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