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Alzheimer’s Association, others provide tips on how to discuss cognitive function, falls
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Elderly patients are at increased risk for cognitive decline and falls, yet these occurrences are often not brought up during appointments by either patients or health care providers, representing a significant number of missed opportunities to address issues of quality of life and potential morbidity associated with aging.
An Alzheimer’s Association survey found that only 16% of patients’ primary care physicians ask them questions related to cognitive decline. This same survey showed that 94% of PCPs said cognitive assessments are important, but only 47% of them said these assessments were part of their standard protocol during annual wellness visits with older patients.
In addition, a report from Medical Clinics of North America indicated that about 30% of Americans older than 65 years who are not hospitalized experience a fall. Of those, less than half discuss the occurrence with their health care provider.
Over the coming decades, the number of elderly Americans is expected to increase dramatically, and with that increase will likely come increases in the number of elderly patients experiencing falls and cognitive decline. These changes are expected to have a significant impact on health care spending: an article in The New England Journal of Medicine estimated annual costs associated with dementia and cognitive decline to reach $259 billion in 2040, while the CDC reports that costs from hip fractures — the injury most linked to falls — could reach $240 billion that same year.
Therefore, Healio Primary Care asked experts and reviewed the medical literature to find ways PCPs can discuss and curtail these occurrences among their patients.
Assessing cognitive impairment
The Alzheimer’s Association survey revealed 58% of physicians said they did not have time to assess cognitive function during office visits, Joanna Pike, program director at the association, told Healio Primary Care.
Research conducted by Laurence Seematter-Bagnoud, PhD, MD, of the life sciences department at the Institute of Social and Preventive Medicine in Lausanne, Switzerland, acknowledged the limited amount of time PCPs have with their patients.
She indicated that these assessments do not have to be time-consuming, writing in Public Health Reviews that the Mini-Cog examination “is appealing for the use in primary care practice because it can be completed in about 2 to 4 minutes with good sensitivity (73% to 99%) and specificity (75% to 93%) and does not depend on linguistic and educational background.”
Ronald C. Petersen, PhD, MD, a neurologist at Mayo Clinic, discussed other cognitive assessment tests — the 10-item Functional Activities Questionnaire, the Montreal Cognitive Assessment and the Short Test of Mental Status — in a Mayo Clinic Proceedings article.
“These are not perfect tools, but they are far more sensitive than casual conversations or ad hoc questions,” he wrote, adding that mild cognitive impairment’s similarities to forgetfulness poses challenges.
“Subtle forgetfulness, such as misplacing objects and having difficulty recalling words, can plague persons as they age and probably represents normal aging. The memory loss that occurs in persons with amnestic mild cognitive impairment is more prominent,” he wrote in the New England Journal of Medicine.
“Typically, [patients] start to forget important information that they previously would have remembered easily, such as appointments, telephone conversations, or recent events that would normally interest them (e.g., for a sports fan, outcomes of sporting events). However, virtually all other aspects of function are preserved. The forgetfulness is generally apparent to those close to the person but not to the casual observer,” Petersen added.
He told Healio Primary Care that certain medical conditions, like anxiety or depression, or severe congestive heart failure or emphysema concurrent with hypoxemia, hypercapnia, or markedly elevated hematocrit, can also potentially impact cognitive functioning.
Pike said the PCP must bring up the subject of cognitive impairment, even with such time constraints and gray areas.
“PCPs cannot assume their patients will mention it. These tests take only a few minutes, and can provide valuable information,” she said.
Once a patient has been diagnosed with mild cognitive impairment, behavioral or nonpharmacologic approaches may stave off the most serious cognitive impairment symptoms, according to Melanie J. Chandler, PhD, of the division of psychology at Mayo Clinic in Jacksonville, Florida.
She co-authored a study that appeared in JAMA that concluded that among 272 older patients with the condition, wellness education had a greater effect on mood than computerized cognitive training and yoga had a greater effect on memory-related activities of daily living than support groups
Chandler explained in an interview that the interventions they studied do not put all the burden on PCPs.
“These interventions are best provided by a multidisciplinary team (such as physical therapists, certified yoga instructors, occupational therapists, nurses, licensed professional counselors, social workers, etc.) led by a neuropsychologists who is trained to deliver cognitive rehabilitation, knows the topic area for the wellness education, and can provide group psychotherapy,” she said.
Preventing falls
Discussing falls and steps to prevent falls appears to be another victim of tight appointment windows. A study in Frontiers in Public Health concluded only about 33% of 739 primary care office visits addressed falls, fall risks, or medical consequences of a fall. Another report in the Journal of the American Geriatrics Society, indicated “few primary care providers report following any guidelines for falls prevention.”
Collectively, these studies suggest short interventions to assess fall risk could be useful.
Seematter-Bagnoud’s article in Public Health Reviews provides a way for PCPs to accomplish this objective.
