The learning outcome for this activity: Participants will have increased knowledge of using the Age-Friendly 4Ms Framework while caring for an older adult patient experiencing Dementia, Depression or Delirium 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
Siyang Li PharmD
Emily Zaragoza, MD
Topic: Age-Friendly Health Systems:
Dementia, Depression, and Delirium 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:
• Differentiate between dementia, depression and delirium
• Identify AGS Beers Criteria© medications that place older adults 65 and over at risk for adverse events
• Identify the interrelationship of the 4Ms in the context of an acute or chronic condition
• 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.
SBAR: Case Scenario
(S) Situation: Nina, a 86 year old female is accompanied by her daughter, Rita, to the clinic for right
shoulder pain. She reports that for the last 2-3 days her mother was complaining of right shoulder
pain and has been crying, restless, and not sleeping, which is different from her usual behavior. Her
mother has not been eating or drinking well.
Rita reports sometimes her mom says she hears their dad talking to her at night and sees him in the
corners of rooms. Nina’s husband passed away 1 year ago. It is near his birthday. Daughter reports
her mother is “stubborn” and still likes to garden though told by multiple providers not to climb the
stairs when watering her plants. Nina is Italian-speaking only and has recently had a caregiver come
to her house to help with daily needs. Rita denies witnessing any falls injuries.
(B) Background: PMH: Alzheimer's dementia, depression, stroke, MI, HTN, hyperlipidemia, and
osteoporosis.
Medications: donepezil 10 mg PO daily, sertraline 50 mg PO daily, metoprolol succinate 100 mg PO
daily, atorvastatin 20 mg PO daily, alendronate 70 mg tab PO once weekly, calcium 1 tab PO daily,
multivitamin 1 tab PO daily, Vitamin D2 1000U PO daily

6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
SBAR: Case Scenario (Cont.)
(A) Assessment: VS: BP 168/100 mmHg, repeat BP 170/96 mmHg, HR 90/min, RR 20/min, Temp 97.8F, SpO2
98% on room air
Patient reports it hurts in Italian, unable to provide numeric score from 1-10, facial grimacing noted, guarding
shoulder noted.
Mentation: Alert, oriented to person only. Language barrier for adequate mental status and mood screening.
Mobility: Patient walks in unassisted wearing appropriate footwear; slow walking speed
Skin: Clean, dry, some tenting. Skin intact with normal capillary refill.
Respiratory: CTA bilaterally, no wheezes, rhonchi, crackles
Cardiac: Regular rate and rhythm, harsh late peaking crescendo decrescendo systolic murmur and heard best at
the R 2nd ICS
Musculoskeletal: Moderate swelling on the right shoulder, no obvious deformity, no ecchymosis. Mild tenderness to
palpation, uncooperative with remainder of exam secondary to pain with movement.
Psych: Anxious and uncooperative during exam, swatting
(R): Recommendation: Let’s discuss…

7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Recommendations
If thought to be delirium with acute or emergent cause of pain and/or behavior, activate EMS.
Prepare patient demographic sheet and give report to medic when arrives. Update patient and
family regarding plan. Otherwise, consider further assessment for dementia and depression.
• What are some differences between dementia, depression, and delirium?
• What are some risk factors for developing depression and delirium?
Let’s learn more…

8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Screen for Delirium: Confusion Assessment Method
The CAM Diagnostic Algorithm
Feature 1: Acute change in mental status and fluctuating course
Feature 2: Inattention
Feature 3: Disorganized thinking
Feature 4: Altered level of consciousness
The diagnosis of delirium by CAM requires the presence of features 1 and 2 AND either 3 or 4
Source: Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R. (1990). Clarifying confusion: The confusion assessment method. Annals of Internal Medicine, 113(12), 941-948.
Delirium instruments and training modules by Dr. Sharon Inouye and colleagues:
https://www.hospitalelderlifeprogram.org/delirium-instruments

9. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Consider potential causes of delirium
D: Drugs, dehydration, detox, deficiencies, discomfort/pain
E: Electrolyte disturbance, elimination issues, environment
L: Lungs (hypoxia), liver, lack of sleep, long emergency department stay
I: Infection, iatrogenic events, infarction (cardiac, cerebral)
R: Restricted movement/mobility, renal failure
I: Impaired sensory issue, intoxication
U: Urinary tract infection, unfamiliar environment
M: Metabolic abnormalities (pancreas, thyroid), medications

10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Screen for Dementia: Mini-Cog™
Three-item recall and clock drawing test (CDT)
• Instruct patient to repeat 3 unrelated words (may be repeated; word registration not scored)
• Instruct patient to draw a clock and have it read 11:10 (10 past 11) (clock drawing test scored)
• Instruct patient to recall the 3 words (word recall scored)
Scoring
• Clock Drawing Test scoring: 2 points if normal clock; 0 (zero) points if abnormal clock. A normal clock must
include all numbers (1-12), each only once, in the correct order and direction (clockwise) with two hands
present, one pointing to the 11 and one pointing to 2. Hand length not scored.
• 3-Item recall scoring: 1 point for each word recalled without cues
Results
• 0-2: Positive screen for dementia
• 3-5: Negative screen for dementia; does not rule out some degree of cognitive impairment
For more information about the Mini-Cog, please refer to the AFHS intranet banner > Video podcast

