The 5 Ms: A Simple Framework to Care for Older Patients

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WASHINGTON, D.C.—For the first time in U.S. history, older adults are projected to outnumber children by 2034, and their care poses unique challenges to the rheumatologist.¹ Normal physiologic changes of aging include but aren’t limited to falling renal function, changes in pharmacokinetics and bone density loss.

Dr. Namrata Singh

At the ACR Convergence 2024 Review Course, Namrata Singh, MD, MSCI, FACP, assistant professor, Division of Rheumatology, University of Washington, Bellevue, provided a framework that we can use to think about and care for our geriatric patients called The 5 Ms.

Geriatric Syndromes, Multimorbidity & Polypharmacy

Dr. Singh kicked off her talk with some important definitions that help us better understand geriatric care.

Geriatric syndromes are clinical conditions in older people that don’t fit into disease categories but are highly prevalent in older age, multifactorial, and associated with multiple comorbidities and poor outcomes. Examples include frailty, delirium, falls, visual impairment, social isolation, immobility, sarcopenia and dementia.²

Multimorbidity is defined as the concurrent existence of more than one medical condition in the same individual. It’s a broader concept than comorbidity. Comorbidity centers on an index condition, such as rheumatoid arthritis (RA), with other conditions (e.g., osteoporosis and cardiovascular disease) circling around it. Multimorbidity, on the other hand, puts the patient at the center.³

Polypharmacy, defined as the concurrent use of five or more medications, can be particularly dangerous for older patients and is common in people with rheumatic disease. Numbers aren’t the enemy, explained Dr. Singh. Unnecessary, ineffective and harmful prescribing is.

Polypharmacy often results from prescribing cascades, in which additional medications are prescribed to treat the adverse effects of previously prescribed medications, effects that are misdiagnosed as a new medical condition.⁴ For example, a patient with arthritis is prescribed ibuprofen, which results in hypertension, which is treated with a calcium channel blocker, which causes ankle swelling, which is treated with a diuretic, which causes gout, which is treated with allopurinol. See how one medication suddenly devolves into four?

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Geriatric syndromes, multimorbidity and polypharmacy are interconnected via multidirectional relationships and synergistic interactions. So to truly care for our older patients comprehensively, we need to take the whole ecosystem into account.⁵

The 5 Ms

If the concepts above felt like a lot, join the club. There are a lot of moving pieces to consider when caring for older patients, and it all can feel overwhelming, especially in the context of a 15- to 20-minute follow-up visit. Dr. Singh invited us all to take a deep breath as she introduced a tool that can help: The 5 Ms—multicomplexity, mind, mobility, medications and “what matters most.”⁶

1. Multicomplexity. This describes the whole person, typically an older adult, living with multiple chronic conditions, advanced illness, and/or complicated biopsychosocial needs. So we need to think about the big picture and understand our patients’ rheumatic disease in the context of comorbid conditions and psychosocial needs.

First, assess and prioritize pain and function. Can your patient complete activities of daily living? Do they need a mobility device? Second, assess and prioritize psychosocial needs. Are there comorbid depressive symptoms? Is social isolation or access to adequate nutrition an issue? Are the patient’s recent no-shows because they couldn’t afford transportation or medication refills? “Interdisciplinary teams are key here,” Dr. Singh said.

2. Mind. Cognitive concerns are common in patients with rheumatic diseases, especially when it comes to older patients. Dr. Singh encouraged us to be aware of the three Ds: dementia, delirium and depression. We can recognize and correct things that are reversible or modifiable, like cardiovascular risk factors, uncontrolled inflammation due to rheumatic disease, depression and chronic pain.

3. Mobility. Counseling on fall prevention and optimizing muscle strength and endurance are crucial components of managing mobility in older adults with rheumatic diseases, especially since they’re at particularly high risk of developing sarcopenia and functional limitations. Think about physical activity, fall risk, the need for assistive devices like canes, and home safety. Also consider bone health, nutrition and potentially inappropriate medication use (see below).

4. Medications. The main take-home concept here is deprescribing—the thoughtful and systematic process of identifying problematic medications and either tapering or stopping these in a safe way to help older adults maximize their wellness and goals of care.

So try to identify problem medications and ask yourself if the patient truly needs them. A good place to start is the American Geriatric Society Beers Criteria, which is updated every three years and gives us information on potentially inappropriate medications that are to be avoided in older adults. Examples include antidepressants, opioids, benzodiazepines, neuropathic pain medications (eg pregabalin, gabapentin) and muscle relaxants.⁷

5. What Matters Most. “A mother shouldn’t pick a favorite child,” joked Dr. Singh, “but I have a favorite ‘M.’” She said that one of the most powerful questions you can ask a patient is “what matters most to you right now?” That’s because every person’s meaningful health outcome goals and care preferences are different.

So list and rank your patient’s values and outcomes of interest in order of importance, and remember that this list can shift over time. Does increased survival matter most? Or is it instead comfort or physical function? Then, ask yourself if the plan you’re discussing is aligned with the patient’s goals and preferences.

Conclusion

When caring for the geriatric patient, the big picture matters, and the 5 Ms can help guide care. It’s important to be proactive and take both biological and psychosocial changes associated with aging into account.

“At the end of the day, nothing can overcome shared decision making with patients, families and caregivers,” concluded Dr. Singh. “Prioritize their quality of life.”

Samantha C. Shapiro, MD

Samantha C. Shapiro, MD, is a clinician educator who is passionate about the care and education of rheumatology patients. She writes for both medical and lay audiences and practices telerheumatology.

References

1. U.S. Census Bureau. Population projections.
2. Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: Clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007 May;55(5):780–791.
3. Radner H, Yoshida K, Smolen JS, Solomon DH. Multimorbidity and rheumatic conditions—Enhancing the concept of comorbidity. Nat Rev Rheumatol. 2014 Apr;10(4):252–256.
4. Rochon PA, Gurwitz JH. The prescribing cascade revisited. Lancet. 2017 May 6;389(10081):1778–1780. Erratum in Lancet. 2017 Jun 3;389(10085):2192.
5. van Onna M, Boonen A. Challenges in the management of older patients with inflammatory rheumatic diseases. Nat Rev Rheumatol. 2022 Jun;18(6):326–334.
6. Buehring B, van Onna M, Myasoedova E, et al. Understanding the multiple dimensions of ageing: 5Ms for the rheumatologist. Lancet Rheumatol. 2024 Dec;6(12):e892–e902.
7. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023 Jul;71(7):2052–2081.