Only 11% of adults aged 65 years and older gave an “A” grade to the U.S. healthcare system in a 2024 survey sponsored by Age Wave and The John A. Hartford Foundation (JAHF). The Harris Poll group conducted a nationally representative online survey, which included the views of 2,500 older adults.
These low marks reflect the reality that health providers do not always consider the views of older people when providing care, according to JAHF President Terry Fulmer, PhD, RN, FAAN. The foundation’s mission is to inspire age-friendly approaches to healthcare delivery.
Dr. Fulmer spoke about how to do this at the 2025 Critical Care Congress, in Orlando, Fla., by detailing the “4Ms framework” (Figure). The framework is a synthesis of aspects of care needed to improve health outcomes for older adults, based on an expert consultation process coordinated by JAHF (J Aging Health 2021;33[7-8]:469-481).
The framework includes four evidence-based elements that, if assessed and acted on, “will provide safe and effective care for older adults,” said Jane Carmody, DNP, MBA, RN, FAAN, a JAHF senior program officer, in an interview following the Critical Care Congress. “You can add any ‘M’ you want as long as you do these four well,” said Dr. Carmody, who worked in nursing leadership and specialized in geriatric care before coming to JAHF eight years ago.
To date, more than 4,800 hospitals, practices, convenient care clinics and nursing homes across the United States have adopted the 4Ms framework when working with older adults, Dr. Fulmer said, adding that this number continues to grow in America and throughout the world.
That said, Dr. Carmody pointed out that some aspects of the 4Ms framework are easier to implement than others—for example, whether an older adult received a delirium, depression or dementia screening (the mentation M) as part of their care plan. These routine screenings are straightforward to document, Dr. Carmody said, as are conversations with patients to review their medication lists and observe their mobility. The goal is for the 4Ms to be reliably and consistently provided, and adopting the framework gives any healthcare personnel an elegant method to assess and act on mentation, medications and mobility consistently.
The “what matters” component of the 4M framework “drives all the other [framework items],” Dr. Carmody noted, adding that JAHF is funding evaluation and research of the 4Ms. The group recognizes that documenting the “what matters” component “can be a challenge,” she said.
When the “what matters” framework item indicates that an older adult requires treatment adjustments, a shared decision for the revised care plan will promote the best outcomes. This is particularly the case when the insights revealed by the 4M framework are respected by the provider, Dr. Carmody stressed.
The foundation works with pharmacists to champion the 4Ms. Dr. Carmody noted that pharmacists, being the most accessible clinical professional for older adults, are in a great position to promote all 4Ms. The overall goal of the 4Ms movement is to give any healthcare provider, not just geriatrics specialists, the tools to work more compassionately and confidently with older adults—and this goes for family members as well.
The Pharmacist’s Role
“A lot of times we just assume that patients want to extend their life, and that’s not always the case,” said Dana Carroll, PharmD, a geriatrics specialist who practices at University Medical Center, in Tuscaloosa, Ala. If a pharmacist makes this assumption without checking, they may keep adding medications to an older adult’s care plan, Dr. Carroll noted, adding to the likelihood of polypharmacy.
“Polypharmacy increases the risk for adverse events, doctor’s visits, ER visits and decreased quality of life,” she said. However, some older adults may not take any of the medications on their lists, given their unstated preference for a higher quality of life with fewer side effects rather than an extended life span. Sometimes such a patient may suddenly begin to take all the medications at once, Dr. Carroll said, increasing the risk for an adverse event.
“The first thing is to understand the patient’s perspective and preferences and goals for their heath and medications,” she said, a point also made in the 4Ms framework.
Sometimes it will be appropriate to start a new medication in an older adult, assuming this corresponds with the patient’s goals and after a provider and pharmacist have decided that its benefits outweigh the risks. In such cases, it is important to remember that both pharmacokinetics and pharmacodynamics change as people age, Dr. Carroll stressed; therefore, higher doses could be more harmful than in a younger person.
“Start new medications with a really low dose and gradually increase,” said Dr. Carroll, who calls providers if she thinks their starting dose is too high for an older adult. And just as drugs need to be added to an older adult’s care plan, sometimes they should be discontinued.
“We should ask more often, ‘Do you like this medication? Do you dislike this medication?’ Include patients in the decision-making process,” Dr. Carroll said.
The sources reported no relevant financial disclosures beyond their stated employment.
This article is from the July 2025 print issue.