Integrating the 4Ms Framework into Neuroscience Nursing: Reflections on a Path to Age-Friendly Stroke Care.

Neuroscience nurses are caring for a rapidly aging population with nearly 17% of Americans currently over age 65, a proportion expected to double by 2050.1,2 This demographic shift is acutely felt in stroke care, where aging remains the most significant nonmodifiable risk factor.3 Nearly 3-quarters of all strokes occur in older adults, and among survivors aged 65 and older, 89% live with 2 or more chronic conditions.3,4 Consequently, neuroscience nurses at the bedside are rarely treating stroke in isolation; they are managing complex multimorbidity that traditional disease-based models often fail to address. To bridge the gap in patient-centered care for older adults, the John A. Hartford Foundation partnered with the Institute for Healthcare Improvement, the American Hospital Association, and the Catholic Health Association to launch the Age-Friendly Health Systems initiative anchored by the 4Ms framework: What Matters, Medication, Mentation, and Mobility (Fig. 1).1,5 This framework is designed to be scalable and adaptable across disciplines. By embedding these principles into the culture of care, the Age-Friendly Health Systems (AFHS) movement seeks to transform how clinicians deliver care.1,5 Disease-specific applications of this model remain limited, and the literature does not currently describe systematic implementation of the framework in cerebrovascular disease. Although the 4Ms were designed for use across disciplines and disease states, they provide a critical framework for innovation in neuroscience nursing. While the interdisciplinary team contributes to the 4Ms, the neuroscience nurse is the gatekeeper of these elements at the bedside. At our institution, recognition as an AFHS in 2021 created an infrastructure for measurement and documentation of the 4Ms; however, the 4Ms framework was introduced through a hospital-wide initiative rather than a stroke-specific implementation effort. As a result, neuroscience nurses encountered the framework primarily as documentation requirements and performance metrics, often without explicit connection to stroke care. This lack of stroke-specific context limited engagement and understanding among bedside nurses. In 2025, we began to consider how the 4Ms have been applied to older adults with stroke. This reflection describes our experience with the framework in stroke nursing practice, drawing on observed practice patterns, local performance data, and nursing literature to explore how the 4Ms have aligned, or could better align, with inpatient stroke care. Given that neuroscience nurses may be unfamiliar with the 4Ms, we include a concise overview with our experience as context for reflection and future implementation.FIGURE 1: 4Ms framework of an age-friendly health system.The 4MS Framework in Neuroscience Nursing Understanding What Matters to each older adult underpins care in an AFHS. This approach ensures health care decisions reflect an individual’s values, goals, and life context, particularly for those with multiple chronic conditions, aligning with the goal-concordant care principles central to stroke palliative care recommendations.6 When care aligns with patient priorities, outcomes improve, as does overall well-being.5What Matters conversations in our hospital have primarily been the responsibility of social workers, and only 40% of older adults with stroke have a What Matters conversation documented. As a result, stroke nurses are uninvolved in assessing What Matters. This separation may partially explain lower adherence to this domain and full 4Ms implementation on stroke units, highlighting an opportunity to strengthen nurse–patient relationships through intentional engagement in What Matters conversations.7 The Medication domain of the 4Ms framework promotes the safe use of necessary drugs and the avoidance of high-risk or unnecessary medications. The goal is to ensure what matters, mentation, and mobility are not negatively influenced by medication.1,5 Neuroscience nurses act as the final safety check before administration of high-risk medications like benzodiazepines and anticholinergics. At our hospital, only 34% of older adults with stroke have no high-risk medications prescribed during hospitalization. Nurse-led improvement initiatives implemented on general medicine units (which included patients with stroke) at another hospital demonstrate that substantially higher adherence is achievable, even when high-risk medications are clinically indicated for some patients.7 This gap underscores an opportunity to more clearly frame medication safety as a nursing advocacy responsibility, particularly given the association between medication-related delirium and adverse stroke outcomes.8 Mobility emphasizes maintaining functional independence and preventing complications related to immobility with protocols promoting early and frequent mobilization, avoidance of restraints, and