Care of the Older
Adults- 5Ms of
Geriatrics
Ria Paul MD
Confidential – For Discussion Purposes Only
Objectives
To understand Geriatric Principles in Primary Care
To increase understanding of 5 Ms of Geriatrics
Confidential – For Discussion Purposes Only
What are the Geriatrics 5Ms?
Mobility Mind Medications Multicomplexity Matters Most
Created by: Sarah C. Phillips, MD; Chelsea Hawley, PharmD;
Laura Triantafylidis, PharmD; Andrea Wershof Schwartz, MD MPH
Modifications by: Ria Paul MD Tinetti et al, JAGS 2017
Module 1: Mobility
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017
Fall Prevalence
CDC, 2017; Hafner, 2014
Confidential – For Discussion Purposes Only
Objectives
Differenti
Differentiate between intrinsic and extrinsic fall risk factors
Become familiar with Timed Up and Go (TUG) Test
Confidential – For Discussion Purposes Only
Fall Risk Factor Modification
Intrinsic Fall Risk Factors Extrinsic Fall Risk Factors
Advanced age Footwear or foot problems
Cardiovascular abnormalities Home hazards
Chronic conditions Improper use of assistive device
Cognitive impairment Multifocal eyeglasses
Functional limitations New glasses prescription
Gait and balance problems Substance use
Medications
Orthostatic hypotension
Vision problems
M. E. Tinetti & Kumar, 2010; STEADI, CDC 2017.
Confidential – For Discussion Purposes Only
Toe to Head Approach
Socks,
shoes,
toenail Musculoskeletal
Bowel
Cardiovascular Bladder
Extrinsic
Factors
Medications,
Sensory
Cognition
Confidential – For Discussion Purposes Only
Timed up and go test
Confidential – For Discussion Purposes Only
CDC Home Safety Checklist
STEADI, CDC 2017.
Confidential – For Discussion Purposes Only
Module 2: Medications
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017
Objectives
−Identify when a patient is experiencing
polypharmacy
−Utilize evidence-based tools for deprescribing
−Review the Beers Criteria
Confidential – For Discussion Purposes Only
POLYPHARMACY
PROBLEM
• Disability
• Frailty
• Drug-drug interactions
• Impaired cognition
• Slowed gait speed
How many
meds? >
5
Adverse drug events: 5th leading cause of Gnjidic D et al. J Clin Epidemiol 2012
death Doan J et al. Ann Pharmacother 2013
Langeard et al. Frontiers in Pharmacology 2016
Confidential – For Discussion Purposes Only
Deprescribing
Planned or supervised process of
dose reduction or stopping
medication(s) that may be causing
harm or no longer providing
benefit
Scott IA et al. JAMA. 2015; 175(5):827-834.
Confidential – For Discussion Purposes Only
Deprescribing Protocol
1. Reconcile 2. Consider 5. Implement
3. Assess
all risks/benefits 4. Prioritize and monitor
eligibility
medications of use deprescribing
Scott IA et al. JAMA. 2015; 175(5):827-834.
Confidential – For Discussion Purposes Only
Use Medication Assessment
Tools!
• American Geriatrics Society Beers
Criteria
• Medication Appropriateness Index
• Anticholinergic Risk Scale
• STOPP and START
AGS Beers Criteria 2015
Hanlon JT et al. J Clin Epidemiol.1992
Gallagher P Int J Clin Pharmacol Ther 2008
Ruldolph et al. Arch Intern Med 2008
Phung E et al. Journal of Palliative Medicine 2018
Confidential – For Discussion Purposes Only
Module 3: Mind
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017
Objectives
Apply the Mini-Cog as a screening tool for dementia
Formulate the initial diagnostic evaluation for dementia
Confidential – For Discussion Purposes Only
Some Dementia Warning Signs
Trouble remembering • Defers to family
• Problems with self-care
“Poor historian”
• Unexplained weight
Appointment mix-ups loss
• Vague symptoms
Can’t follow instructions
Getting lost Alzheimer’s Association and National Chronic Care Consortium,
2003.
Confidential – For Discussion Purposes Only
Normal Aging vs Dementia
Preclinical
?
Cognitive
Mild
Decline
Cognitive
Impairment
Dementia
Time (years)
Confidential – For Discussion Purposes Only
Primary Care Evaluation of Cognitive Impairment
Screen Evaluate Manage
GSA KAER Toolkit, 2017.
Confidential – For Discussion Purposes Only
Mini-Cog Test
Confidential – For Discussion Purposes Only
Screen Evaluate Manage
Labs and
History
Imaging
Function Mood
Cognition
GSA KAER Toolkit, 2017.
Confidential – For Discussion Purposes Only
Screen Evaluate Manage
Neuropsychology (if available)
- Can provide comprehensive, objective information about which cognitive functions are
affected and establish a baseline for future re-evaluations
- Most helpful for MOCA 19-27, SLUMS 18-27, MMSE 18-28
Specialty physicians
− Geriatrics
− Neurology
Resource referral
GSA KAER Toolkit, 2017.
Confidential – For Discussion Purposes Only
Screen Evaluate Manage
Medications for dementia
− Acetylcholinesterase Inhibitors (AChI)
− NMDA Antagonists
Early/mild Middle/moderate Late/severe
Start AChI
Start ±
AChI NMDA antagonist
Confidential – For Discussion Purposes Only
Module 4: Multicomplexity and
Matters Most
Geriatrics 5M’s: Tinetti, Molnar and Huang, JAGS 2017
Multicomplexity
Challenges in caring for older adults
Multiple chronic diseases
Limitations of current clinical guidelines
Limited or no data on older adults
Multifactorial nature of geriatric problems and
syndromes
Range of patient preferences
JAGS 2012 patient-centered care for older ad
Confidential – For Discussion Purposes Only
Multicomplexity
American Geriatrics Society
Approach to Older Adults
with Multimorbidity
Patient Look at the Estimate What is Communicate
preferences evidence prognosis feasible a plan
American Geriatrics Society, 2012.
Confidential – For Discussion Purposes Only
What Matters Most?
Tinetti et al, JAGS 2017
What Matters Most?
Confidential – For Discussion Purposes Only
What Matters Most?
• Resources for patients
• [Link]
• [Link]
• Resources for providers
• [Link]
• [Link]
Confidential – For Discussion Purposes Only
Multicomplexity
[Link]
Confidential – For Discussion Purposes Only
Questions?
Confidential – For Discussion Purposes Only 33
