The 4Ms Framework: A Game-Changer for Family Caregivers Navigating Care at Any Age

Family caregivers face numerous challenges, including managing doctor visits, medication schedules, care coordination, daily care decisions, and maintaining work-life balance. However, through my work with caregiving consultations, I find that caregivers often prove to be the experts who know their loved ones best. While this expertise is invaluable, it's still hard to balance what matters most to your loved one amid the complexity of care. Enter the 4Ms framework, an evidence-based approach that can transform how families approach caregiving.

What Are the 4Ms?

The 4Ms framework serves as a caregiving outline that consists of four interconnected elements: 

• What Matters
• Medication
• Mentation
• Mobility

When implemented together, these elements represent a broad shift to focus on the needs of older adults, organizing care around the person's wellness and strengths rather than solely on disease.

Let's explore how each "M" can guide your caregiving approach:

What Matters: The Foundation of Person and Age-Friendly Centered Care

The first step of “What Matters” is to establish the core values of the older adult and the impact on the quality of life. These values are the fundamentals on which a person's beliefs are rooted, including ideas about happiness and fulfillment. As a family caregiver, regularly asking "What matters most to you?" can revolutionize care planning.

“What matters” goals are the activities that matter most to an individual, such as babysitting a grandchild, spending time in nature, walking with friends in the morning, or continuing to work as a teacher. With a focus on the person receiving care's core values, Medication, Mentation, and Mobility usually come up because addressing them enables people to do more of What Matters to them. Health care preferences include medications, healthcare visits, testing, and self-management tasks that an individual is able and willing to do, and how this care relates to autonomy in carrying out those activities that matter the most on a daily basis.

Practical tip: Medication: Beyond Just Managing Pills

Overprescribing medication to older adults is a common phenomenon, and it comes with dire consequences. As many as 50% of older adults are overprescribed medication that is not medically necessary. Family caregivers play a crucial role in medication safety.

Key medications to watch for include:

• Benzodiazepines
• Opioids
• Anticholinergic medications (like diphenhydramine/Benadryl)
• Sleep medications
• Muscle relaxants

These medications can dramatically affect the other components of the 4Ms framework. Proper deprescribing for older adults helps promote age-friendly care across care settings, especially at home.

Mentation: Supporting Brain Health

Mentation refers to the health of the mind, focusing on the prevention, identification, treatment, and management of issues such as dementia and depression in community-based settings and delirium in hospital settings.

Family caregivers are often the first to notice changes in thinking, mood, or behavior. The impact that cognitive function may have on the validity of assessment tools emphasizes the importance of testing for dementia as well as depression to develop a comprehensive understanding of an older adult's mentation.

Important connections: Older adults who experience depression are at twice the risk for developing cognitive impairment. There is an indication that addressing the depression through behavior modifications, such as mobility, and/or medications, may reduce the risk of developing cognitive impairment.

Mobility: More Than Just Preventing Falls

Screening for safe mobility is a requirement for ensuring that older adults are receiving age-friendly care. As a family caregiver, you can support mobility by:

• Getting all older people, regardless of setting, out of bed or have them leave the room for meals
• Assessing and managing impairments that reduce mobility, such as pain; impairments in strength, balance, or gait; and high-risk medications
• Creating safe home environments by removing throw rugs and ensuring adequate lighting

The Power of Integration

The 4Ms are meant to be used as a set. The evidence is clear that the interactions among and between each other are critically important to assess and manage for better care outcomes. For example, medication side effects can impact mobility and thinking, while mobility issues can affect mood and independence.

Practical Application for Family Caregivers

Here's how to implement the 4Ms in your caregiving:

1. Start with What Matters: Have regular conversations about your loved one's goals and preferences. Use these to guide all care decisions.
2. Create a Medication Safety Plan: Work with healthcare providers to review all medications regularly. Question any medication that doesn't support what matters to your loved one.
3. Monitor Mental Health: Stay alert to changes in thinking, mood, or behavior. Know that psychotherapy and physical activity (mobility) may be effective treatments for depression, as well as medication, when risks of polypharmacy and other negative impacts are carefully considered.
4. Promote Daily Movement: Identify and set a daily mobility goal with each older adult that supports what matters and then review and support progress towards a mobility goal.

The Caregiver Advantage

Family caregivers have unique insights that professional healthcare providers may miss. You know your loved one's personality, preferences, and baseline functioning better than anyone. Family or other caregivers can place a clock and calendar in the view of the older adult and make changes in lighting to orient the person to the time of day. You can also invite family or other caregivers to use familiar and orienting items (e.g., family pictures and favorite music).

Quality of Life Through the 4Ms

 The 4Ms approach is a great way to ensure that older adults reliably get the best care possible. By using this framework, family caregivers can:

• Ensure care decisions align with their loved one's values and goals
• Reduce harmful medication effects
• Support cognitive and emotional well-being
• Maintain independence and function longer

The 4Ms framework doesn't add more tasks to your caregiving responsibilities. Instead, the 4Ms helps organize and focus your efforts on what truly matters. By keeping these four elements in mind, you can provide more effective, personalized care that honors your loved one's dignity and enhances their quality of life.

Remember, the 4Ms are relevant regardless of an older adult's diagnosis or needs. They apply regardless of the number of functional problems an older adult may have, or that person's cultural, racial, ethnic, or religious background. This makes the framework a valuable tool for all family caregivers, regardless of their specific situation.