What is the recommended evaluation for a patient with cognitive impairment and risk of falls?

Neurology-Specific Evaluation for Cognitive Impairment with Fall Risk

For patients with cognitive impairment and fall risk, conduct a targeted neurological assessment focusing on executive function deficits, gait and balance disorders, and medication review, as these are the most critical modifiable factors that predict falls in this population. 1

Cognitive Domain Assessment

Executive function testing is mandatory—not just general cognitive screening—because executive dysfunction is a prominent and independent fall risk factor even without formal dementia diagnosis. 1

• Assess specific cognitive domains beyond basic screening: executive function, visuospatial abilities (including constructional praxis), verbal fluency, attention, and memory 1, 2, 3
• Use Montreal Cognitive Assessment (MoCA) or St. Louis University Mental Status (SLUMS) Examination rather than MMSE alone, as MMSE has limited sensitivity for detecting MCI and executive dysfunction 1, 4
• Trail-Making Test specifically identifies fall risk in cognitively impaired patients 3
• Verbal fluency and visuospatial ability (cube drawing from Addenbrooke's Cognitive Examination-Revised) significantly discriminate between fallers and non-fallers 2, 3

Neurological Examination Priorities

Focus on the triad of gait/balance disorders, lower extremity sensorimotor deficits, and cognitive-motor integration, as these directly predict falls. 1, 5

Gait and Balance Testing

• Perform Timed Up-and-Go (TUG) test, though recognize its low predictive validity when used in isolation 1
• Assess semitandem, near-tandem, and tandem stance 3
• Measure steps needed to turn 180° and sit-to-stand performance 3
• Evaluate coordinated stability and gait velocity 3

Sensorimotor Assessment

• Test lower extremity strength, sensation (particularly proprioception), and coordination 5
• Screen for peripheral neuropathy, especially in diabetic patients, as proprioceptive deficits substantially increase fall risk 1, 6, 7
• Assess for Parkinson's disease or parkinsonism, as these frequently co-occur with cognitive impairment and falls 5, 8

Postural Stability

• Measure postural sway on both firm floor and foam surfaces—increased sway on foam is an independent predictor of falls in cognitively impaired patients 2, 3
• Assess medio-lateral displacement specifically, as this combined with visuospatial ability yields 85.1% accuracy for fall prediction 2

Medication Review

Conduct comprehensive medication review with specific attention to psychotropic and cardiovascular medications, as these are modifiable fall risk factors. 1

• Review central nervous system medications (benzodiazepines, antipsychotics, antidepressants, antihistamines) for potential deprescribing 6
• Evaluate cardiovascular medications (diuretics, β-blockers, calcium antagonists, ACE inhibitors, nitrates) for orthostatic effects 6
• Consider total medication burden, as polypharmacy independently increases fall risk 1, 3
• Assess for medications causing cognitive impairment that may be reversible 1

Functional Assessment

Evaluate instrumental activities of daily living (IADLs) with emphasis on executive components, as functional decline predicts both fall risk and safety concerns. 1, 4

• Use Pfeffer Functional Activities Questionnaire (FAQ) or Disability Assessment for Dementia (DAD) with informant input 4
• Assess initiation, organizing, planning, and effective implementation of tasks 1
• Evaluate home safety, driving capacity, and risk for delirium in context of preexisting dementia 1

Screening for Reversible Causes

Screen for depression, vitamin B12 deficiency, and hypothyroidism, as these are reversible contributors to both cognitive impairment and fall risk. 1, 6, 7

• Geriatric Depression Scale—depressive symptoms are independently associated with falls in cognitively impaired patients 3
• Vitamin B12 levels—deficiency causes proprioceptive deficits and cognitive impairment 6, 7
• Thyroid function tests 6
• Assess for delirium as distinct from baseline cognitive impairment 6

Sensory Function

Evaluate vision and hearing, as sensory deficits compound cognitive impairment to substantially increase fall risk. 1, 6

• Assess visual acuity and visual field deficits 6, 7
• Screen for hearing loss (presbycusis), a known and potentially reversible dementia risk factor 1
• Recognize that sensory impairments interact with cognitive deficits in attention, visuospatial awareness, and judgment to amplify fall risk 1

Cardiovascular Assessment

Measure orthostatic blood pressure, as orthostatic hypotension causes 6-33% of falls presenting as syncope in elderly patients. 6

• Obtain orthostatic vital signs immediately 6
• Consider carotid sinus hypersensitivity in unexplained recurrent falls (accounts for 30% of unexplained syncope) 6
• Perform 12-lead ECG to evaluate for arrhythmias, particularly with hypertension or cardiovascular disease history 6

Neuropsychological Referral Indications

Refer for formal neuropsychological evaluation when diagnostic confidence is insufficient or when detailed cognitive profiling is needed for safety planning and intervention targeting. 1

• Baseline testing is recommended when subjective cognitive concerns arise, before overt symptoms develop 1
• Repeat evaluation in 1 year if abnormalities suggest future decline; 2 years if evaluation is normal but risk factors present 1
• Neuropsychological testing objectively establishes extent and severity of impairment and tracks progression over time 1

Critical Pitfalls to Avoid

• Do not rely on MMSE alone—it misses executive dysfunction and early MCI 1, 4
• Do not assume falls are "just part of aging"—40% of elderly patients with syncope have amnesia for the event, and cardiovascular syncope presents as falls in 20% of cases 6
• Do not overlook executive function deficits—these predict falls even without formal dementia diagnosis 1
• Do not skip informant history—patients with cognitive impairment lack insight into their deficits 4
• Do not perform isolated gait tests without comprehensive assessment—single tests have low predictive validity 1
• Do not discharge without "Get Up and Go Test" to evaluate safety 6

Follow-Up Strategy

Schedule serial assessments every 6-12 months using the same instruments to track progression and adjust interventions. 1, 4

• Monitor cognition, functional autonomy, behavioral symptoms, and fall frequency 4
• Re-evaluate medication regimen at each visit 1
• Update safety recommendations as cognitive-motor profile changes 1