“A first set of questions identify whether the patient is at risk and investigates previous falls, fear of falling, and perception of unsteadiness when standing or walking The performance in gait and balance is based on the up-and-go test (i.e., the patient gets up from the chair, walks 3 meters, turns around and sits back down) or by observing whether he or she stops walking, when talking, a strong predictor of the probability of falling,” she wrote.
“A gait speed less than 0.8 m/s (i.e., 5 s or more to walk 4 m at a usual pace) should trigger further assessment for future falls, frailty, and mobility impairment,” Seematter-Bagnoud added.
Other experts and studies suggest the risk for falling is more psychological than physical.
Researchers wrote in the Journal of Gerontology that one of the biggest risk factors for an older person to fall, is the same person’s fear that such an event will occur.
The impact of such feelings was borne out in a study facilitated by Ana Lavedan of the department of nursing and physiotherapy at the University of Lleida in Spain. She found that 41.5% of 640 individuals aged 75 years and older had a fear of falling. Of those, 41.7% suffered at least one fall within the next 24 months.
A research scientist at the Hinda and Arthur Marcus Institute for Aging Research at Hebrew SeniorLife in Boston told Healio Primary Care PCPs need to stress to that falls should not be assumed as a fact of life.
“Remind patients and caregivers that falls are not an unavoidable part of getting older,” Sarah M. Berry, MD, MPH, added. “Many underlying causes of falls can be treated or corrected, and it is possible to prevent future falls. Be sure patients understand how their living environment, medical conditions, medications, and even behavior (for example, the fear of falling) can contribute to falls when they aren’t properly addressed,” she said in the interview.
“At every regular check-up, be sure to talk with your patients about falls. You have to be curious and ask about the circumstances of a fall in order to prevent future falls,” she continued.
There are other ways patients can modify their homes to reduce risk of falls, Jennifer Caudle, DO, a board-certified family physician and associate professor of family medicine, Rowan University School of Osteopathic Medicine, Stratford, N.J. said in an interview.
“Patients can avoid falls by making sure they know potential side effects of medications, as some may cause dizziness, fatigue, or other symptoms which can increase the likelihood of falls; securing loose rugs or remove them entirely from the home; using nonslip mats in the bath and shower, considering using of a bath seat; using a cane, walker or other assistive device if they have problems ambulating or staying steady; providing adequate support for going up and down stairs and getting into the tub/shower by installing hand-rails and grab bars and testing their eyes and hearing regularly,” she said.
Berry added that muscle-strengthening exercises can be another critical part of falls prevention.
“Staying even moderately active — within the parameters of what’s feasible for individual patients—can help someone with a fear of falling or reduced muscle strength/stability. Just be sure to remind patients that the risk for falls changes considerably in winter vs. summer,” she explained.
An American Family Physician article indicated that treatment from a fall injury will vary, and can include one or more of the following: exercise, environmental modification, nutrition therapy, knowledge, psychological interventions, medication management, urinary incontinence management, and referrals to physical or occupational therapy, social or community services, or specialists such as cardiologist, neurologist or ophthalmologist. – by Janel Miller
For more information:
American Geriatrics Society webpage on assessing gait and balance: https://geriatricscareonline.org/FullText/B001/B001_VOL001_PART001_SEC004_CH029
CDC’s webpage on assessing gait and balance: https://www.cdc.gov/steadi/index.html
Health in Aging’s webpage on choosing an assistive device: https://www.healthinaging.org/tools-and-tips/choosing-right-cane-or-walker
Health in Aging’s webpage on mobility concerns: https://www.healthinaging.org/age-friendly-healthcare-you/care-mobility
Mayo Clinic’s webpage on helping patients with mild cognitive impairment: https://connect.mayoclinic.org/page/living-with-mild-cognitive-impairment-mci/tab/resource-5394/
References:
AAFP.org. "USPSTF issues final guidance on preventing falls, fractures." https://www.aafp.org/news/health-of-the-public/20180418uspstffalls.html. Accessed June 6, 2019.
Alz.org. “2019 Alzheimer’s disease facts and figures.” https://www.alz.org/media/Documents/alzheimers-facts-and-figures-2019-r.pdf.
CDC.gov. “A tool kit to prevent senior falls: The costs of fall injuries among older adults.”
https://nfsi.org/wp-content/uploads/2013/10/Costs.pdf. Accessed June 11, 2019.
Chandler MJ, et al. JAMA Netw Open. 2019;doi:10.1001/jamanetworkopen.2019.3016.
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Forbes.com. "Social Security feels pinch as baby boomers clock out for good." https://www.forbes.com/sites/greatspeculations/2018/06/21/social-security-feels-pinch-as-baby-boomers-clock-out-for-good/#b5dc65c49951. Accessed June 6, 2019.
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Disclosures: Berry reports receiving royalties from UpToDate. Chandler reports she received grants from Patient-Centered Outcomes Research Institute (PCORI) during the conduct of the study. No other relevant financial disclosures were reported. Please see the study for those authors’ relevant financial disclosures.