Why Every SNF PT Should Be Using the Mini-Cog

Cognitive impairments are everywhere in skilled nursing facilities, and too often, they go unrecognized. Research estimates that 60–70% of SNF residents demonstrate some degree of cognitive decline, yet many facilities still lack a standardized process for identifying acute cognitive changes that directly affect mobility, safety, and clinical decision making.

And this isn’t just a documentation issue. It’s a patient-safety issue, a falls issue, and a PT-practice issue.

The Problem: SNFs Are Missing Cognitive Red Flags

In many facilities, PTs rely on quick orientation questions (“What’s your name? Where are you?”) or general observations of alertness. That’s helpful, but it is not cognitive screening.

When PTs rely solely on orientation:

• Subtle cognitive changes are missed.

• Mobility progression can outpace patient capacity.

• Falls become more likely in an already frail population.

• PTs lack objective data to communicate concerns to nursing or the interdisciplinary team.

• Important red flags (poor recall, impaired problem solving, new confusion) go undocumented.

Across SNFs, this gap leads to missed early detection, inconsistent communication between disciplines, and preventable adverse events during mobility tasks, something PTs directly oversee.

The Mini-Cog: A Simple Fix That Stays in PT’s Lane

Here’s the good news:
Physical therapists don’t need a 30-minute neuropsych test to do their job safely.

The Mini-Cog is:

• Quick — takes ~3 minutes.

• Validated — with ~73% sensitivity and ~84% specificity.

• PT-appropriate — requires no specialized SLP or neuropsych training.

• Objective — combines recall + clock drawing to screen memory and executive function.

• Efficient — easy to document, communicate, and justify.

For PTs, this sits comfortably within scope:

• It screens for functional cognition relevant to mobility.

• It informs safety decisions.

• It guides appropriate referrals (nursing, SLP, medical).

• It enhances interdisciplinary communication through objective data.

Administration of the Mini-Cog

The Mini-Cog takes about three minutes and includes three-word recall and a clock-drawing task.

1. Three-Word Recall

State three unrelated words (e.g., “Banana – Sunrise – Chair”).
Have the patient repeat them to confirm they were heard.
Tell them you will ask for the words again later.

2. Clock Drawing

Provide paper and pen.
Say: “Please draw a clock with all the numbers, and set the hands to 10 past 11.”
Do not cue or demonstrate. Observe overall accuracy and organization.

3. Recall

Ask the patient to repeat the original three words.

Scoring & Interpretation

• 3 words recalled = normal

• 1–2 words recalled → look at the clock

• 0 words recalled = abnormal

• Clock abnormal = abnormal screen

If Abnormal

PTs should modify mobility plans for safety, increase supervision/cueing as needed, and communicate results clearly to nursing/medical staff for follow-up.

Why SNFs May Benefit from Standardizing the Exam

When the Mini-Cog is integrated into PT evaluations and daily practice:

• Early cognitive changes are detected sooner.

• PTs communicate clearer, objective concerns to nursing.

• Mobility progression becomes safer and more individualized.

• Falls decline, one implementation project even targets a 20% reduction.

• Documentation becomes stronger, supporting insurance reimbursement.

• Interdisciplinary consistency improves: everyone is speaking the same language.

In short:
A 3-minute tool can change the trajectory of care for high-risk SNF patients.

Parting Words

Cognition dictates safety, and safety dictates how far and how fast a patient can progress in therapy. When cognitive shifts go unnoticed, PTs inadvertently take unnecessary risks. These risks can lead to preventable injuries, avoidable hospitalizations, and poorer long-term outcomes.

Standardizing the Mini-Cog across SNF PT practice is not just an efficiency upgrade. It’s a professional responsibility. A three-minute screen offers enough insight to detect red flags early, initiate appropriate referrals, and ensure that every mobility task is performed with the patient’s true abilities in mind. For a vulnerable population, those three minutes may be the difference between a safe session and a catastrophic fall.

Special thanks to my classmates Anna Law, Will Loethen, Luci Mach, and Sarah Andre for assisting with the research and writing on this topic!

References

1. Thomas, K. S., et al. (2017). Prevalence of dementia and cognitive impairment in U.S.
nursing homes: A national study. Journal of the American Geriatrics Society, 65(5), 937–
943.
2. Lenze, E. J., et al. (2019). Cognitive and physical rehabilitation in older adults. Physical
Therapy, 99(1), 47–56.
3. Resnick, B., et al. (2020). Interdisciplinary communication and cognitive screening
practices in skilled nursing facilities. Geriatric Nursing, 41(4), 463–469.
4. Abayomi SN, Sritharan P, Yan E, et al. The diagnostic accuracy of the Mini-Cog
screening tool for the detection of cognitive impairment-A systematic review and meta-
analysis. PLoS One. 2024;19(3):e0298686. Published 2024 Mar 14.
doi:10.1371/journal.pone.0298686
5. Kolanowski, A., et al. (2018). Cognitive impairment in nursing home residents: Scope
and impact. Journal of the American Medical Directors Association, 19(6), 456–462.
6. Dykes PC, Curtin-Bowen M, Lipsitz S, et al. Cost of Inpatient Falls and Cost-Benefit
Analysis of Implementation of an Evidence-Based Fall Prevention Program. JAMA
Health Forum. 2023;4(1):e225125. Published 2023 Jan 6.
doi:10.1001/jamahealthforum.2022.5125

Disclaimer

I am a current Doctor of Physical Therapy (DPT) student sharing information based on my formal education and independent studies. The content presented in this newsletter is intended for informational and educational purposes only and should not be considered professional medical advice. While I strive to provide accurate and up-to-date information, my knowledge is based on my current academic and clinical rotations and ongoing learning, not extensive clinical practice.