How to Put the 4Ms Into Practice

What if the most important thing we can do for an older adult in the emergency department (ED) isn’t just to treat what brought them in - but to protect what matters most to them? Introducing the 4Ms framework: What Matters, Medication, Mentation, and Mobility, a foundation for delivering age-friendly care. In today’s episode, Dr. David Zodda joins GEMCast host Dr. Christina Shenvi to share his expertise on the 4Ms and the importance of addressing them in emergency care. David Zodda is an award-winning board-certified emergency medicine physician, fellowship-trained in evidence-based medicine, and recipient of the National Medicine Award for Clinical Excellence. He is also the founder of BetterMedicine.com, an online social media platform turning research into practical strategies for better health. He practices at Northern Light Mercy Hospital in Portland, Maine. Zodda shares personal stories, highlights emerging evidence, and offers practical approaches to integrate the 4Ms into your practice. Tune in to learn how using the evidence-based framework can help patients maintain independence, reduce avoidable hospitalizations and readmissions, and deliver care that treats the patient, not just the diagnosis. Additional resources and information for this episode can be found at https://gedcollaborative.com/resource/cms-measure/how-to-put-the-4ms-into-practice-age-friendly-care-in-the-ed/ Timestamps 00:00 - Introduction 07:50 - What Matters 11:36 - Mentation 16:59 - Mobility 23:07 - ED Boarders 26:31 - Medication 30:03 - Top Takeaway 31:04 - Future Research 32:38 - Conclusion

Every time a patient comes to the Emergency Department (ED) for care, there is an opportunity to identify and address factors in their life that may be contributing to their presentation. Social determinants of health (SDOH), including housing instability, access to transportation, economic hardship, and access to healthcare, are the non-medical aspects of a person’s life that influence their health. In today’s episode, Kristie Foster, Director of Nursing Operations at Mt. Ascutney Hospital in Vermont, joins host Dr Christina Shenvi to discuss the screening programme she implemented at her critical-access ED. At the heart of the SDOH screening programme is Kristie’s focus on compassionate care. It starts with a personal, conversation-based approach in which ED technicians use a simple checklist to identify common needs. When a need is identified, a three-tiered approach is initiated to connect patients with resources that can address those needs. Tune in to learn more about how the screening programme works in practice and hear stories from this successful intervention. Additional resources for this episode can be found at https://gedcollaborative.com/resource/what-matters/bringing-the-heart-back-to-medicine-by-addressing-social-drivers-of-health/.

In today’s episode of GEMCast, host Dr. Christina Shenvi is joined by Dr. Cameron Gettel to discuss a critical but often overlooked issue in the emergency department (ED): the emergency care needs of family caregivers for persons living with dementia (PLWD). Caregivers play an integral role in supporting these patients, but what about their own acute care needs? Dr. Gettel is an emergency physician and health services researcher at Yale University. His recent study on ED utilization of family caregivers of PLWD found that these caregivers have a 30% higher rate of ED visits compared to matched counterparts. Tune in as Dr. Shenvi and Dr. Gettel discuss why this may be, and how healthcare systems and physicians may attend to the needs of both PLWD and caregivers when they visit the ED. For more information visit https://gedcollaborative.com/resource/dementia/caring-for-the-caregiver-how-the-ed-can-support-caregivers-of-patients-with-dementia/.

