What Van Halen Can Teach Us About the Care of Older Patients

Van Halen, the American hard rock band, dominated the music scene of the 1980s, becoming known not only for their dramatic pyrotechnics and dance moves but also for their particular pickiness when it came to preparing their dressing rooms. Their lengthy 1982 contract rider contained a stipulation that, in addition to towels and chips, a bowl of M&Ms be provided for the band—with the brown M&Ms picked out. This unusual request was the pretext for several cancelled performances—if the band discovered on arrival that there were indeed brown M&Ms in their dressing room snack bowl, they would refuse to play the show.¹

As a geriatrician, my curiosity was piqued by the explanation cited for this strange behavior in a story reported on NPR: Van Halen apparently used the brown M&Ms as evidence of attention to detail on the part of the concert venue. If the venue staff had not noticed this small detail buried in the rider, the band could not trust that the complex music system and stage had been set upcorrectly, that the elaborate pyrotechnics would function safely. The presence of the brown M&Ms called into doubt the stability and safety of the entire concert setup.

This tale from the entertainment industry resonates in the work we do as physicians caring for older adults: what are the analogous brown M&Ms we can notice when it comes to the care of frail patients with complex conditions? What are the details that, when amiss, can alert us to the risk level or stability of our patients and cause us to worry about the patient’s resilience to physiologic stress? Unlike Van Halen, when we notice these brown M&Ms we cannot cancel the show; we must use these warning signs as a reminder to check the functioning of the whole system in these high-risk patients and help support them.

A physician assessing an older adult with multiple medical problems may be tempted to address issues one at a time, medical problem by medical problem, a process that can be exhausting and overwhelming for both patient and physician. Three simple geriatric assessment tools can help us pay closer attention to identify the “brown M&Ms”—the details that should prompt us to look further into the overall function and frailty of our older patients and take steps to minimize their risk for adverse outcomes.

First, when our patients enter the examination room, we can watch how they walk. Gait speed is an important predictor of mortality² and is one of the most frequently used criteria to identify frailty.³ When we notice a patient walking slowly, it can prompt us to focus on their arthritic knees or proximal muscle strength, asking whether they require better pain control, physical therapy, or an assistive device; their balance, considering whether they would benefit from vitamin D or B₁₂ supplementation or a home safety assessment to install grab bars in their shower; and overall fall risk, prompting an evaluation of medications that could be deprescribed or fall risk factors that could be mitigated such as orthostatic hypotension or vision or hearing impairment.⁴

Second, as part of our physical examination, we can observe our patients performing the “sock-on, sock-off” test.⁵ If we notice our patients wearing slip-on shoes year round, or having difficulty donning socks—a task that requires balance, vision, dexterity, joint flexibility, and muscle strength—we have a second warning sign that they may be in danger of losing their independence and their ability to dress and care for themselves. A simple sock donner from an occupational therapist, a home health aide for a few hours a week, or a referral to local elder services might be the intervention that helps keep that older adult living independently.

The third of the brown M&Ms involves paying attention to patients’ toenails, a part of the examination not typically at the top of a busy internist’s list. As geriatrician Juergen Bludau instructed in Atul Gawande’s Being Mortal, for an older patient, “you must always examine the feet.”^6(p40) I have been surprised many times in my career thus far by the disconnect between how a patient is dressed and how their feet may look. Even if they have no difficulty taking off their socks and shoes, the dexterity required to cut one’s own toenails may prove more challenging. I ask my students, if you were injured and could not reach your toenails to cut them, what would you do? Ask a friend or family member, they suggest, see a podiatrist or get a pedicure. When our patients’ toenails are long but they have not been able to do one of these things, we worry about the patients’ support network, caregiver burnout or inability to attend to details, or whether they have the executive function or financial resources to seek the support they need, let alone manage their medications or other instrumental activities of daily living. Unkempt feet prompt a podiatry referral, as well as a closer look at the patient’s overall functional status and support system, and perhaps involvement of social work or local elder services.

When clinicians notice the presence of any of these 3 subtle signs in a patient’s examination, slow gait, difficulty donning socks, or unkempt toenails, we can use them as Van Halen did the brown M&Ms: as reminders to take a look at the stability and resilience of the whole system, the whole person. When we notice these features, our concern level increases for our patient’s frailty, physiologic reserve, and their risk for falls, for hospitalization, for institutionalization, for death.

Beyond worry, we can use these 3 quick maneuvers as flags to prompt us to take a different approach to help our complex or frail older patients, and to involve our interdisciplinary team from nursing, social work, physical and occupational therapy, home health aides, dentistry, nutrition, pharmacy, and more. We can use these signs as reminders to make sure these patients have health care proxies, advance directives, or physicians order for life-sustaining treatments on file to communicate their wishes in an emergency. We can be prompted to reassess that long problem list and think about prognosis and goals of care, perhaps relaxing the hemoglobin A1c goal or deprescribing medications whose risk/benefit ratio may have changed for the patient.⁷

Our older patients with multiple comorbidities benefit when we notice these details and tailor our care appropriately. If the brown M&Ms for Van Halen represented a breach in their trust of the system, for us as clinicians caring for older adults, they can represent an opportunity to use our observation skills to do our best to allow them to enjoy the sweetness of quality of life and the things that matter to them most.