removal of tethering devices like catheters.5 The Mobility domain is particularly relevant to patients with stroke who often have hemiparesis, ataxia, balance deficits, or spasticity. Specific to stroke, high-dose, very early (within 24 hours) mobilization should be cautiously evaluated, but early mobilization by nurses when medically stable is advised.9,10 On our stroke units, adherence to mobility expectations has been relatively high (88%) compared with other 4Ms domains. This likely reflects longstanding stroke-specific education emphasizing early, safe mobilization and its impact on outcomes. The Mentation domain addresses delirium, dementia, and depression.5 These conditions frequently coexist but are often overlooked in the complexity of acute stroke care. Delirium impacts ∼1-quarter of acute stroke patients, while post-stroke dementia affects one-third of survivors and is linked to poorer functional outcomes and increased mortality.8,11,12 For the neuroscience nurse, mentation management involves active prevention and screening with delirium prevention as a core priority. Because pharmacologic management of delirium is discouraged, nurses lead evidence-based nonpharmacologic interventions, including adequate hydration, providing personal sensory aids (glasses, hearing aids), minimizing environmental overstimulation, and orienting patients regularly to promote uninterrupted sleep.5 To ensure early recognition, nurses utilize validated screening instruments such as the Confusion Assessment Method, Confusion Assessment Method for the ICU, or the Nursing Delirium Screening Scale, which should be integrated into daily assessments.5 Furthermore, because depression is a significant barrier to recovery, nurses can screen using depression screening tools.5,12 Lessons Learned and Future Plans The roll-out of AFHS 4Ms in many hospitals is fragmented and may start on single units or with single Ms.13 Our challenges, much like those of other hospitals, include the complexity of wide-scale roll-out and in the circumstance of our stroke units, high turnover and reliance on temporary or contract staff nurses.7 Data from the AFHS dashboards in our hospital indicate that while our neuroscience units are performing at or above other units with mobility and delirium screening, the implementation of the What Matters and Medication domains are low. Only 4% of older adults with stroke meet all 4Ms during hospitalization. Feedback from stroke nurses reveals a significant gap; less than half knew the hospital was recognized as an AFHS, and nearly 80% were either unfamiliar or only slightly familiar with the 4Ms. Nurses expressed a desire to learn more about the 4Ms and prioritized shared decision making and What Matters conversations for future education. Our experience suggests that domains previously considered core components of stroke nursing care—such as mobility and delirium screening—have performed well, while overall recognition of the 4Ms as a driving framework has not. Without explicit connections to stroke outcomes, the 4Ms risk being perceived as an external requirement rather than a nursing-relevant approach. One team successfully implemented the 4Ms on 2 general medicine units that included patients with stroke and found that the relationship perspective of nurse-partner rather than nurse-patient was beneficial in the experience of both the nurse and patient, and that the What Matters domain drove that relationship and application of the other domains.7 Based on these lessons, we advocate for the development and launch of a stroke-specific 4Ms model (Fig. 2). By adapting the framework to the realities of stroke care, neuroscience nurses can ensure that treatment aligns with patient goals, medications support cognitive safety, and mobility is preserved. This approach has the potential to enhance relevance, engagement, and sustainability.FIGURE 2: 4Ms stroke-related considerations.Conclusion The 4Ms framework offers an evidence-based model to guide holistic, person-centered care for older adults.1,5 Stroke, a disease fundamentally intertwined with aging, presents a compelling opportunity for the specialty-level adaptation of this model. However, the successful integration of the 4Ms into the high-acuity environment of a stroke unit requires more than administrative policy; it requires bedside leadership and a clear linkage to stroke care priorities. The novel application of this model to the care of older adults with stroke requires further evaluation. We provide an initial reflection on integrating the 4Ms into stroke care. While robust data and published models are lacking, our experience underscores the need for targeted education, a stroke-specific approach, and ongoing research. Future quality improvement initiatives should evaluate the impact of the 4Ms on patient outcomes and nursing practice. By embracing this framework, neuroscience nurses can lead the charge in recognizing that age-friendly care is, by definition, stroke-friendly care.