Confidence in, and self-rating of, driving ability among older drivers.

Active drivers (n = 125) in a representative cohort of older individuals age 77 years and older in New Haven, Connecticut were interviewed. Confidence in different driving situations, self-rating of driving ability, and driving patterns were assessed during these in-person interviews. A history of crashes, moving violations and being stopped by police was available for approximately the past 6 years. Concurrent driving performance was assessed in a subsample (n = 35). Analyses focused on determining the relationship of confidence and self-rating of driving ability to: (1) each other; (2) driving patterns; (3) adverse driving events; and (4) driving performance. All participants rated themselves as being average or above average drivers compared to others their age, with the majority rating themselves as above average. Individuals who drove more miles and more frequently were more likely to rate themselves better drivers than same-age peers. Individuals who rated themselves as "much better" drivers than their peers tended to have higher confidence levels than those who rated themselves a "little bit better" or the "same" as other drivers. On-road driving performance and history of adverse events were not associated with self-ratings of driving ability. Confidence was associated with driving frequency and mileage, but not age or education. Although men were more likely to drive under risky conditions, for those conditions in which each drove, men and women were equally confident. No relationship was found between confidence and adverse driving events or driving performance. Understanding the relationship of confidence and self-rating of driving ability to driving patterns, adverse events and driving performance may provide additional insights into identifying older drivers at increased risk for problems and formulating intervention strategies to help lower risk.

Development of a test battery to identify older drivers at risk for self-reported adverse driving events.

OBJECTIVES: The purposes of this study were (1) to develop a battery of tests that assessed a wide range of functional abilities relevant to driving yet could be performed in a clinician's office and (2) to determine which of these tests were most closely associated with self-reported adverse driving events. DESIGN: A cohort study. SETTING: An urban community. PARTICIPANTS: Participants were drawn from the Project Safety cohort, a probability sample of noninstitutionalized older persons in New Haven, Connecticut, initiated in 1989. The current study included surviving, active drivers in the cohort (N=125). MEASURES: The test battery assessed visual, cognitive, and physical abilities potentially relevant to driving, and was administered in participants' homes by trained interviewers between October 1994 and July 1995. Outcome measures included the self-report of a crash, moving violation, or being stopped by police in any Project Safety interview since the inception of the cohort. Analyses compared performance on the elements of the test battery with participants' histories of adverse driving events. RESULTS: Of the 125 drivers, 50 (40%) had reported an adverse event in a mean period of 5.76 (+/-.25) years before the current interview. The elements of the test battery independently associated with a history of events, adjusting for driving frequency, included near visual acuity worse than 20/40 (adjusted odds ratio 11.90), limited neck rotation (OR 6.10), and poor performance on a test of visual attention, the number cancellation task (OR 3.00). The resulting regression equation yielded a sensitivity of 80%, a specificity of 55%, and an area under the curve of .75 by receiver operating characteristic analysis. CONCLUSION: These findings suggest it may be possible to identify individuals potentially at risk for self-reported adverse driving events using simple tests of functional ability. If validated, such an approach could be used to identify individuals who need a more detailed assessment of functional abilities to determine the severity and etiology of impairments, and their effect on driving performance, as well as possible interventions to correct or compensate for the impairments.

The time and change test: a simple screening test for dementia.

BACKGROUND: Although dementia screening tests are available, they have not gained widespread use in hospital or primary care settings. Our goal was to develop a simple, standardized, performance-based test incorporating real-world activities to augment screening efforts in older populations: the Time and Change (T&C) Test. METHODS: The study followed a prospective cohort design, involving medicine and surgery services at an urban teaching hospital. From consecutive admissions, 776 participants aged 70-98 years, 14% with dementia, were enrolled. T&C ratings were validated against a reference standard based on the modified Blessed Dementia Rating Scale and the Mini-Mental State Examination (MMSE). Convergent validity with other cognitive measures, test-retest agreement, and interobserver reliability were assessed. RESULTS: The T&C Test had a sensitivity of 86%, specificity of 71%, and negative predictive value of 97%. The T&C Test demonstrated convergent agreement with three cognitive measures, agreeing most strongly with the MMSE (r = .58). Test-retest and interobserver agreement rates were 88% and 78%, respectively. Education explained 3% of the variance of the T&C Test, compared with 13% of the MMSE. The T&C Test took a mean of 22.9 seconds to complete and was acceptable to participants. Refusal of any test component occurred in 39 individuals (5%). CONCLUSIONS: The T&C Test is a simple, accurate, reliable, performance-based tool for detection of dementia. With its quick, easy-to-use, real-world nature, we hope the T&C Test will be used for widespread cognitive screening in older populations.

