Geriatric neurology.

We can expect to live long enough to develop multiple disorders and receive multiple medications in the face of shrinking medical resources and changing philosophical approaches to aging. Clinicians will be faced with a rapidly aging and increasingly complex patient population. Neurologic diseases account for over ninety percent of those with severe incapacitation. This article lays the conceptual groundwork for the fundamental issues inherent to geriatric neurology; these issues require special attention when training residents, general practitioners, and specialists.

Dementia and driving: an attempt at consensus.

The number of older drivers in Sweden will be rapidly increasing during the next decades. A possible relationship exists between the increased relative crash risk of older drivers and the prevalence of age-related diseases such as dementia. However, a clear-cut policy for evaluating driving competence in demented persons is still lacking. In recognition of this fact, the Swedish National Road Administration invited a group of researchers to formulate a consensus on the issue of driving and dementia. This consensus document is aimed at providing primary care physicians with practical advice concerning the assessment of cognitive status in relation to driving. Suggestions are based on a review of existing research and discuss the use of general and driving-specific sources of information available to the physician. Consensus was reached on the statement that a diagnosis of moderate to severe dementia precludes driving and that certain individuals with mild dementia should be considered for a specialized assessment of their driving competence.

Performance-based driving evaluation of the elderly driver: safety, reliability, and validity.

BACKGROUND: Our driving population is aging and faces increased risk for injury and death from motor vehicle crashes. Clinicians are often asked to judge the driving safety of their patients without adequate guidelines. This article describes the development of a systematic performance-based road test for measuring driving skills of elderly drivers and its correlation with cognitive measures. METHODS: This was a prospective, masked, observational study in which a driving instructor's global scores ("criterion standard") and cognitive test scores were correlated with research driving scores created by two independent research raters sitting in the back seat of the care during each driving test. A convenience sample of 30 licensed drivers with a broad range of cognitive skills, over age 60, were studied on a closed course and in traffic. RESULTS: Statistically significant correlations were observed between the "criterion standard" and closed course scores (r = .35, p < .05) and between the "criterion standard" and in-traffic scores (r = .64, p < .01). Significant correlations were obtained between in-traffic and cognitive test scores, e.g., Mini-Mental State Exam (r = .72, p < .01). Inter-rater reliability on the closed course was .84 and on the in-traffic component was .74. Internal consistency for the closed course was .78 and for in-traffic was .89. CONCLUSION: This study documented the safety, reliability, and validity of a systematic road test for elderly drivers with a range of cognitive skills. Larger studies are needed to determine the cognitive factors that independently predict driving performance.

Dementia and the older driver.

Many demented patients continue to drive who, as a group, appear to be at increased risk for crashes, when compared with controls. Some studies have shown significant relationships between cognitive and functional measures, driver status performance on driving tests, and crash data. A number of methodologic problems in the studies reduce the level of confidence to which the data can be generalized. Diagnosis is not an adequate predictor of function. There is great heterogeneity of the rate of progress as well as the cognitive strengths and weaknesses among patients with dementing disorders. Performance-based guidelines for driving competence are essential rather than dependence on diagnostic labels. Ultimately, there would be no concern if there were no injury. There would be little concern if our cars and roadways were designed in such a way that the driver played little role in the traffic interaction. The potential for such systems exists but is expensive and unlikely to be built on a large scale. Therefore, it is necessary to identify the characteristics of the drivers who pose "unacceptable" risk to themselves and others. Functional information obtained from the family should be supplemented by an observational assessment of the patient, ideally by a trained specialist. The health care team's goal is to help the aging patient maintain autonomy in the face of declining health and psychosocial status. This outcome relies on a close alliance between physicians, nurses, occupational therapists, psychologists, social workers, and others to understand and manage the functional aspects and complex interactions between aging, disease, and social support systems. Treatment teams with skills in functional assessment and knowledge about the available social services are invaluable in caring for the functionally declining elderly patient. Recommendations to withdraw driving privileges on the basis of a diagnosis of dementia may ultimately be borne out by appropriate studies, but these studies have not been conducted. There is a great need for a consensus process to identify dangerous drivers, ideally with performance-based measures. This would then support uniform laws across the country that protect the patient, the physician, and the public. Education of the medical and lay community of the "warning signs" of declining driving skills could do much to heighten awareness in the community, much as the warning signs of cancer have been publicized. With the aging of our nation's population and the strong association of aging with dementing disorders, there is reason to be concerned, especially when dementing illnesses affect judgment. Demented drivers may pose a significant public health problem.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of patients with Alzheimer's disease.

Alzheimer's disease represents the most common cause of dementia in the elderly. Current estimates suggest that nearly 50% of those over age 85 years have the disorder. Many gaps still exist in our understanding of its etiology and management. Scientific discoveries that once seemed to promise effective treatments have not lived up to our expectations. There are, however, many therapeutic interventions (environmental and pharmacologic) that can greatly enhance the quality of the lives of patients with Alzheimer's disease and that of their families.

Acquired cognitive disorders of the elderly.

Many gaps still exist in our understanding of the etiology and the management of dementing disorders. However, there are fairly well established guidelines for the clinical diagnosis of Alzheimer's disease, the major cause of acquired cognitive disorders in the elderly. The management of patients with dementing disorders should involve the entire family. The medical needs pale beside the functional and psychosocial issues. Therefore, a multidisciplinary approach in a team setting is ideal, where goals can be established and coordinated and communication with the family, patient, and consultants can be facilitated. Patients and family members need to know that life beyond the diagnosis can be meaningful. With the help of support groups, they learn to maximize the positive aspects and can cope with the struggle ahead. It should not be forgotten, however, that not all families had good relationships before the onset of the decline and often are in great need of counseling to manage the anger and guilt they will often experience. Future research is needed not only on the search for better medical treatments but also on the establishment of guidelines for the physician and family to deal with complex social issues such as when one is no longer safe to drive an automobile. Prospective studies on victims of head injury could establish the link of trauma to Alzheimer's disease, that has been proposed. The role of physicians in public policy for prevention of high risk behaviors (such as boxing) is controversial, but at the very least, physicians should play a major role in educating their patients of these dangers. Because of the rapid aging of our population, pressure for research and policy changes in national health and long term care financing has been growing, largely due to the impressive efforts of the Alzheimer's Association. In order to give the kind of attention that is required in the care of these patients, there must be a change in the present system of reimbursement. This will never happen, unless it can be demonstrated that lower costs of health care can be achieved by anticipating the needs of these patients and their families. It is quite possible that costs can be reduced by delaying the need for nursing home placement or decreasing utilization of emergency medical care and hospitalization. However, these assumptions must be investigated further.