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

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.

Physical examination plays an important role in the older patient to detect physiologic changes of aging, risk factors, and signs of pathology.

While most of the general principles of the standard examination for adults apply to older patients, there are additional specific considerations. For example, focused examinations of cognitive and functional status are critical, as are assessments of hearing, vision, nutritional status, and the nervous system.

Healthcare professionals should be acquainted with an evidence-based model which specifically considers the needs of the elderly. A good example is the Age-Friendly Health System initiative.

This system was devised by the John A. Hartford Foundation in partnership with The Institute for Healthcare to optimize the care of older adults and empower them in their medical care. The initiative uses a 4 M's system of geriatric medicine – namely, What Matters, Mobility, Medications, and Mentation.

The first element of the 4M's identifies what matters the most to a patient regarding their health outcome and care preference. This may include managing any symptoms they may have, preserving functions, or maximizing the longevity of life.

During the physical examination, physicians can monitor health conditions and can help patients achieve realistic and achievable outcomes that align with their individual goals and healthcare preferences.

Most older adults take multiple medicines for various health conditions. This is known as polypharmacy and can pose a high risk of health hazards due to drug-drug interaction, drug-disease interaction, or inappropriate doses. Polypharmacy can potentially cause adverse events such as falls, and cognitive and functional decline, or in extreme cases, fatality.

Risks due to polypharmacy can be minimized by the second 4M component- medication. In this, clinicians evaluate the patient's prescription using the Beers list- a consensus document specifying potentially harmful drugs for older patients.

If such medicines are identified in the patient's medication, there are multiple validated strategies, such as the deprescribing protocol as outlined by the Journal of the American Medical Association Internal Medicine, to help with the consideration of deprescribing potentially inappropriate and harmful medications.

The third element, Mentation, involves screening for cognitive impairment in older patients to improve the detection of dementia, depression, and delirium at an early phase.

There are a number of cognitive tests available for screening and diagnosis of underlying cognitive impairment. A widely used and validated tool for screening for cognitive impairment is the Mini-Cog.

The last 4M component is the patient's Mobility. Older adults are susceptible to falls. The risk of falling increases with age and other medical conditions such as arthritis, vision impairments, or neuropathies.

Identification and reduction of fall risk factors is a key element of the physical examination in older adults. Specific methods to evaluate mobility in older adults include chair stands and the Timed Up and Go, both of which are validated tests to evaluate impaired mobility and risk of falls.

Overall, the 4Ms model is a reliable framework that enables physicians to provide consistent and quality support to geriatric patients. While a comprehensive evaluation of the older adult includes physical exam considerations included in each of the 4 M's, each individual visit does not need to include every portion of this protocol.

In this video, we demonstrate an approach to the physical examination of the older adult that includes components of the 4 M's framework.

To begin, ensure that the patient is comfortable by asking questions such as whether they have any pain or need to use the restroom. Enquire if the patient has any specific sensory disabilities, such as vision or hearing impairment.

Next, examine the patient for potential signs of nutritional deficiencies, including malnutrition. Assess for temporal wasting, atrophy of large muscle groups, supraclavicular wasting, and poor denture fit. Monitor for weight loss on recent visits or changes in the fit of clothing.

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.

After that, take note of common clues to hearing disability, including difficulty in hearing people in the same room or over the telephone, difficulty following conversations or need to ask people to repeat themselves, or trouble hearing people due to background noise.

To detect hearing impairment, perform the finger rub or whisper test along with the otoscopic examination of the ear canals for cerumen impaction. The detailed examination of the ear has been discussed in the previous JoVE video "Ear Exam."

If deficits are detected, refer the patient to an audiologist.

To identify any visual deficits, perform maneuvers, including extraocular movements and observation for nystagmus. Also, examine visual fields and perform tests for visual acuity using a standard Snellen eye chart. The detailed examination of the eye has been discussed in the previous JoVE video, "Eye Exam".

To begin, ask the patient what matters most in their life and healthcare.

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Next, offer to guide them through a self-directed website— Priorities Care self-directed priority identification website— to better understand them and their healthcare goals.

Ask the patient if they have considered who would help make medical decisions for them if they could not do it themselves. If yes, ask if they have completed an advanced directive, living will, health care surrogate, or power of attorney forms.

Patients can visit the website "Prepare for Your Care" to complete the process of selecting a healthcare surrogate decision-maker and document their wishes.