The effect of estrogen replacement therapy on cognitive function in women: a critical review of the literature.

OBJECTIVE: To conduct a review of the available clinical trials to determine whether sufficient evidence exists to support the conclusion that estrogen replacement therapy has a beneficial effect on cognitive performance in post-menopausal women and in women with Alzheimer's disease. Studies were identified through a MEDLINE search of all English-language publications between 1970 and 1996 in which the words estrogen and cognition or estrogen and memory appeared. DATA EXTRACTION: Data were extracted for each study, including features of subjects and eligibility criteria, duration of follow-up, and treatment regimen. Baseline characteristics were evaluated, including age; menopausal status; follicle-stimulating hormone, luteinizing hormone, and estradiol levels; mood; and measures of cognitive function. Psychological tests were evaluated for construct validity. RESULTS: Nineteen studies were reviewed, including 10 randomized trials of estrogen replacement therapy versus placebo. Extreme heterogeneity among subjects and variability in the use of cognitive measures across the studies precluded performing a quantitative summary. Of the 10 randomized trials, eight claimed therapeutic benefits for estrogen therapy, three of which reported significant improvements in memory and two of which showed improvements in attention. These studies did not control for potential confounds such as depression and vasomotor symptoms. Of the nine observational studies, five found a significant association between estrogen use and cognitive function. CONCLUSION: Although several observational studies provide encouraging evidence for the beneficial effect of estrogen on cognitive function, there is currently inadequate evidence available from randomized, controlled trials to support the conclusion that estrogen replacement therapy improves cognitive function in post-menopausal women or women with Alzheimer's dementia.

A predictive model for ADL dependence in community-living older adults based on a reduced set of cognitive status items.

OBJECTIVE: To develop and validate a simple tool, based on a reduced set of Mini-Mental State Examination (MMSE) items, that can be used to predict the onset of ADL dependence, and to compare the predictive accuracy of this new tool with that of the MMSE. DESIGN: Two prospective, population-based cohort studies, in tandem. The predictive model developed in the initial cohort was subsequently validated in a separate cohort. SETTING: General community in New Haven, Connecticut. PARTICIPANTS: For the development cohort, 775 community-living persons, 72 years of age and older, who were independent at baseline in their ADI, function. For the validation cohort, 1038 comparable subjects. MEASUREMENTS: All subjects underwent a baseline interview and cognitive assessment in their homes by a trained research nurse using standard instrument. Self-reported ADLs were ascertained at 1 year and 3 years for the development cohort and at 1 year and 21/2 years for the validation cohort. RESULTS: ADL dependence developed in 221 (28.5%) subjects in the development cohort. Although the rate of ADL dependence increased within each MMSE domain as the number of incorrect items increased, only orientation and short-term memory remained significantly associated with ADL dependence in multivariable analysis. A predictive model, based on the presence of impairments in these two domains, was developed that stratified subjects into three risk groups. Rates of ADL dependence were 22% (neither domain impaired), 44% (one domain impaired), and 68% (both domains impaired) (P < .001). The corresponding rates in the validation cohort, in which 191 (18.4%) subjects developed ADL dependence, were 15%, 26%, and 45% (P < .001). The area under the ROC curves for the MMSE and the reduced item strategy were nearly identical at 0.63 and 0.62, respectively. CONCLUSIONS: A simple and valid six-item strategy, based on the presence of impairments in orientation and short-term memory, predicts the onset of ADL dependence as effectively as does the 30-item MMSE. This new tool may be useful as part of a more comprehensive assessment when determining an older person's risk for developing ADL dependence.

Long-term cognitive sequelae of cerebral malaria in Vietnam veterans.

