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 COPD 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
Sarah Bertini,
APNC
Rebekah King, APNC
Aldo Calvo D.O
Topic: Age-Friendly Health Systems:
Chronic Obstructive Pulmonary Disease (COPD) 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:
• Recognize the correlation between impaired oxygen perfusion and mentation and mobility
• Identify the interrelationship of the 4Ms in the context of a 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.
Case Scenario: COPD Exacerbation
(S) Situation: Linda is a 69 y/o female with complaint of productive cough and dyspnea worsening over the past week. States
that a “cough is normal” for her but over the past week it has become more frequent and more productive. Has productive
cough while in clinic and expectorates a half-dollar size amount of purulent, thick sputum. Also reports nasal congestion,
paroxysmal nocturnal dyspnea, chest tightness, and headache. She denies having a current PCP and states that she hasn’t
seen a doctor in over 2 years. Her husband encouraged her to come in today but she was hesitant because she “doesn’t like
doctors.”
(B) Background: PMH: COPD and GERD
COPD was diagnosed by past PCP. Patient denies ever completing pulmonary function testing. Her PCP “just told her she had
COPD.” She had been on “a couple of inhalers” but stopped taking them over a year ago due to cost. Has Medicare Part A
and Part B, not Part D insurance so medications are not covered.
Medications: Over-the-counter omeprazole 20mg PO daily. Allergic to Penicillin.
Family history: Negative for COPD and lung cancer
Social history: History of 50 pack years of smoking, quit 2 years ago. Denies current or past e-cigarette use, illicit drug use.

6. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: COPD Exacerbation (Cont.)
(A) Assessment: VS: BP 104/76 mmHg, Pulse 90/min, RR 24/min, Temp 98.5F, SpO2 93% on room air
Mentation: PHQ-2 = 2 (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.
Skin: Mildly pale, warm, cap refill <3 sec
HEENT: Pupils equal, round and reactive to light, extraocular movements intact; Bilateral tympanic membranes intact, no
erythema or bulging; rhinorrhea present; posterior oropharynx moist with mild cobblestone appearance, no exudate noted
Respiratory: Increased respiratory effort with walking, effort within normal limits while at rest. Tachypnea. Inspiratory and
expiratory wheezes noted in lower fields bilaterally. No rhonchi or crackles noted. No tripoding or use of accessory muscles.
Cardiovascular: Regular rate and rhythm, S1, S2, no peripheral edema noted
(R) Recommendation: Let’s discuss…

7. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario Recommendation
Recommendation:
COPD with acute lower respiratory infection (J44.0)
• Prednisone 40mg PO daily x 5 days
• Albuterol inhaler with spacer 1-2 puffs Q 4-6 hours PRN wheezing, shortness of breath
• Doxycycline 100 mg 1 tablet PO twice a day x 7 days
• Follow up phone call in 48 hours
• Follow up appointment in 1 week at MinuteClinic
COPD Management
• Patient in need of primary care provide and pulmonary function tests
• Discussed What Matters to the patient regarding what she is looking for in a primary care provider. A referral was given to a
geriatric specialist in the area. Patient scheduled a visit and was seen within 10 days.
• Pulmonary function tests were completed and patient was diagnosed with Moderate COPD (GOLD 2)

8. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Information about COPD
Chronic obstructive pulmonary disease (COPD) is a common respiratory condition
High level of resource utilization
• Frequent office visits, recurrent hospitalizations due to acute exacerbations and need for chronic therapies (i.e.
inhalers, oxygen)
The pathological changes that occur as a result of COPD include:
• Mucus gland hyperplasia
• Fibrosis, narrowing and reduction in the number of small airways and
• Airway collapse
• Chronic inflammation
• Increased number of goblet cells
Three cardinal symptoms of COPD: dyspnea, chronic cough and sputum production
• Most common early symptom: exertional dyspnea
Source: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report.

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COPD Resources: Global Initiative for COPD GOLD Report
Global Initiative for Chronic Obstructive Lung Disease. (2020). Global Strategy for the Diagnosis,
Management and Prevention of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD)
2020 Report. Available at: https://goldcopd.org/gold-reports
Refer to the GOLD Report for evidence-based information related to evidence-based diagnosis,
management and prevention of COPD
This report includes assessment tools. Example: CAT™ COPD Assessment Tool has the patient rate
symptoms from 1 to 5. The higher the score, the more significant the symptom(s).
• I never cough (1) ….. I cough all the time (5)
• I have no phlegm (mucus) in my chest at all (1) ….. My chest is complete full of phlegm (mucus) (5)
• My chest does not feel tight at all (1) ….. My chest feels very tight (5)
• When I walk up a hill or flight of stairs I am not breathless (1) ….. When I walk up a hill or flight of stairs I am
very breathless (5)
• I am not limited doing any activities at home (1) ….. I am very limited doing activities at home (5)
• I am confident leaving my home despite my lung condition (1) ….. I am not at all confident leaving my home
because of my lung condition (5)
• I sleep soundly (1) ….. I don’t sleep soundly because of my lung condition (5)
• I have lots of energy (1) ….. I have no energy at all (5)
Source: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report.

10. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
Case Scenario: Discussion
• What other pharmacological treatments could have been applied for this patient?
• If the patient was not able to establish care with a PCP how would that have changed the treatment plan?
• What patient education should be addressed with a patient with COPD?
Let’s discuss each of these questions further…

11. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
What other pharmacological treatments could have been applied for
this patient?
• Short-acting anticholinergic inhaler (i.e. Ipratropium bromide): Research has found that a
combination of a Short-Acting Beta Agonist (SABA) and anticholinergic inhaler results in more
bronchodilation than either agent used alone
• Introduce the possibility of including the CAT™ Assessment Tool score

12. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
If the patient was not able to establish care with a PCP, how would
that change the treatment plan?
At 1 week follow-up the provider could start maintenance therapy and collaborate with a PCP:
• Long-Acting Muscarinic Antagonist (LAMA or long-acting anticholinergic)
i.e. tiotropium (Spiriva) 18mcg (1 capsule) inhaler daily
• Follow up in 6 weeks if still no PCP

13. Created in collaboration between MinuteClinic and the Frances Payne Bolton School of Nursing, Case Western Reserve University - 2020.
What educational topics/chronic care items should be addressed
with each patient that has a history of COPD?
Inhaler Technique
• Clinician should demonstrate correct technique, observe patient practice and provide correction if needed
• Medication adjustments should NOT be made unless a review of inhaler technique has been completed to verify the patient is
administering the medication correctly
• Address cost of medications and seek input from pharmacist for lower priced appropriate alternatives
Smoking Cessation
• Smoking cessation can reduce the rate of decline in lung function
• Best cessation rates are achieved when counseling is combined with medication therapy
• Address e-cigarette use
Vaccinations
• Infection is a common cause of COPD exacerbations. Influenza and pneumococcal vaccines should be offered and encouraged to
all patients with COPD.
Making End-of-Life Decisions
• End-of-life discussions are important and part of care provision and What Matters to the patient
• End-of-life care planning should include discussions with the patient and their families about their views on resuscitation, advance
directives, artificial methods of feeding, and place of death preferences

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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
• Refer to primary care provider she trusts and will see
• Ability to afford medication: Encourage to apply for Medicare Part D insurance supplement and review pharmacy cost saving options
• Individualize plan to address cost and access to health care and affordable medications
• Consider advance care planning discussion
Medication: Optimize use to reduce harm and burden, focusing on medications affecting mobility, mentation, and what matters
• Choose medications that are most affordable and assure proper use; Educate patient to review inhaler use with pharmacist
Mentation: Focus on dementia and depression and delirium
• Promote adequate SpO2 to prevent change in mentation
• Decrease dyspnea and COPD exacerbations to prevent depression and delirium
• Educate patient and family that in older adults COPD exacerbation and/or respiratory infection may present as delirium
Mobility: Maintain mobility and function and prevent/treat complications of immobility
• Increase mobility; Walk multiple times daily; Physical therapy to promote mobility; Decrease episodes of dyspnea
Provide 4Ms brochure with suggestions for patient/family to share with primary care provider, methods to prevent COPD exacerbation-
• Don’t forget to scan into the EHR whenever individualized.

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

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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.

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References
1. Han, MK, Dransfield, MT, Martinez, FJ. Chronic Obstructive Pulmonary Disease: Definition, clinical manifestations, diagnosis and staging. Up
To Date. https://www.uptodate.com/contents/chronic-obstructive-pulmonary-disease-definition-clinical-manifestations-diagnosis-and-
staging?source=autocomplete&index=3~4&search=copd. Updated May 14, 2018. Accessed July 10, 2019.
2. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic
Obstructive Pulmonary Disease: 2020 Report. www.goldcopd.org. Accessed February 23, 2020.
3. McDonough, JE, Yuan R, Suzuki, M, et al. Small-airway obstruction and emphysema in chronic obstructive pulmonary disease. N Engl J Med
2011; 365:1567
4. Ferguson, GT, Make, B. Management of stable chronic obstructive pulmonary disease. Up To Date.
https://www.uptodate.com/contents/management-of-stable-chronic-obstructive-pulmonary-
disease?source=autocomplete&index=2~4&search=copd. Updated January 16, 2019. Accessed July 10, 2019.
5. Warnier, MJ, vanReit, EE, Rutten, FH, et al. Smoking cessation strategies in patients with COPD. Eur Respir J 2013; 41:727.

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Thank You