Next, perform a routine physical examination pertinent to the patient's identified goals. For example, if the patient identifies 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 to identify barriers to this and risks for falls.

To obtain information on a patient's drug use, ask what medications they are taking, including over-the-counter medicines and supplements. Then, inquire how the patient administers their medications and if they use a pill box or receive assistance from a visiting nurse, family member, or friend.

Compare the patient's medication list to the Beers List to identify potentially inappropriate medications.

Consider the application of the deprescribing protocol as outlined by the Journal of the American Medical Association Internal Medicine or JAMA IM , if potentially inappropriate medications or polypharmacy are identified. The JAMA IM Deprescribing protocol consists of 5 steps.

First, ascertain all of the medications that the patient is currently taking by asking them and, if necessary, contact the patient's family and their pharmacy. After that, identify the reason for each medication.

Second, consider the overall risk of adverse events in the patient given their health conditions and preferences.

Next, assess each medication and the risks versus the benefits of continuing or stopping it.

After that, prioritize medications to be discontinued, beginning with the medications deemed to have the most potential for harm and least potential for benefit.

Lastly, engage in a step-wise process of stopping medications and monitoring for recurrent symptoms over time.

During the encounter, observe the patient's speech and take note of repetitive statements, vague answers, and word-finding difficulties.

Then, 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.

Doctor: "Oftentimes, my patients have people in their life. They are involved in their day to day. Is there someone in your life that you feel comfortable with me talking with to get to know you better?"

Patient: "Oh sure, yeah. Probably my daughter knows me the best these days. She is like a mother hen. She watches over me all the time. So, sure. I think she can talk about me."

Doctor: "Oh great, thank you."

Normalize the testing for the patient. Inform them that the routine assessment for difficulties with memory and thinking is done as part of the whole examination.

If in the inpatient setting, assess for attention to rule out delirium prior to performing the Mini-Cog. To assess attention, ask the patient to recite the days of the week backward or to spell the word WORLD backward.

Next, perform the Mini-Cog, a three-item recall test for memory. There are validated lists of words on the Mini-Cog form and website, including: "banana, sunrise, chair" or "leader, season, table".

Doctor: "I am going to tell you three words. I would like you to do your best to repeat those words to me and then remember them. In a few minutes, I will ask you what the words are again."

Patient: "OK"

Doctor: "The words are— banana, sunrise, chair."

Patient: "Banana, sunrise, chair."

Doctor: "Great"

Give the patient a paper with a pre-drawn circle on it. Ask them to draw a clock with all the numbers on it and clock hands to indicate a particular time, for instance, ten minutes past eleven o'clock.

Now, ask the patient to repeat the words they were given previously.

Doctor: "Can you remember the three words that I asked you to remember? "

Patient: "Oh, umm...Banana, sunrise, and chair, I think."

Doctor: "Great"

If the patient uses an assistive device for mobility, ask which type of device they use and, if applicable, which side they use it on. Also, ask if the device has been fitted by a physical therapist.

Observe their use of the equipment and ensure it is being used on the proper side and at the appropriate height.

Review the patient's resting vital signs and perform orthostatic vital signs. Have the patient sit for 5 minutes and then take their vital signs. Have them stand from the seated position, with the use of the assistive device if necessary. Assess the vital signs 1 and 3 minutes after standing.  

Next, perform the chair stand test using a standard chair without wheels and arms. Ask the patient to cross their arms in front of their chest and stand from the seated position as many times as they are able in 30 seconds. If necessary, the patient can use their arms to stand, and this should be included in the documentation.

After that, perform the Timed Up and Go or TUG  test. Prior to beginning the test, place a chair without wheels and with arms 3 meters or 10 feet from an identifiable mark on the floor. Have a stopwatch ready to time them.

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.

Doctor: "I am going to ask you to cross your arms in front of your chest, and you can stand up, walk to the wall and then come back to chair and have a seat."

Patient: "OK."

Doctor: "Whenever you are ready."

Start the timer and ask the patient to stand from the seated position with arms crossed in front of their chest. If they are unable to stand, they can use their hands to push off the arms.

Once they stand, ask the patient to walk around 10 feet, turn around, walk back to the chair and sit down. Stop the timer once they sit down.

While the patient is walking during the TUG, observe their gait. Components of their gait include gait speed, stride length, step length, step width, step height, and arm swing.