Comprehensive Primary Care for Older Adults: The Geriatric 5Ms Framework

Primary care for adults ≥65 requires a distinct approach addressing multimorbidity, functional status, and patient priorities. The Geriatric 5Ms (Mindy, 2017) provide a structured framework: Mind, Mobility, Medications, Multicomplexity, Matters Most.

1. Mind: Cognition & Mental Health

• Screen: MoCA/Mini-Cog annually; PHQ-2/GAD-2 for depression/anxiety.
• Diagnose dementia subtype (AD, VaD, LBD, FTD) — guides prognosis, treatment, planning.
• Manage BPSD: non-pharmacologic first; antipsychotics only for severe danger, time-limited.
• Delirium prevention: HELP protocol (orientation, mobility, sleep, hydration, sensory).

2. Mobility: Function & Fall Prevention

• Assess: gait speed (<1.0 m/s = frailty marker), Timed Up-and-Go, SPPB.
• Fall risk: STEADI algorithm — screen, assess, intervene.
• Interventions: PT/OT, resistance/balance exercise, home safety, vitamin D if deficient, deprescribing fall-risk drugs.
• Assistive devices: proper fit, training.

3. Medications: Optimization & Deprescribing

• Medication reconciliation at every transition.
• Beers Criteria, STOPP/START, MedStopper, FORTA — identify PIMs.
• Target: benzodiazepines, anticholinergics, PPIs, hypoglycemics, antihypertensives (orthostasis), anticholinergic burden.
• Simplify regimens: once-daily, combination pills, blister packs, deprescribing plans.

4. Multicomplexity: Multimorbidity & Care Coordination

• Prioritize conditions by patient impact, not disease guidelines alone.
• Treatment burden assessment: "Can you manage all this?"
• Interdisciplinary team: NP/PA, pharmacist, SW, RN, PT/OT, nutrition, community health worker.
• Care coordination: warm handoffs, shared care plans, EHR interoperability, transitional care management (TCM).

5. Matters Most: Goals of Care & Advance Care Planning

• Elicit values: "What gives your life meaning? What are your fears? What trade-offs are acceptable?"
• Document: advance directive, healthcare proxy, POLST/MOLST, code status.
• Revisit at transitions: hospitalization, functional decline, new diagnosis, annually.
• Palliative care integration early — not just end-of-life.

Additional Geriatric Syndromes

• Frailty: Fried phenotype (weight loss, exhaustion, low activity, slowness, weakness) or deficit accumulation index. Pre-frail = intervention window.
• Urinary incontinence: Screen; typed evaluation; pelvic floor PT, pessary, anticholinergic-sparing meds.
• Malnutrition: MNA-SF; oral nutritional supplements, dietary counseling.
• Sensory impairment: Vision/hearing correction — huge QOL impact.
• Polypharmacy: ≥5 meds — systematic review.

Care Models That Work

• GRACE (Geriatric Resources for Assessment and Care of Elders): NP/SW home visits + interdisciplinary team.
• PACE (Program of All-Inclusive Care for the Elderly): capitated, adult day center, interdisciplinary.
• Primary care geriatrics clinics: Extended visits, team-based, 5Ms-embedded.

Geriatric primary care is not "internal medicine for old people" — it is a distinct clinical discipline optimizing healthspan, not just lifespan.