How are cognitive deficits and fall risk related?
The million dollar question, right? Rehab teams often have to consider recommendations that may significantly limit a patient’s independence. Naturally, we don’t make such recommendations lightly. But we are required to make a rough clinical prediction: what’s the likelihood this individual patient will suffer a fall if they don’t use a walker/wheelchair? And what can the speech-language pathologist bring to the table for the team to consider in their recommendations?
Walking Requires Thinking
A team of physical therapy researchers, in their study Relationships Between Performance on Assessments of Executive Function and Fall Risk Screening Measures in Community-Dwelling Older Adults, review the cognitive aspects of gait. Some interesting facts:
- Elders with cognitive deficits are twice as likely to fall compared to those without cognitive deficits.
- Cognitive deficits related to fall risk generally affect more than one cognitive domain, including: attention, memory, visuospatial ability, and executive function.
- Impaired executive function is associated with changes in walking, impaired mobility, and increased risk of falls.
- Decline in walking may be present prior to the onset of dementia, particularly in patients with impaired executive function.
The research team found a significant correlation between executive function performance and patients’ performance on fall risk assessment tools that incorporate a mobility task (specifically, the Timed Up and Go (TUG) and gait speed). Gait speed itself is increasingly being referred to as the “sixth vital sign”: for elders, the faster their typical walking speed, the longer their life expectancy.
SLP and PT Fall Risk Assessment Tools
The specific assessment tool for executive function used in this study was the Trail Making Test Part B (available free online!). Team collaboration to assess fall risk could easily include the SLP administering this and/or other clinical assessments of executive function, while the PT conducts mobility tasks. When choosing specific tasks, another clinically helpful finding about specific mobility tasks was that the Five Times Sit to Stand test (FTSTS) did not correlate with executive function performance in this study.
For SLPs, other clinically useful measures of executive function, depending on your setting and population, might include:
- Behavioral Assessment of Dysexecutive Syndrome(BADS)
- Stroop Color-Word Test (inhibition)
- Wisconsin Card Sorting Test (plan, sequence, problem-solve)
- Caregiver measures such as Dysexecutive Questionnaire (DEX & DEX-C from the BADS and BADS-C)
- Structured observation & interview as client performs ADL in as natural a setting as possible
Predictions can never be perfect. But when our patient is exhibiting impairments in multiple domains associated with fall risk, such as executive function and gait speed, we can confidently make recommendations and explain our reasoning so the patient and their loved ones can make an informed choice.
Blackwood, J., Shubert, T., Fogarty, K., Chase, C. (2015). Relationships between performance on assessments of executive function and fall risk screening measures in community-dwelling older adults. Journal of Geriatric Physical Therapy, 00, 1-8. DOI: 10.1519/JPT.0000000000000056Res
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