11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Screen for Depression: PHQ-2© Scale
Over the past 2 weeks, have you often been bothered by any of the following:
• Little interest or pleasure in doing things?
• Feeling down, depressed or hopeless?
Scoring: Total PHQ-2 score ≥3 suggests elevated symptoms of depression
PHQ-2© Not at all
0-1 day
Several days
2-6 days
More than half of
the days
7-11 days
Nearly every day
12-14 days
Little interest or
pleasure in doing things
0 1 2 3
Feeling down,
depressed or hopeless
0 1 2 3

12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Screen for Depression:
If PHQ-2 is Positive, Complete PHQ-9
Over the past 2 weeks, have you often been bothered by any of the following:
Total PHQ-9 Score: 1-4 minimal depression; 5-9 mild depression; 10-14 moderate depression; 15-19 moderately severe depression; 20-27 severe depression
PHQ-9© Not at all
0-1 day
Several days
2-6 days
More than half of the days
7-11 days
Nearly every day
12-14 days
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed or hopeless 0 1 2 3
Trouble falling or staying asleep, or sleeping too
much
0 1 2 3
Feeling tired or having little energy 0 1 2 3
Poor appetite or overeating 0 1 2 3
Feeling bad about yourself-or that you are a failure
or have let yourself or your family down
0 1 2 3
Trouble concentrating on things, such as reading the
newspaper or watching television
0 1 2 3
Moving or speaking so slowly that other people
could have noticed. Or the opposite-being so fidgety
or restless that you have been moving around a lot
more than usual.
0 1 2 3
Thoughts that would be better off dead, or of hurting
yourself
0 1 2 3

13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Feature Depression Delirium Dementia
Onset Weeks to months Hours to days Months to years
Course Chronic; responds to
treatment
Acute; reversible Chronic, progressive
Orientation Intact Varies, fluctuates Impaired
Sleep Disturbed, hypersomnia Disturbed; not pattern;
Changes nightly
May be disturbed; may
have pattern at night
Mood Low; apathetic;
decreased pleasure in
activities; change in
appetite
Fluctuates Fluctuates; may be
depressed in early stage;
may demonstrate apathy
Self-awareness Likely concerned about
any memory impairment
May be aware of
cognitive changes;
fluctuates
Likely to hide or be
unaware of cognitive
deficits
Function May be unaffected or
impaired
May be unaffected or
impaired
Impairment progressive
Differentiating Depression, Delirium, Dementia
Adapted from: Gagliardi, J. P. (2008). Differentiating among depression, delirium, and dementia in elderly patients. Virtual Mentor, 10(6), 383-388.
Huang, J. (2016). Merck Manual: Professional Edition. Delirium and Dementia. Available at http://www.merckmanuals.com/professional/neurologic-
disorders/delirium-and-dementia/dementia

14. 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
• Assessment is difficult, rely on patient’s daughter. Ask if daughter has durable power of attorney and if a health care proxy. If
acute or emergent, needs EMS; Based on history, patient likely enjoys gardening…pictures about gardening may help
behavioral symptoms
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what
matters
• Consider polypharmacy and possibility for deprescribing (e.g. Vitamin D, MVI, atorvastatin, calcium); https://deprescribing.org
Mentation: Focus on dementia and depression and delirium.
• What are reversible causes or possible delirium? Head injury with fall? Are dementia medications needed at this time (risk vs
benefit)? Could anniversary death of husband trigger depression? Consider possibility of dementia, depression, and delirium
concurrently.
Mobility: Maintain mobility and function and prevent/treat complications of immobility
• Encourage daily mobility. Consider use of assistive device, exercise program, PT when stable.
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider

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

16. 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.

17. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
References
Alagiakrishnan, K. (2019, April 26). What are the DSM-5 criteria for delirium? (G. L. Xiong & F. Talavera, Eds.). Retrieved August 19, 2019,
from https://www.medscape.com/answers/288890-31777/what-are-the-dsm-5-criteria-for-delirium
Delirium. (2018, June 27). Retrieved August 19, 2019, from https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-
causes/syc-20371386
Huang, J. (2019). Overview of Delirium and Dementia - Neurologic Disorders. Retrieved August 19, 2019, from
https://www.merckmanuals.com/professional/neurologic-disorders/delirium-and-dementia/overview-of-delirium-and-dementia
O'Sullivan, R., Inouye, S. K., & Meagher, D. (2014, September). Delirium and depression: Inter-relationship and clinical overlap in elderly
people. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338740/
Shin, R. D., H. A., & Shlamovitz, G. Z. (2019, July 16). Delirium, Dementia, and Amnesia in Emergency Medicine (F. Talavera & J. S. Huff,
Eds.). Retrieved August 19, 2019, from https://emedicine.medscape.com/article/793247-overview
Tampi, R. (2019). Evaluation of Dementia. Retrieved August 19, 2019, from https://online.epocrates.com/diseases/242/Evaluation-of-
dementia

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Thank You