Dr. Danya Khoujah joins GEMCast host Dr. Christina to dive into the first clinical practice guideline in the Geriatric Emergency Department (GED) Guidelines 2.0, which is dedicated to delirium. Delirium is a clinical syndrome characterised by acute and fluctuating disturbances of attention, awareness, perception or consciousness and it commonly affects older adults presenting to the ED. However, it is often missed, which has significant impacts on mortality and functional status of older patients. Khoujah is an attending physician in the Department of Emergency Medicine at AdventHealth Tampa in Florida, and host of GEDC’s expert-panel webinars. She is part of the multidisciplinary team that created this GRADE-based clinical guideline, and in this episode, she talks through the development and recommendations arising from the guideline. The group aimed to assess the quality and applicability of direct and indirect evidence, with the goal of providing ED clinicians a patient-centred approach to delirium. To do so they asked 3 key questions: Which older patients in the ED are at higher risk of delirium? Which diagnostic tests are effective at identifying ED delirium? Do older ED patients with delirium need a CT head? Tune in to today’s episode to hear more about screening, diagnosing and brain imaging for delirium in the ED, and keep an eye out for upcoming clinical guidelines in the GED Guidelines 2.0 series including medication safety, fall prevention, Find more information about this topic at https://gedcollaborative.com/resource/delirium/delirium-clinical-practice-guidelines-what-do-we-know-and-what-should-we-do/ GEMCAST is a Geriatric Emergency Medicine Podcast created to help clinicians, nurses, or paramedics who take care of older adults, particularly in the Emergency Department setting. GEMCast episodes, show notes and recommended resources can be found on the GEDC website at gedcollaborative.com/resources/?type=podcast.

In this GEMCast episode host Dr. Christina Shenvi is joined by Dr. Meredith Busman, Director of Observation Medicine at Corewell Health West in Grand Rapids Michigan, Program Director for the Observation Medicine Fellowship at Emergency Care Specialists, and co-chair of the ACEP Accelerate Observation Medicine: Science and Solutions conference. Observation medicine is an outpatient service that encompasses rapid treatment, assessment, and reassessment of select patients with the hopes of avoiding admission. Learn more about this new and rapidly developing subspecialty of emergency medicine, how ED-directed observation units function, and how they are particularly beneficial for older patients or those with dementia. The care provided in an observation unit uses predetermined protocols and pathways, leading to the notably shorter length of stay (LOS) – Dr. Busmans’ unit has an average LOS of just 17 hours! A rapid turnaround, coupled with efficient care from specialists and multidisciplinary input, leads to better outcomes for patients. In older patients who are susceptible to unfavorable outcomes such as delirium and deconditioning from either ED boarding or inpatient stays, the impact of a specialized service can be significant on acute and long-term health. Alongside the benefits for patients, an observation unit helps offload patients from other services and can improve patient flow through busy EDs. For more show notes visit https://gedcollaborative.com/resource/boarding/the-17-hour-turnaround-rapid-safe-observation-care-for-older-adults/.

Dr. Stephen Gamboa is an Adjunct Associate Professor at UNC and medical director of UNC Health Pardee's emergency department in Hendersonville, North Carolina. In today’s GEMCast episode, he shares his first-hand experiences from two major natural disasters: the 2017 Tubbs Fire in Northern California and Hurricane Helene, which hit Western North Carolina in 2024. As he joins host Dr. Christina Shenvi, the two talk about how these events have a disproportionate impact amongst our frail older patients, which can be attributed to age-related comorbidities, reduced mobility, and higher care needs. Tune in and hear a variety of innovative solutions brought about by the various challenges that these major events can pose. The immediate impacts of natural disasters, such as smoke inhalation and needing to rapidly evacuate homes and skilled nursing facilities (SNFs), are just the tip of the iceberg. Older patients with decompensation or exacerbations of chronic conditions made up a large proportion of the increased demand on EDs following these disasters. Coupled with power outages, electricity shortages, no internet connectivity, and pharmacies closing, Dr. Gamboa describes how his team had to adapt quickly and how system-level support from UNC during Hurricane Helene, including staff, equipment and transport, was crucial to providing care to these vulnerable patients. Find more information about this topic at https://gedcollaborative.com/resource/falls/fire-flood-and-fragility-disasters-through-a-geriatric-lens/ . GEMCAST is a Geriatric Emergency Medicine Podcast created to help clinicians, nurses, or paramedics who take care of older adults, particularly in the Emergency Department setting. GEMCast episodes, show notes and recommended resources can be found on the Geriatric Emergency Department Collaborative (GEDC) website at https://gedcollaborative.com/resources/?type=podcast.

