Age Friendly - Focus on What Matters: Simplifying Complex Care of Older Adults

May-June 2019


What does it mean to be age-friendly? At its most basic in a health care context, it means providing safe, high-quality care that lines up with what matters most to an older adult. Mary Tinetti, MD, Chief of Geriatrics at Yale School of Medicine and Yale-New Haven Hospital, and co-chair of the advisory group for the Institute for Healthcare Improvement's Age-Friendly Health Systems initiative, explains the keys to providing the best care possible for older adults.

What defines an age-friendly health system?

In an age-friendly health system, all the people who work in the health system and interact with older adults are familiar and comfortable with, understand, and are competent at addressing what matters to each individual. They know how to adjust their interactions and expectations to meet each person's needs. This is whether they clean rooms or welcome patients into an office or whether they're clinicians, social workers or physical therapists.

To do that, you must understand that people accumulate more conditions and become more complex as they age. They may have some vision and hearing difficulties that need to be recognized and adjusted for. They may have mobility issues, so they need more help moving around. Most importantly, we must recognize that older individuals vary in what matters most to them. Some of them want their blood pressure as normal as it can be or their glucose levels always spot-on. Others are more concerned with feeling comfortable and unburdened by day-to-day health care details. Faced with tradeoffs across many conditions and treatments, older adults vary in the outcomes they most value and desire. Being age-friendly means recognizing and responding to individuals' different needs, interests and priorities.

A central part of the age-friendly approach is focusing on improving care on the so-called "4Ms." How do you explain this focus and why it is so important?

By creating the 4Ms, we're trying to make care that is very complex more manageable. We've identified the core issues that should drive all care and decision making for older adults. The 4Ms apply regardless of the individual diseases people have because these are the areas that are affected by essentially all diseases. They also apply regardless of how many functional problems the patient may have, or the cultural, ethnic or religious backgrounds they bring with them.

The 4Ms are:

  • What Matters — This means acknowledging that older adults vary in what matters most to them about their health and their health care
  • Medication — Ensuring it does not interfere with What Matters, Mentation and Mobility
  • Mentation — This includes preventing, identifying, treating and managing depression, dementia and delirium
  • Mobility — Supporting older adults to move every day

How might the age-friendly approach work in a patient's life?

An older adult with Parkinson's disease can help us understand why using the 4Ms is important. Parkinson's disease affects walking and other movement, but it also affects parts of the brain that help with memory, problem-solving and carrying out tasks of daily life.

There are medications for treating Parkinson's that will help with mobility, but they can make thinking worse. So, if a clinician just focused on improving somebody's mobility, the treatment plan could contribute to confusion or memory difficulties. On the other hand, if you ignore treating someone's mobility, they may not be able to do what's important to them.

This is where the "what matters" communication comes in. "From what you've said, Mrs. Smith, I understand that what matters most to you is to be able to walk to the corner store and pick up your groceries twice a week." To do that, she needs to be able to walk. She also needs to remember what she wants to get at the store and how to find her way back home. If you just say, "I see your tremor is worse. Let's increase your medication," and Mrs. Smith gets more confused, she can't do something that's important to her. On the other hand, if we say, "This medicine is making you too confused. I think we need to stop it," and then she can't move, then she still can't do what matters to her.

The age-friendly approach means saying something like, "Mrs. Smith, I recognize it's important to you to be able to walk to the store and get your groceries. Let's look at your medications. Let's balance them to get the right amount. Let's stop this other one that may be making you a little confused, and then let's see if you're able to maintain your mobility without making your memory worse."

It simplifies care planning to ask what matters most to the patient because it helps you determine where to focus. If you put what matters most to a patient at the center of decision-making discussions, then you can balance everything else.

NOTE: This interview has been edited for length and clarity. Go to the Institute for Healthcare Improvement website to read the full interview at Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement in partnership with the American Hospital Association and the Catholic Health Association of the United States.


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