The brains of fatal cases of cerebral malaria exhibit capillary occlusion, punctiform hemorrhages, and focal necrosis in subcortical white matter. Some studies have suggested that the brain pathology of survivors is similar to that of fatal cases. The purpose of this study was to investigate the hypothesis that cerebral malaria survivors would exhibit neuropsychological impairment due to the residual cerebral damage sustained from the infection. Vietnam veterans reporting a history of cerebral malaria were compared with a group of veterans with a history of combat-related injuries on standard neuropsychological tasks and on dichotic listening (DL). The cerebral malaria group performed worse on memory tasks and exhibited greater clinical impairments on DL, consistent with presumed disruption of subcortical white matter tracts.

Impairments in physical performance and cognitive status as predisposing factors for functional dependence among nondisabled older persons.

BACKGROUND: Little is known about the processes underlying the development of functional dependence. We set out to determine whether impairments in physical performance and cognitive status contribute independently to the risk of functional dependence in nondisabled older persons. METHODS: Among a probability sample of 1,103 community-living adults, aged 72 years and older, we evaluated the 945 subjects who reported no disability in the activities of daily living. Subjects underwent a comprehensive assessment, including physical performance and cognitive testing. RESULTS: Among the 775 subjects alive with complete outcomes data, 221 (28.5%) developed dependence in activities of daily living at either the 1- or 3-year follow-up interview. The rates of functional dependence were 18%, 20%, 26%, and 50% (p < .001) and 18%, 23%, 31%, and 47% (p < .001), respectively, across quarters of worsening physical performance and cognitive status. Compared with subjects in the best group, those with the worst physical performance and cognitive status were more than five times as likely to develop functional dependence (67% vs 13%; p < .001). After adjustment for age, gender, number of chronic conditions, and housing stratum, the risk of functional dependence increased across quarters of both worsening physical performance (relative risks [RR] 1.0, 1.1, 1.3, 2.1) and cognitive status (RR 1.0, 1.3, 1.5, 2.0), independent of the effect of the other. Similar results were found for subjects who developed functional dependence at one year, for those who developed functional dependence at three years, and for the combined endpoint of functional dependence or death. CONCLUSIONS: Impairments in physical performance and cognitive status contribute independently to the risk of functional dependence in nondisabled, community-living older adults. A better understanding of the processes underlying functional dependence may facilitate the design of effective and efficient strategies to prevent or slow functional decline.

Subcortical hyperintensities on MRI and activities of daily living in geriatric depression.

Data from 30 elderly inpatients with major depression were analyzed to explore the relationship between subcortical hyperintensities (SH) on MRI and activities of daily living (ADLs). A comparison of subjects based on a median split of the severity of SH revealed that subjects with greater SH performed worse on both instrumental and physical ADLs. A hierarchical multiple regression revealed that age, depression severity, neuropsychological test performance, and SH variables accounted for a total of 53% of the variance in ADL functioning. Severity of SH accounted for an additional 18% of the variance over and above the other three variables. Results suggest that severity of subcortical disease measured by MRI improves prediction of functional impairment in elderly individuals.

Self-efficacy, physical decline, and change in functioning in community-living elders: a prospective study.

This study examines whether high self-efficacy is protective against a decline in functional status in community-residing elderly persons. Data came from a sample of 1,103 subjects aged > or = 72 years who were ambulatory within the household and who received in-home assessments at baseline and 18 months later to obtain information on sociodemographic, psychosocial, and health status variables, including physical performance tests. Functional status was based on six basic self-care tasks (ADLs). Using OLS regression, lower self-efficacy was marginally related to decline in functional status, after controlling for sociodemographic and health-related variables. As hypothesized, there was a significant interaction effect between self-efficacy and change in physical performance, suggesting that low self-efficacy was particularly predictive of functional decline among older individuals who showed a decline in physical performance at follow-up. These findings provide support for the buffering effect of self-efficacy on functional decline in the face of diminished physical capacity.

Evaluating the risk of dependence in activities of daily living among community-living older adults with mild to moderate cognitive impairment.

