Cognition Screening and medical tests can be used to assess signs and symptoms consistent with cognitive decline and can include some of the following screens: ● Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975; Kurlowicz & Wallace, 1999). ● Mini-Cog test (Borson, Scanian, Brush, Vitaliano, & Dokmak, 2000). ● St. Louis University Mental Status Examination (SLUMS; Morley & Tumosa 2002). ● Clock Drawing Test (CDT; Lorentz, Scanlan, & Borson, 2002). ● Short Blessed Test (Brooke & Bullock, 1999). ● Verbal Fluency Tests (Canning, Leach, Stuss, Ngo, & Black, 2004). ● Animal Naming Test (Howe, 2007). ● Montreal Cognitive Assessment (MoCA; Nasreddine et al, 2005). The most well-known screening exam for cognitive decline is the MMSE. The MMSE takes 10 to 15 minutes to complete, as does its alternative test, the St. Louis University Mental Status Examination (SLUMS). The Mini-Cog test is a 3-minute instrument used to screen for cognitive impairment that includes a three-item recall, interrupted by the Clock Drawing Test (CDT) where the individual draws the time on a blank circle representing a clock face. The Mini-Cog is less influenced by education or socioeconomic status and uses a simple scoring system (Borson et al., 2000). The Short Blessed Test, verbal fluency, and animal naming tests are brief screening tools that can detect changes in cognition. The verbal fluency test is a simple screening tool. The examiner asks the participant to name as many words as possible that start with the letters F, A, or S in 60 seconds. Participants can’t use words with same stem like friends, friendly, friend. Normative data depends on education and age, but in general, adults ages 60 to 79 years should be able to name 25 to 42 words, whereas adults age 80 to 95 years should be able to name 22 to 37 words. Scores increase as education increases (Tombaugh, Kozak, Rees, 1999). A screening tool that is less biased by education is the animal naming test. For this tool, the examiner asks the participant to name as many animals in 60 seconds as possible without repeating. The animal names are recorded for accurate measurement and to check for repeats. A general cutoff is that fewer than 15 animals named indicates cognitive impairment. Additional normative data for the sixth decade of life is 17 animals, seventh decade is 16 animals, the eighth decade is 14 animals, and adults over 90 years of age should be able to name at least 13 animals (Tombaugh et al., 1999). The Montreal Cognitive Assessment (MoCA) is a newer 30-point one-page test that can be completed in 10 minutes (Nasreddine et al, 2005). Cognitive demands due to any of the potential age-related cognitive declines can result in delays in balance reaction times, muscle response, and amplitude of force generation during dual-task postural activities. Difficulties are more significant in balance-impaired and cognitively impaired older adults than in healthy, successfully aging older adults. Fear of falling Fall-related psychological difficulties that often result from a fall should be investigated and screened for by clinicians. Fear of falling, poor falls efficacy, and/or poor balance confidence are common consequences of past falls or near falls. Fear of falling can be defined as a “lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing” (Tinetti & Powell, 1993). Falls efficacy refers to the confidence in one’s ability to perform ADLs without falling (Tinetti et al., 1990). Balance confidence is defined as the “confidence in one’s ability to maintain balance and remain steady” (Powell & Myers, 1995).
There are several assessment tools designed to measure one or more of these three psychological consequences of falls, with no real consensus on the best tool to use. A review of the literature by Moore and Ellis identifies the Falls Efficacy Scale (FES; Tinetti, et al, 1990), ABC (Powell & Myers, 1995), and the Survey of Activities and Fear of Falling in the Elderly Scale (SAFFE; Lachman et al., 1998) as the three most widely used instruments (Moore & Ellis, 2008). There are shorter, modified versions of each of these and no clear choice based on reliability or validity. A newer assessment, the Falls Efficacy Scale International (FES-I; Delbaere et al., 2010), has a 16-item and a 7-item version and shows good validity and reliability, although cut-points and responsiveness to change over time are still under investigation. Thus, the two instruments of choice based on ease of completion are the FES (>70 indicates a fear of falling; Tinetti, et al, 1990) and the ABC (<67% = older adults at risk for falling; predictive of future fall; Lajoie & Gallagher, 2004). Either of these instruments should be used to determine if an older adult is avoiding ADLs due to apprehension surrounding falls. Asking a yes/no question on fear of falling (e.g., “Are you fearful of falling?”) may indicate when the full scale should be used. This may work better for women than men (Myers et al., 1996). Frailty Clinicians should note the presence of frailty in older adults who are at least 75 years of age or who may show signs of becoming frail. Frail older adults, especially women, are at increased risk for recurrent falls, hip fracture, any non-spine fracture, and death (Ensrud et al., 2007). Thus, it is important to evaluate for the presence of this condition. Although there is not gold standard model for assessing frailty, using a model like the Fried frailty model described earlier would be a good addition to an evaluation of an older adult who is suspected of being frail, such as residents in a long-term care facility. Using a five-item model would allow a clinician to define pre-frail as having two of five factors, frail as having three of five factors, and severely frail as having four or five of five factors. Suggested factors could be balance, gait speed, fall history, grip strength, or leg strength. These are all physical factors related to frailty. Other models include cognition, incontinence, or depression. Although multicomponent interventions have superior outcomes when combating frailty, the optimal time to intervene appears to be in the pre-frail stage (Cadore, Rodriguez-Manas, Sinclair, & Izquierdo, 2013). Environmental hazards Environmental risk hazards were cited in Table 1 as extrinsic fall risk factors. In the 2015 National Falls Prevention Action Plan (Cameron et al., 2015), home safety, as it relates to fall prevention, is one of the four goals intended to reduce fall incidence. The other three goals are physical mobility, medication management, and environmental safety in the community. Checking for home and environmental hazards is also a recommendation in the AGS/BGS clinical guidance statement (AGS/BGS, 2015). Handouts on home safety surveys are included in the STEADI fall prevention materials and there is good evidence for use of safety assessments in a multifactorial fall risk assessment and as part of an intervention plan (CDC/ STEADI, 2017). The STEADI “Check for Safety” brochure also prompts older adults to check items such as trip hazards on the floor, lighting, stair safety, and bathroom safety. Home hazard assessments should also include follow-up and modifications as needed in order to be effective. In summary, a thorough fall risk assessment may be triggered after a general fall risk screening. This assessment, at a minimum, should include examination of gait and balance if problems in these areas or reported or observed during the screening. Additional assessments may include tests for strength, ROM, posture, sensation and sensory integration, cognition and dual-tasking, cardiovascular status, fear of falling, frailty, and environmental hazards. These assessments should match the individual’s physical and cognitive capabilities. These physical, cognitive, and environmental areas should be assessed based on
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