate decision-maker, and document their wishes. Healthcare systems often have forms and tools available to clinicians. Some evidence-based resources include the Patient Priorities Care website and the Prepare for Your Care website. These tools help patients and their caregivers consider what matters most to them in their healthcare and who should help them make decisions.

Medication: Evaluation of a patient's medication list, including over-the-counter medications, is essential to help guide focused physical examination and clinical decision-making. Half of the patients over 65 years of age take five or more medications daily, which is the traditional definition of "polypharmacy." With increasing numbers of medications, there is a high risk for drug-drug interactions, drug-disease interactions, and potentially inappropriate medications or doses. Studies of polypharmacy outcomes have found associations with falls, adverse events, hospitalizations, cognitive and functional decline, and mortality. The physical exam should include ongoing assessment for medications' common and severe side effects (for example, orthostatic hypotension with anti-hypertensives, bradycardia with B-blockers, bruising with aspirin). A helpful resource to identify potentially harmful medications in older adults is the Beers List, a list of medications categorized by the mechanism of action. There are multiple validated strategies to help with the consideration of deprescribing potentially inappropriate and harmful medications when identified. 

Mentation: Assessment of cognitive function is a standard part of the physical examination in older adults. Though U.S. Preventive Services Task Force (USPSTF) does not recommend for or against screening for cognitive impairment as part of the annual wellness visit, the impact of cognitive impairment can be substantial, and screening should be considered in key clinical situations. According to the Alzheimer's Association, more than 5 million people in the United States are diagnosed with Alzheimer's Dementia, which is currently the sixth leading cause of death and the most common form of dementia. Screening for cognitive impairment can improve the detection of dementia at an early phase and help patients and families increase services within the home and improve safety. Many cognitive tests are available for screening and diagnosis of underlying cognitive impairment. A widely used and validated tool is the Mini-Cog. Additional cognitive testing modalities are available for detailed cognitive assessment and the diagnosis of cognitive impairment. 

Mobility: Impairment in mobility is closely related to the risk of falls, which substantially impact older adults. Approximately 30% of persons over 65 years of age fall annually, and half of those falls are recurrent. Ten percent of falls result in serious injury, including fractures (common fractures include the hip, rib, spine, and clavicular), subdural hematoma, or soft tissue injuries. Ten percent of all emergency room visits in older adults are related to falls, and six percent of emergency hospitalizations in older adults are related to falls. Identifying and reducing fall risk factors is a crucial element of the physical examination in older adults. Risk factors for falls in older adults include advancing age (greater than 75 years of age), specific medical conditions (arthritis, neuropathy, anemia, vision impairment, orthostatic hypotension, restricted mobility requiring use of an assistive device, cognitive impairment), greater than four prescription medications, and impairment in balance, gait, and muscle strength. In addition to standard assessments of range of motion, strength, and sensation, specific methods to evaluate mobility in older adults include chair stands and the Timed Up and Go, which are validated tests to evaluate impaired mobility and risk of falls. In addition, while performing these tests, observation should be made of the patient's gait and use of an assistive device. 

1. General considerations in the older adult

1. Prior to beginning the physical examination, ensure that the patient is comfortable (that is, not in pain, does not need to use the restroom) and ask about any specific sensory considerations that you should be aware of during the encounter (that is, vision and hearing impairment).
2. Observe for nutritional deficiencies, including malnutrition. Monitor for weight loss on recent visits or changes in the fit of clothing. Assess for temporal wasting, atrophy of large muscle groups (quadriceps), supraclavicular wasting, and poor denture fit. 
3. Observe the patient for potential signs of neglect or cognitive impairment, including inappropriate clothing choices for the season, unkempt appearance, or signs of poor hygiene.
4. Sensory Impairments 
   1. Hearing Impairment: In addition to asking about hearing impairment, the examiner should observe for common clues to hearing impairment, including difficulty hearing people in the same room or over the telephone, difficulty following conversations or the need to ask people to repeat themselves, and difficulty hearing people due to background noise. Routine screening for hearing impairment should include a finger rub or whisper test in addition to an otoscopic examination of the ear canals for cerumen impaction. Additional instrument-based audiometry and referral to audiology can be performed if deficits are detected. 
   2. Vision impairment: In addition to asking screening questions for vision impairment or deficits, the examiner should perform maneuvers, including extraocular movements and observation for nystagmus. Visual fields should be tested in addition to testing visual acuity with a standard Snellen eye chart.

2. What matters 

1. Ask if the patient has considered their specific healthcare goals, including tasks they would be doing more if they could physically do them. 
2. To help patients identify their priorities, help them through a self-directed website or direct them to it if they have computer and internet access. One example is the Patient Priorities Care self-directed priority identification website: https://myhealthpriorities.org/. 
3. Ask the patient if they have considered who would help make medical decisions for them if they could not. If yes, ask if they have completed an advanced directive, living will, healthcare surrogate, or power or attorney forms/documentation. 
4. Patients can visit the website Prepare for Your Care (https://prepareforyourcare.org/welcome) to complete the process of selecting a healthcare surrogate decision-maker and document their wishes. 
5. Perform a physical examination as pertinent to the patient's identified goals. For example, if the patient places the desire to volunteer in a library but is having hand pain, examine for signs of arthritis, inflammatory conditions, or signs of vascular compromise. If the patient identifies a goal to walk a mile a day, perform the mobility-based maneuvers listed below to identify barriers to this and risks for falls. 

