The learning outcome for this activity: Participants will have increased knowledge and ability to apply the Age-Friendly 4Ms Framework to older adult patients presenting with community-acquired pneumonia in a convenient care setting.

1. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Grand Rounds
PharmD.
NP
Physician
Topic: Age-Friendly Health Systems:
Community-Acquired Pneumonia (CAP) in the Older Adult
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2. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Providing Age-Friendly Care
The goal is for all care with older adults to be Age-Friendly care, which:
• Follows an essential set of evidence-based practices;
• Causes no harm; and
• Aligns with What Matters to the older adult and their family caregivers.
AFHS-specific Grand Rounds cases focus on the 4Ms Framework as it pertains to patients 65 years of age and older
What Matters, Medication, Mentation, and Mobility will be addressed as a set and ASSESSED and ACTED ON in each
case scenario. The 4Ms include:
• What Matters: Know, align and act on each older adult’s specific health outcome goals and care preferences
• Medication: Optimize medication use to reduce harm and burden, focusing on medications affecting mobility, mentation,
and what matters; If medication is necessary, use Age-Friendly medication that does not interfere with What Matters to the
older adult, Mobility, or Mentation
• Mentation: Focus to prevent, identify, treat, and manage dementia, depression and delirium in older adults
• Mobility: Focus to maintain mobility and function and prevent/treat complications of immobility in older adults; Ensure that
older adults move safely in order to maintain function and do What Matters

3. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
How to Integrate 4Ms Care into the Clinic Visit
What Matters: These are some guiding questions or statements to help patients discuss what matters most to them:
• What is most important for you during today’s visit?
• What are you looking forward to this week?
• What activities do you enjoy? If applicable, can ask: What is preventing patient from accomplishing tasks or participating in activities?
• Consider discussion about advance care planning if appropriate for the visit
• During development of care plan: I would like to individualize your treatment with what matters most to you
Medication
• Ask about all prescriptions: prescribed, over-the-counter, laxatives, vitamins, supplements, herbal remedies
• Reconcile medications with electronic health record
• Cross-check for medications that may be on the AGS Beers© Criteria list
Mentation
• Assess patient’s ability to register, use kiosk, follow directions
• Screen for depression using the PHQ-2© and, if positive, continue with the PHQ-9©
• Screen for dementia using the Mini-Cog™
• Assess for delirium for any acute change in mental status using the Confusion Assessment Method
Mobility
• Assess mobility, gait, gait speed, balance, footwear beginning when the patient walks in using the Modified Get Up and Go test
• Assess hand dexterity, fine motor movements as patient removes insurance cards from wallet or writes or signs name

4. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Learning Objectives
At the end of this session, providers will be able to:
• Identify physiologic factors that place older adults at increased risk for infection
• Recognize that infections often present atypically in older adults
• Identify the interrelationship of the 4Ms in the context of an acute or chronic condition, such as
community-acquired pneumonia
• Integrate Age-Friendly care using the 4Ms Framework in care of older adults 65 years of age and over

5. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Community-Acquired Pneumonia (CAP)
(S) Situation: Lillian is a 78 year old female who presents with a non-productive cough with resulting
shortness of breath for the past few days with report of malaise and feeling feverish with some chills but
hasn’t taken her temperature.
(B) Background: PMH: Hypertension, osteoarthritis, osteoporosis
Medications: lisinopril 20 mg PO daily, alendronate 70 mg PO once a week
High-Dose influenza vaccine was administered 1 month ago. She is unsure when or if she received a
pneumonia vaccine.
Lives alone and enjoys volunteering 3 times a week in the children’s room at her local library

6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Community-Acquired Pneumonia (CAP) (Cont.)
(A) Assessment: VS: BP 130/76mmHg, HR 76/min, RR 22/min, Temp 97.6F, SpO2 93% on room air
Mentation: Alert and oriented to person, place, time. Normal affect, PHQ-2 = 0 (negative); Mini-Cog 5 (negative)
Mobility: Patient walks in unassisted wearing appropriate footwear. Get Up and Go test: No difficulty getting up
from a chair, walking 10 feet, turning around, walking back, and sitting back in chair.
Mouth: Erythematous oropharynx
Respiratory: Dull, diminished breath sounds, crackles, and bronchophony right lower lobe
Cardiac: Regular rate, rhythm, S1, S2, No S3, S4, murmur, capillary refill normal
PV: Pulses 2+ and equal bilaterally; no edema
(R) Recommendation: Likely CAP: Refer for further evaluation with a chest X-ray (CXR) and treatment per
institutional guidelines. Consider What Matters to the patient and plan accordingly.
Let’s discuss…

