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.