Reimagining Cirrhosis Care for Older Adults: A 5Ms Approach

Background: Cirrhosis is increasingly prevalent among older adults, driven in part by the rising burden of metabolic dysfunction-associated steatotic liver disease, which disproportionately affects this population. These patients are particularly vulnerable to premature geriatric syndromes, including frailty, disability, and cognitive impairment, reflecting the combined-if not synergistic-effects of aging and end-stage liver disease. As a result, they experience high symptom burden and health care utilization. Despite this complexity, cirrhosis care remains largely organized around disease-specific management and liver transplant evaluation, often failing to address geriatric and patient-centered needs. Approach: The Age-Friendly Health Systems initiative, developed by the John A. Hartford Foundation and the Institute for Healthcare Improvement, provides a standardized framework for high-quality care of older adults through the 4Ms: What Matters, Medication, Mentation, and Mobility. Although widely implemented across health systems, its application to hepatology remains limited. We propose an adaptation of the 4Ms framework for hepatology practice, supplemented by a fifth domain-Multicomplexity-to capture the intersecting challenges of symptom burden, multimorbidity, psychosocial vulnerability, and fragmented care. We describe how each domain can be operationalized within routine hepatology care and aligned with existing liver-specific tools and workflows. "What Matters" addresses prognostic uncertainty in cirrhosis and emphasizes structured advance care planning and goals-of-care conversations, particularly in the context of evolving transplant eligibility. "Medication" focuses on reducing polypharmacy and medication-related harm through careful prescribing in the setting of hepatic dysfunction and aging. "Mentation" targets identification and management of cognitive impairment, including minimal hepatic encephalopathy, alongside psychiatric comorbidities. "Mobility" emphasizes assessment and treatment of sarcopenia and frailty using liver-specific tools such as the Liver Frailty Index. "Multicomplexity" captures broader biopsychosocial and system-level challenges, including symptom burden, multimorbidity, social determinants of health, and care fragmentation. We further highlight palliative care as a complementary strategy for operationalizing the 5Ms in hepatology, supported by the PAL-LIVER trial, a multisite cluster randomized study demonstrating that trained hepatologist-delivered palliative care is noninferior to specialist-delivered care in improving quality of life and enhanced emotional well-being and patient satisfaction. Conclusions: An Age-Friendly, 5Ms-based approach adapted for hepatology has the potential to improve quality of life, reduce unnecessary health care utilization, and better align care with what matters most to older adults with cirrhosis. Integrating this framework into routine hepatology practice, supported by palliative care training principles and liver-specific tools, represents a scalable strategy for improving care delivery. Pragmatic implementation studies are needed to evaluate effectiveness, scalability, and sustainability across diverse health system settings.