3. Medication

1. Ask what medications the patient takes, including over-the-counter medicines and supplements. 
2. Ask how the patient administers their medications and if they receive any assistance (visiting nurse, family member or friend, pill box). 
3. Compare the patient's medication list to the Beers List to identify potentially inappropriate medications. 
4. Consider the application of the deprescribing protocol as outlined by the Journal of the American Medical Association Internal Medicine (JAMA IM) if potentially inappropriate medications or polypharmacy are identified [JAMA IM Deprescribing].
5. Ascertain all the medications the patient is currently taking by asking them and contacting the patient's family and/or their pharmacy if necessary. Identify the reason for each medication. 
6. Consider the overall risk of adverse events in the patient, given their health conditions and preferences. 
7. Assess each medication and the risks versus the benefits of continuing or stopping it. 
8. Prioritize medications to be discontinued, beginning with the medications deemed to have the most potential for harm and least potential for benefit. 
9. Engage in a stepwise process of stopping medications and monitoring recurrent symptoms over time.

4. Mentation 

1.  During the encounter, observe the patient's speech and note repetitive statements, vague answers, and word-finding difficulties. 
2. Ask the patient if they have noticed any changes in their memory or thinking. If they provide permission, ask friends and family for collateral history to further elucidate the presence or absence of cognitive changes. 
3. Normalize the testing for the patient. Tell them that difficulties with memory and thinking are routinely assessed as a part of the assessment. 
4. If in an inpatient setting, assess for attention to rule out delirium prior to performing the Mini-Cog. To assess attention, you can ask the patient to recite the days of the week backward or to spell the word WORLD backward. 
5. Perform the Mini-Cog. First, tell the patient, "I am going to give you a list of three words. I want you to repeat them back to me and try remembering them. After some time, I will ask you what the words were again." There are validated lists of words on the Mini-Cog form, including: "banana, sunrise, chair" or "leader, season, table." The Mini-Cog is available in a variety of languages. 
6. Next, give the patient a piece of paper with a circle drawn on it and ask them to draw a clock. Say, "Please draw a clock with all the numbers on it. Draw the time to be ten past eleven." 
7. Ask the patient to repeat the words they were given previously. 
8. Tally the patient's score. They receive one point for each word they could recall, one point if the numbers are placed correctly on the clock, and one point if the clock hands are in the correct position.

5. Mobility 

1. Ask the patient if they use an assistive device, whether it has been fitted by a physical therapist, which assistive device they use, and which side they use it on. Observe their use of the equipment and ensure it is being used on the proper side and at the appropriate height. 
2. Review the patient's resting vital signs and perform vital orthostatic signs. Have the patient sit for 5 minutes and then take their vital signs. Have them stand from the seated position, using an assistive device if necessary. Measure the vital signs again 1 and 3 minutes after standing.  
3. Chair Stands: Using a standard chair without wheels and arms, have the patient cross their arms in front of their chest and stand from the seated position as many times as they can in 30 seconds. If necessary, the patient can use their arms to stand, which should be included in the documentation. 
4. Timed Up and Go (TUG) 
   1. Before beginning the test, place a chair without wheels and with arms 3 meters to 10 feet from an identifiable mark on the floor. Have a stopwatch ready to time them. 
   2. Have the patient start with their back against the chair. Ask them to cross their hands in front of their chest and tell them the instructions. Say, "I will ask you to stand from the seated position without using your arms. You will then walk 10 feet, the spot marked ahead, turn around and come back."
   3. Start the timer and have them stand from the seated position with arms crossed in front of their chest (arms crossed in from of chest to prevent the patient from using arms to stand).  If they are unable to stand, they can use their hands to push off the arms. 
   4. After they stand, have them walk 3 meters (~10 feet), turn around, walk back to the chair and sit down. Stop the timer. 
5. While the patient is walking during the TUG, observe their gait. Components of their gait include gait speed, stride length, step length, and step width—definitions of each are below. 
   1. Gait speed: The distance over time. 
   2. Stride length: The distance between successive points of heel contact of the same foot. 
   3. Step length: The distance between corresponding successive points of heel contact of the opposite feet.
   4. Step/stride width: The side-to-side distance between the line of the two feet. 
   5. Step height: The distance the patient's foot comes off the floor with each step. 
   6. Arm Swing: The amount that a patient's arms naturally swing during walking.

Gait Observation: Abnormal gait patterns can indicate underlying pathology and may predispose the patient to falls. Normal gait changes in aging can include decreased overall gait speed, decreased stride length, increased stride width, and decreased step height without shuffling.

Assist Device Use Evaluation: While observing the patient use their assist device, note which side they are using a single-sided device (that is, cane). They should be using the device on the opposite side from the affected side or injury. For example, if the patient has osteoarthritis affecting their left knee, they should be using the cane in their right hand. The proper height for an assist device is at the wrist crease while standing with the arm dangling on the side or with the elbow flexed ~20º when holding the device.