Patients with cognitive impairments are 2-3 times more likely to suffer from falls, indicating the patient’s mental capacity has an impact on their overall risk.

Cognitive impairments range from acute (induced by metabolic issues or medication) to chronic, and from mild to severe. Cognitive impairment is characterized by a decline in occupational, social or day-to-day functional status as well as presence of amnesia, agnosia, language deficits, apraxia, gait abnormalities, behavioral changes.  These changes are most frequently observed by family members and care providers who spend time with the patient and more familiar with their baseline function.

The connections between cognition and patient falls have been postulated to be related to some of the following items:

• decline of motor function is part of the dementia process which increases with duration of the illness
• loss of higher-level cognitive functions, particularly executive function contributing to the increased fall risk
• dual-task performances weaken postural control even in the early stages of Alzheimer’s disease
• gait speed is impacted by either accelerating or deceleration
• stride length variability, extra pyramidal symptoms (e.g. tremor, rigidity) and contractures affect mobility in a negative manner in advanced stages of cognitive impairment

Screening for Cognition Decline

The ideal assessments and diagnosis can be performed during routine checkups with the patient’s primary provider utilizing a history and physical, testing, and labs and occasionally procedures.  In the event the patient has not had a workup recently, a simple screening can be used to identify patients at risk for a decline in cognition, and hence for strong encouragement for additional workup.

In the home care setting, a simple test which can be performed would be the MiniCog (mini cognition) test comprising of the following:

1. Instruct the patient to listen carefully and repeat the following

APPLE WATCH PENNY

MANZANA RELOJ PESETA

2. Administer the Clock Drawing Test [CDT] (e.g. draw hands of the clock to represent the time “forty five minutes past ten o’clock” on an empty circle)

3. Ask the patient to repeat the three words given previously

_________ _________ __________

Mini cog Scoring

Number of correct items recalled _______ [if 3 then negative screen. STOP]

If answer is 1-2

Is CDT Abnormal? No Yes

If No, then negative screen

If Yes, then screen positive for cognitive impairment

If screen is positive based on Mini-cog, follow up should be done with the patient’s primary care provider for additional workup and diagnosis as appropriate.

Actions which can be taken once patients have been found to be at risk due to cognitive decline:

• additional sensitivity and vigilance to gait patterns and fall risk patterns
• engage in activities which improve cognitive function with patient and include family members as a means of instructing them
• provide instruction on behavioral management to decrease chances of falls from emotional outbursts or behavioral problems

Sources

• Härlein, J., Dassen, T., Halfens, R. J.G, Heinze, C. Fall risk factors in older people with dementia or cognitive impairment: a systematic review. Journal of Advanced Nursing Volume 65, Issue 5, pages 922–933, May 2009. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2648.2008.04950.x/abstract
• British Columbia Ministry of Health Cognitive Impairment in the Elderly – Recognition, Diagnosis and Management retrieved from http://www.bcguidelines.ca/guideline_cognitive.html#recommendation_1
• UT Center of Excellence in Geriatrics Care Minicog retrieved from http://geriatrics.uthscsa.edu/tools/MINICog.pdf