7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Recommendation Considerations and Where to Treat
For older adults, preference is to treat at home to prevent complications that may arise from a hospitalization.
Issues important to the decision to treat at home versus in the hospital include level of acuity, ability to take oral
medication, living conditions, social support, underlying psychiatric issues, cognitive impairment, and functional
impairment. Consider What Matters to the patient and plan accordingly.
CURB-65 Score for Pneumonia Severity. One point for presence of each of the following:
• C: Confusion
• U: Urea: BUN >19mg/dL
• R: Respiratory Rate ≥30 breaths/min
• B: Low BP: Systolic BP90 mmHg or Diastolic BP 60 mmHg
• Age ≥65 years
Scoring, where to treat: 0-1: Low risk-outpatient management; 2: Outpatient management versus admission; 3-5:
Severe-Inpatient admission and treatment
Confusion and increased BUN in older adults may be due to multiple factors
Original Study: Lim, W., van der Eerden, M. M., Laing, R., Boersma, W., Karalus, N., Town, G., Lewis, S., & Macfarlane, J. (2003). Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation
study. Thorax, 58(5), 377-382. http://dx.doi.org/10.1136/thorax.58.5.377

8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Immune Senescence
(Age-associated dysregulation and dysfunction of the immune system)
• Fundamental alterations in quantitative and qualitative immune
responses occur with aging, a process that has been called
immune senescence
• Infection is the primary cause of death in one-third of
individuals aged 65 years and older and is a contributor to
death for many others
• Infection also has a marked impact on morbidity in older
adults, exacerbating underlying illnesses and functional decline
• Multiple biologic and societal factors account for the increased
susceptibility of older adults to infection and their poorer
outcomes when diagnosed with an infection
Immune Response

9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Atypical Presentation of Illness in Older Adults
• Older adults may have a severe infection that does not manifest with the typical signs and/or symptoms
characterizing the same condition in younger adults
• Older adults with infection may lack fever, increased white blood count, or localizing, infection-specific
symptoms or signs
Example: Rather than a fever, productive cough, and pleuritic chest pain, pneumonia in an older adult may present as afebrile or with a
low-grade temperature elevation to 99ºF and an increased oxygen requirement. The white blood cell count may not increase with infection
until the infection is severe or the patient has sepsis.
• Infection in older patients may also be associated with nonspecific symptoms such as delirium, new onset
falls, and anorexia

10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
An Important Note about Fever
Relatively healthy, community-dwelling older adults may be appropriately managed using conventional
definitions of fever. In these patients, a temperature >38°C (100.4ºF) indicates a potential for serious
infection, while hypothermia relative to baseline body temperature may signify severe infection or sepsis
However, in some older adults, fever is absent in 30%-50%, even in the setting of serious infections such as
pneumonia or endocarditis. Consider use of a lower threshold for fever in older patients:
• Single oral temperature >37.8°C (>100ºF)
• Persistent oral or tympanic membrane temperature ≥37.2°C (99.0ºF)
• Rise in temperature of ≥1.1°C (≥2°F) above baseline temperature
The blunted febrile response in older adults is due to impairment in multiple systems responsible for
thermoregulation (e.g., shivering, vasoconstriction, hypothalamic regulation, and thermogenesis by brown
adipose tissue)

11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Back to the case…
Summary: ASSESS and ACT ON the 4Ms as a set
What Matters: Know and act on each patient’s specific health outcome goals and care preferences
• Treat patient with goal to allow her to be able to return to volunteering at the library
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters
• Treat CAP per guidelines keeping in mind antibiotic stewardship
• Increase fluid intake to stay hydrated
• Refer to primary care provider for follow up-medication use, hydration, vital signs, respiratory status and CAP response to treatment
Mentation: Focus on dementia and depression and delirium
• Educate patient to promote cognitive stimulation (e.g. puzzles, games, reading newspaper)
Mobility: Maintain mobility and function and prevent/treat complications of immobility
• Formulate daily mobility plan to maintain optimal ambulation and independence (e.g. walking around home 3 times a day, then walking
up and down the block to increase stamina)
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider; include need for follow up and who to call
if condition worsens (e.g. primary care provider, clinic number, family, emergency services)
 Don’t forget to scan into the EHR whenever individualized.

12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
For more information about treatment of CAP…
Evidence-based clinical practice guidelines on the management of adult patients with community-acquired
pneumonia:
Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A., Dean, N. C., Fine, M. J. Flanders, S. A., Griffin, M. R., Metersky, M.
L., Musher, D. M., Restrepo, M. I., & Whitney, C. G.; on behalf of the American Thoracic Society and Infectious Diseases Society of America. (2019). Diagnosis
and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases
Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST

13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Interprofessional Team Discussion…

14. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Acknowledgements
Age-Friendly Health Systems is an initiative of The John A. Hartford Foundation and the Institute for Healthcare
Improvement (IHI) in partnership with the American Hospital Association (AHA) and the Catholic Health
Association of the United States (CHA).
MinuteClinic’s commitment to be an Age-Friendly Health System is supported by a grant from The John A.
Hartford Foundation to the Case Western Reserve University Frances Payne Bolton School of Nursing.

15. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Thank You