← All EducationNABR Medical Group — Staff Education
Age-Friendly Health Systems Framework

The 4 Ms of Geriatric Care

A framework for delivering high-quality, patient-centered care to older adults in every care setting.

The 4 Ms framework, developed by the John A. Hartford Foundation and the Institute for Healthcare Improvement, guides clinicians to assess and act on What Matters, Medication, Mentation, and Mobility for every older adult, at every interaction.
M

What Matters

Goals · Preferences · Values · Care Priorities

Know and align care with each older adult's specific health outcome goals and care preferences, including end-of-life care.

Ask and Document

  • What are your most important health goals?
  • What activities must you be able to do?
  • What are your greatest fears or worries?
  • What does a good day look like for you?

Care Planning

  • Advance directives and code status
  • Healthcare proxy designation
  • Goals of care conversations
  • Align treatment decisions with stated values

Functional Priorities

  • Independence in ADLs
  • Ability to live at home
  • Pain and symptom management
  • Social connection and engagement
i Avoid treatment decisions based solely on numbers or guidelines. Always filter clinical choices through what the patient has said matters most to them.
Shared Decision-Making Advance Care Planning Person-Centered Care Goals of Care
M

Medication

Polypharmacy · Deprescribing · High-Risk Drugs · Side Effects

If medication is necessary, use age-friendly medications that do not interfere with What Matters, Mentation, or Mobility — and reduce or eliminate those that do.

Review at Every Visit

  • Remove non-essential medications
  • Adjust doses for renal function
  • Check for drug-drug interactions
  • Reconcile after hospitalizations
  • Review OTC medications

High-Risk Medication Classes

  • Benzodiazepines (fall and delirium risk)
  • Opioids (sedation, constipation)
  • Antipsychotics (cognitive effects)
  • Anticholinergics (cognitive, urinary)
  • Sedating antihistamines
  • High-dose antihypertensives

Adverse Effects to Monitor

  • Orthostatic hypotension
  • Fall risk
  • Confusion or cognitive decline
  • Urinary retention or incontinence
  • GI symptoms
  • Excessive sedation
Beers Criteria — AGS guideline for potentially inappropriate meds in older adults
START/STOPP — Screening Tool for deprescribing decisions
⚠ Polypharmacy (5 or more medications) dramatically increases adverse event risk. The goal is not to minimize medications — it is to optimize them relative to the patient's goals and function.
Deprescribing Beers Criteria Renal Dosing Drug Reconciliation Fall Risk
M

Mentation

Dementia · Delirium · Depression · Cognition

Prevent, identify, treat, and manage dementia, depression, and delirium across all care settings.

Dementia

  • Affects approximately 68% of ALF residents
  • Screen for memory loss and behavioral changes
  • Establish baseline cognitive status early
  • High risk of falls (60-70%) and wandering (49%)
  • Non-pharmacologic approaches first

Delirium

  • Acute onset confusion — a medical emergency
  • Triggers: infection, dehydration, medications, metabolic changes
  • Hypoactive delirium frequently missed
  • Avoid anticholinergics and benzodiazepines
  • Reorient frequently; minimize room changes

Depression and Mood

  • Screen at every visit (PHQ-2 or PHQ-9)
  • May present as withdrawal or appetite loss
  • Non-pharmacologic first: routine, socialization
  • Monitor for anxiety, agitation, sleep disturbance
  • Medication review — many drugs contribute

Common Delirium Triggers

  • Infection (especially UTI, pneumonia)
  • Dehydration or electrolyte imbalance
  • New or changed medications
  • Pain (undertreated or overtreated)
  • Urinary retention or constipation
  • Sleep deprivation

Non-Pharmacologic Support

  • Consistent daily routines
  • Adequate sleep hygiene
  • Sensory aids (glasses, hearing aids)
  • Social engagement and activities
  • Environmental orientation cues
⚠ New confusion in an elderly patient is infection until proven otherwise. Also consider dehydration, medication changes, and metabolic causes before attributing to underlying dementia.
Cognitive Screening Delirium Prevention Depression Screening MMSE / MoCA PHQ-9
M

Mobility

Falls · Strength · Function · Deconditioning

Ensure that each older adult moves safely every day to maintain function and do What Matters most.

Fall Risk Assessment

  • Gait and balance evaluation
  • Orthostatic blood pressure
  • Vision and hearing check
  • Medication review for fall-risk drugs
  • Home and environment hazard screen
  • Footwear assessment

Exercise Interventions

  • Single-leg stand (with support)
  • Sit-to-stand repetitions
  • Heel-to-toe walking
  • Side leg raises
  • Marching in place
  • Seated range-of-motion exercises

Assistive and Environmental

  • 4-point cane, rollator, wheelchair
  • Grab bars and railings
  • Nonslip footwear (low heel, closed back)
  • Adequate lighting throughout
  • Remove floor hazards
  • Vitamin D supplementation if appropriate

Prevent Deconditioning

  • Daily walking whenever possible
  • Early mobility after hospitalization
  • Avoid unnecessary bed rest
  • Engage PT/OT early and often

Post-Surgical Monitoring

  • Loss of ROM is a red flag
  • Increasing stiffness warrants evaluation
  • Weight-bearing changes — notify surgeon
  • See Orthopedic Wound Guide for wound monitoring
! Deconditioning can occur within 48 hours of bed rest. Functional decline from immobility is often harder to reverse than the underlying condition that caused it.
Fall Prevention Timed Up and Go (TUG) PT/OT Referral Vitamin D Deconditioning

The 4 Ms at a Glance

What Matters Medication Mentation Mobility

Assess and act on all 4 Ms for every older adult, at every care interaction. When one M is compromised, it affects the others — they are deeply interconnected.