In this episode of GEMCast, Dr. Christina Shenvi sits down with Dr. Christina Prather, Director of Geriatrics and Palliative Medicine at George Washington University, for a dynamic, coffee-style conversation about innovations and challenges in geriatric emergency care. They explore strategies for supporting older adults with dementia, preventing avoidable ED visits, and advancing patient-centered care through better communication, system protocols, and interdisciplinary teamwork. Listen in for practical tips, real-world stories, and insights on how emergency clinicians and leaders can better navigate the complexities of cognitive impairment and deliver compassionate, collaborative care to our aging population. Additional resources can be found at https://gedcollaborative.com/resource/dementia/acute-care-of-persons-living-with-dementia-from-the-clinic-to-the-ed-and-back/.

In this episode of GEMCast, host Dr. Christina Shenvi is joined by Dr. James Van Oppen, emergency physician and frailty expert at the University of Sheffield, to discuss the rising importance of frailty in emergency medicine. Frailty, defined as the loss of physiological resilience, is both common and clinically significant for older adults presenting to the emergency department (ED). The two discuss what frailty means, how it can be identified, and how to approach ED assessment and management in a frail patient, emphasizing the value of person-centred care. Furthermore, they highlight recent studies regarding frailty, which can be found in the resources below, and discuss the need for system-wide changes to support frailty care. Alongside his work as an emergency physician and clinical lecturer, Dr. van Oppen is the chair of the geriatric emergency medicine section of the European Society of Emergency Medicine. Tune in to this episode to expand your understanding of frailty and hear some practical tips to improve your clinical practice.

Climate change, and the associated increase in frequency and severity of heat waves, poses a threat to health. Amongst the most at risk for heat-related emergencies are older adults; age-associated physiologic vulnerabilities, chronic conditions, medications that disrupt thermoregulatory responses, and social determinants all contribute to an increased risk of heat-related illness in this population. When an older adult presents to the emergency department (ED) with vague or subtle symptoms of heat exhaustion or heat stroke, they may be missed by ED practitioners – a concerning thought as these patients are at a greater risk of mortality from heat-related emergencies. Optimal management of these presentations requires clinical recognition and treatment within the ED as well as pre-hospital interventions that can be given by emergency medical services (EMS). GEMCast host Dr. Christina Shenvi is joined by Geoff Comp, Associate Program Director at Creighton University School of Medicine/Valleywise Health Medical Center in Phoenix, Arizona, as the two do an in-depth review of this critical topic. Dr. Comp holds a wilderness medicine fellowship through the Wilderness Medical Society and is an expert in heat-related illness. Show notes are available on the Geriatric Emergency Department Collaborative (GEDC) website. https://gedcollaborative.com/resource/atypical-presentations/getting-hotter-heat-emergencies-in-older-adults/

Our population is aging, and with that comes an increase in the number of older adults in emergency departments. Delirium affects up to 1/3 older adults who present to the ED and is a medical emergency that is often overlooked by ED clinicians. In this episode of GEMCast host Dr. Christina Shenvi discusses the importance of recognising delirium, documenting it, and intervening where possible in the ED with Dr. Kayla Furlong and Dr. Gillian Sheppard. Dr. Furlong and Dr. Sheppard are both emergency medicine physicians in St. John’s, Newfoundland & Labrador, who are experts in point of care ultrasound (POCUS). Dr. Furlong is a Clinical Assistant Professor in the Faculty of Medicine at Memorial University and is the Chair of the CAEP Geriatric EM Committee. Dr. Sheppard is an Associate Professor and Chair of the Discipline of Emergency Medicine at Memorial University. She is also a Diplomate of the Royal College of Physicians of Canada with an Area of Focused Competence in POCUS and is the education lead for the Canadian Association of Emergency Physicians Emergency Ultrasound Committee. They have taken a special interest in whether the use of POCUS increases the ED clinicians’ ability to determine the aetiology of a geriatric patient’s delirium or agitation, and in doing so have developed the ABLE approach. They discuss why and how POCUS can be a useful tool and provide helpful tips for ED clinicians for how to implement POCUS. Tune in to learn more about how to approach older adults in the ED considering delirium, agitation, and the challenges they present. For further show notes head to https://gedcollaborative.com/resource/delirium/delirium-agitation-and-the-role-of-pocus-in-older-adults-in-the-ed/