Understanding what matters, medication, mentation + mobility in design
By: Dr. Heena P. Santry
The U.S. population is aging rapidly with U.S. census data demonstrating one in six Americans is over age 65. The largest growth in older Americans over the past decade has been among nonagenarians. Despite increasing functional and cognitive frailty, older Americans fiercely seek to maintain their independence and dignity as they continue to live longer. Hospitalization poses the greatest threat to this independence and dignity.
While diagnoses like a stroke or heart attack can significantly impact functional status, most diagnoses are, in theory, compatible with a full functional recovery. However, the mere experience of hospitalization itself is a risk factor for functional decline, due to preventable issues such as delirium and falls. Additionally, evidence shows that older Americans frequently receive goal-discordant care during acute hospitalizations.
To prepare the U.S. healthcare system for the influx of geriatric patients and address the complex factors contributing to the loss of independence and dignity as Americans age, the John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States, launched the Age-Friendly Health Systems initiative in 2017. The initiative introduces a “4M” framework for caring for older patients across various care settings, based on evidence highlighting issues such as goal-discordant care, overuse of medications that impair cognition and physical function, failure to properly diagnose and treat cognitive dysfunction and high rates of falls.
This year, the Centers for Medicare and Medicaid Services, the agency that administers the Medicare insurance plans that cover the vast majority of Americans age 65 and older, implemented a new Age Friendly Hospital Rating based on the 4M Framework in its Inpatient Prospective Payment System Final Rule. It’s a structural measure that incentivizes acute care hospitals to prioritize this evidence-based approach to care for older patients.
This raises the question: how can designers contribute to achieving these goals? They can begin by understanding the “4M’s”: What Matters, Medication, Mentation and Mobility.
What matters
It’s critical to understand and align care with each older adult’s specific health outcome goals and preferences, including end-of-life care, across all care settings. Hospital room design, even with single-patient rooms, often fails to support meaningful discussions about care goals with patients and their caregivers. For example, physicians often have to stand at the foot of the bed, as the only additional seating is often occupied by a loved one. Introducing more seating options — such as a small folding chair discreetly placed in the front wall of the room — can improve communication. This setup allows for strong eye contact at the patient’s bed level, enabling caregivers to engage with the patient while still facing other important members of the care team, which is essential for effective, high-quality care discussions.
However, such discussions become ineffective if the patient can’t hear what is being said, or if the physician is forced to raise their voice, disrupting the normal cadence of a nuanced conversation. Many geriatric patients experience hearing impairment and may not have their hearing aids with them. A simple technological solution, such as a contained audio system, could greatly improve communication. By allowing the patient to wear a noise-canceling, volume-amplifying headset, while the provider speaks into a microphone at a normal volume, meaningful discussions about outcome goals and care preferences can be more easily facilitated.
Medication
When medication is necessary, prioritize age-friendly options that do not interfere with the older adult’s goals, mobility or mentation across all care settings. Much of the workflow for this measure will be integrated into electronic medical records and developed in collaboration with medical teams and pharmacists to reduce the use of medications that impair what matters, mobility or mentation. However, these medications are often requested by nursing staff for “patient safety” in those with altered mentation, whether to prevent falls in patients who might attempt to get out of bed or to avoid restraints for those at risk of pulling out tubes, lines or drains.
Over the past decade, nursing unit design has advanced significantly with the implementation of digital communication boards, distributed nursing stations and clear lines of sight that support the principles of hourly rounding. Engaging frontline providers in discussions about how unit design can continue to support fall prevention and reduce the use of restraints will be crucial in addressing this issue and the other key pillars of the 4M framework.
Mentation
It is critical to prevent, identify, treat and manage dementia, depression and delirium across care settings. Individuals with pre-existing dementia or depression are more susceptible to altered sleep cycles and disorientation when hospitalized.
While outpatient adopters of the 4M framework can help acute care teams stay alert to these risk factors, universal strategies for preventing delirium among older hospitalized patients include frequent orientation to time and place, as well as maintaining a normal sleep cycle.
The ability of nursing staff to manage orientation is tied to unit design, as previously mentioned. However, maintaining a normal sleep cycle depends entirely on room design and furnishings. Lack of exposure to natural light and spending long periods in bed are key non-biological risk factors for delirium in hospitalized patients. During the earliest design stages, massing diagrams should account for sun exposure in patient care units to ensure maximum daytime sunlight. When natural light is limited, due to geography or time of year, ambient lighting that mimics day and night cycles — ideally on a timer that must be manually overridden — becomes crucial. This prevents the instinct, even among highly skilled healthcare workers, to allow hospitalized patients to sleep throughout the day.
On the flip side, appropriate window treatments that allow for quality sleep when the days are long are also important. Again, if these could be on a timer, unburdening staff from having to adjust the shades manually, while aligning the lightness and darkness of the room with medication administration times, the assurance of a day/night cycle would be seamless. Additionally, Hoyer lifts and appropriate seating that allows patients to be out of bed and comfortable during most of the day are crucial for ensuring orientation to time and place and preventing hospital-acquired delirium.
While many might assume older patients would resist digital innovations, emerging evidence suggests that in the era of AI and various mobile technologies, digital interaction with “avatars” or recorded videos of hospital staff — or even family members — can play a significant role in maintaining orientation. Therefore, it is essential to consider innovative digital technologies as adjuncts to physical space design during the design process.
Mobility
It is crucial to ensure older adults move safely every day to maintain function and do what matters. Moving safely becomes difficult when hospitalized due to unfamiliar surroundings and unavoidable trip hazards such as IV poles. Bed alarms, cameras and restraints (which should be strictly monitored and avoided whenever possible) are variably used for fall prevention in hospitals.
Investing in extra square footage for patient rooms, while costly to construct, might be a worthwhile investment in fall prevention. Larger rooms allow for more clear floor space, making it easier for patients to move even when tubes, lines and drains are in place. The size and placement of toilet rooms are also key considerations for fall prevention, as many falls in the hospital occur when patients need to use the commode.
In addition, evidence shows that loss of muscle mass and coordination accumulates rapidly in hospitalized older patients who remain in bed. Patients are more likely to stay mobile with their own assistive devices, so having safe but accessible storage for devices such as walkers will support safe mobility during hospitalization. While walking with the aid of attendants and assistive devices in the halls is preferred, there are often medical reasons, such as infection or the presence of a drainage system connected to the headwall, that prevent mobility outside the room. In these cases, room size that allows for laps, portable steps or even a walking pad will play a critical role in maintaining mobility in preparation for discharge.
Hospitals will need to consider how to meet the Centers for Medicare & Medicaid Services benchmarks for age-friendly care moving forward. At the design stage, a clear understanding of the 4M framework is an essential resource to help clients create workflows, adopt technological innovations and design patient rooms and nursing unit layouts that prioritize dignity and independence for older patients across the continuum of care. And those interested in learning more can participate in the Age-Friendly Health System Community.
Dr. Heena P. Santry, M.D. MS, FACS, is a healthcare principal at Arcadis.
Images courtesy of Arcadis
