What is the recommended approach to managing geriatric syndromes?

Managing Geriatric Syndromes

Implement the Geriatric 5Ms framework as your systematic approach to managing geriatric syndromes, addressing Mind, Mobility, Medications, Multicomplexity, and what Matters Most to the patient simultaneously. 1

Core Management Framework: The Geriatric 5Ms

The American Geriatrics Society's 5Ms framework provides the algorithmic structure for addressing geriatric syndromes, which reduces morbidity and mortality while improving quality of life 1:

1. Mind (Cognitive and Psychological Health)

• Screen annually for cognitive impairment in all adults ≥65 years using validated tools like the Mini Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) 1, 2
• Assess for depression using the Geriatric Depression Scale (GDS), as depression commonly co-occurs with cognitive decline and affects treatment adherence 1, 3
• Provide cognitive stimulation therapy for mild to moderate cognitive impairment 1
• Treat underlying contributors including depression, vitamin deficiencies (especially vitamin D), and medication side effects 1, 3
• Support caregivers with education and respite services to prevent burnout 1

2. Mobility (Falls and Movement)

• Conduct multifactorial fall risk assessment including medication review, vision testing, gait evaluation, and environmental hazards 1, 4
• Implement multicomponent exercise programs focusing on strength, balance, and gait training supervised by physical therapists 1
• Use the Timed Up and Go (TUG) test as your primary mobility screening tool 2
• Address orthostatic hypotension through medication adjustment and lifestyle modifications 1
• Ensure regular physical activity even for those with limited mobility 1
• Monitor for immobility complications including pressure ulcers and venous thromboembolism 1

3. Medications (Review and Reconciliation)

• Review all medications regularly to identify potentially inappropriate medications using tools like the Beers Criteria 1, 4
• Deprescribe high-risk medications that increase fall risk, cognitive impairment, or incontinence 1
• Avoid polypharmacy (>3 medications daily), which affects self-management abilities and quality of life 1, 4, 3
• Refer patients with polypharmacy concerns to their primary physician or pharmacist for comprehensive medication review 4
• Pay special attention to insulin and warfarin, the leading causes of adverse drug events in older adults accounting for >700,000 emergency visits annually 3

4. What Matters Most (Patient Priorities)

• Identify each patient's meaningful health outcome goals and care preferences early in the care relationship 1
• Align treatment plans with patient values to improve adherence and satisfaction 1
• Discuss advance care planning early, especially before cognitive decline progresses 1
• Involve family/caregivers in care planning discussions, as elderly patients want family involvement in diagnosis, prognosis disclosure, and decision-making 1, 4
• Provide clear, detailed information about prognosis, treatment options, benefit-risk ratios, and potential negative effects of over- and under-treatment 4

5. Multicomplexity (Multiple Conditions)

• Address the intersection of multiple chronic conditions with social determinants of health 1, 3
• Coordinate care across specialties to avoid fragmented approaches 1
• Consider social support needs including living conditions, caregiver presence, and financial status, which directly impact treatment feasibility 1, 3
• Implement early palliative care when appropriate for symptom management, which has been shown to improve quality of life and extend survival by 2.3 months 4, 1

Comprehensive Geriatric Assessment (CGA) Implementation

Perform CGA as a multidisciplinary evaluation that includes functional status, cognitive function, emotional and social function, comorbidity, polypharmacy, and geriatric syndromes 4, 5:

• Use screening questions first to identify high-risk patients who need full CGA 4, 5:

  • Need for help with daily activities before and after illness
  • Hospitalization in past 6 months
  • Vision problems
  • Memory problems
  • Taking >3 medications daily

• Complete the assessment in 45-90 minutes using validated screening tools and performance-based measures 5, 6

• Link CGA to targeted geriatric interventions, as meta-analysis of 28 trials demonstrated reduced early re-hospitalization and mortality 4

• Estimate life expectancy using CGA domains, which is crucial for planning therapeutic strategy 4

Specific Geriatric Syndrome Management

Falls Assessment and Prevention

Ask the critical question: "If this patient was a healthy 20-year-old, would they have fallen?" If no, conduct comprehensive fall evaluation 4:

• Obtain detailed history including age >65, location/cause of fall, gait/balance difficulty, previous falls, time spent on floor, loss of consciousness, syncope/orthostasis, melena, comorbidities (dementia, Parkinson's, stroke, diabetes, hip fracture, depression), visual/neurological impairments, alcohol use, medications, ADL status, and footwear 4
• Implement environmental modifications including rubber/nonskid floor surfaces, even floors, handrails, aisle lighting, bedside commodes, grab bars, properly positioned bedrails, and appropriate patient gowns 4
• Arrange expedited outpatient follow-up with home safety assessments for discharged patients 4
• Admit if patient safety cannot be ensured at home 4
• Evaluate all admitted fall patients with physical therapy and occupational therapy 4

Frailty Management

Recognize frailty as an independent mortality risk factor affecting approximately 25% of persons aged ≥85 years 3:

• Assess frailty systematically, as it predicts outcomes better than chronological age alone 3
• Screen for malnutrition defined as unintended weight loss >5% in 6 months or >10% beyond 6 months 3
• Address inadequate caloric intake, the primary cause of malnutrition, not the underlying illness 3
• Supplement vitamin D to reduce osteoporosis and fracture risk 3

Critical Pitfalls to Avoid

• Never attribute symptoms to "old age" without thorough investigation 3
• Never miss atypical presentations, as elderly patients often lack typical symptoms like polyuria/polydipsia in hyperglycemia due to elevated renal threshold 3
• Never overlook medication burden—systematically review all medications for appropriateness and deprescribing opportunities 3
• Never ignore cognitive status, as it affects informed consent, medication adherence, and self-care abilities 3
• Never fail to assess social isolation, a significant predictor of mortality in older adults 3

Care Coordination and Follow-up

• Use team-driven screening tools to prevent poor outcomes and improve the ED and hospital experience 4
• Coordinate services across multiple providers and settings with dynamic adjustment as needs change 1
• Track and trend adverse drug response admissions and pharmacist interventions 4
• Review high-risk medication lists annually with goals to limit use in geriatric populations 4