BACKGROUND: Although cognitive impairment has been implicated as a risk factor for dependence in activities of daily living (ADLs), little is known about the risk of ADL dependence among older adults with cognitive impairment. METHODS: Among a representative cohort of 1,103 community-living adults aged 72 years and older, we evaluated the 237 subjects with mild to moderate cognitive impairment who were independent in their basic ADLs. All cohort members had undergone a comprehensive assessment, including a battery of qualitative and timed performance tests. RESULTS: ADL dependence developed in 31 (16%) of the 197 subjects who had complete data at the 1-year follow-up. Of the self-reported characteristics, only three--living alone, not being currently married, and having an impairment in IADL function--were significantly associated (p < .05) with the onset of ADL dependence. Several simple tests of physical performance, on the other hand, were strongly associated with the development of ADL dependence. Both timed and qualitative performance tests successfully identified subjects at risk for ADL dependence. A combination of two performance tests--rapid gait and qualitative chair stands--was particularly effective at distinguishing subjects at low (4.7%) and high (34%-39%) risk for ADL dependence. CONCLUSIONS: Among community-living older adults with mild to moderate cognitive impairment, the risk of ADL dependence is high but varies considerably depending on how well and how quickly one can perform simple tasks of everyday function. An assessment strategy based on tests of physical performance may allow clinicians to identify subgroups of cognitively impaired elders at low and high risk for ADL dependence.

Assessment of frontal lobe functions.

The authors describe methods for conducting a thorough assessment of functions subserved by the frontal lobes, employing both bedside and psychometric methods of assessing frontal subsystems. Qualitative or process aspects of frontal behavior observable from formal testing, interview, and social behavior are noted. It is argued that the skilled clinician must be guided by a knowledge of frontal lobe subsystems and their roles in determining specific types of abnormal behavior. The clinician will then be alert to changes in incidental behaviors that indicate frontal impairment, and bedside maneuvers can be designed to discriminate dysfunction. Given the complexity of the behaviors involved and the profound effects of maturation and aging on frontal functions, neuropsychological assessment can provide an invaluable tool for testing these functions.

The frontal lobes and content-specific delusions.

Contemporary research has shown that delusions are often the product of identifiable neurologic disease, particularly when the delusions have a specific theme or are confined to one topic--monosymptomatic or content-specific delusions. Although these delusions are considered rare, some of them can be found at high rates in certain populations and settings. The literature on several classes of content-specific delusions (misidentification, sexual, and somatic) is critically reviewed. The review demonstrates that when adequate diagnostic workups are conducted, a high proportion of such delusions are found to have a neurologic basis. Lesions of the frontal lobes and the right hemisphere are shown to be critical to the development and persistence of many content-specific delusions.

The ability of the Dementia Rating Scale to predict everyday functioning.

The Dementia Rating Scale (DRS) is a brief neuropsychological assessment battery designed to assess five areas of cognitive functioning in the elderly. The relationship between DRS performance and everyday functioning was examined for 50 psychogeriatric patients. Everyday functioning was assessed with a standardized performance measure examining self-care, safety, money management, cooking, medication administration, and community utilization. Regression analyses were conducted for each of the six functional domains. In addition, correlations between the DRS subscales and the functional areas were computed. Results revealed significant predictive relationships (p <.01) between performance on the DRS and most functional domains. The multiple Rs ranged from .52 - .70, accounting for 27% to 49% of the variance. The Initiation/Perseveration subscale was most heavily weighted in each analysis. Significant correlations were obtained between subdomains of cognition and most functional areas. The findings provide evidence of relationships between DRS performance and functional ability.

The phenomenology of multiple partial seizure-like symptoms without stereotyped spells: an epilepsy spectrum disorder?

Consistent with previous reports by neuropsychiatrists, the results of the present investigation confirmed the existence of a neurobehavioral disorder characterized by the subjective experiencing of multiple cognitive, affective, and psychosensory phenomena similar to those associated with more classic partial seizure disorders. According to the literature, such patients typically respond favorably to anticonvulsants although they lack the customary motor manifestations of complex partial seizure (CPS) disorders and typically do not have stereotyped spells. This neuropsychiatric syndrome has recently been termed epilepsy spectrum disorder (ESD). In the present study, 30 patients with ESD were matched with equal numbers of treatment-refractory CPS patients and normal controls. All subjects were administered a standardized interview consisting of 35 cognitive, affective, and psychosensory partial seizure-like symptoms. The results indicated that ESD patients endorsed significantly more partial seizure-like symptoms than did CPS patients and controls. Relatively low levels of symptom endorsement by an unmatched psychiatric comparison sample indicated that the high levels of symptom endorsement by ESD patients could not be attributed to the presence of psychiatric dysfunction per se. Analysis of responding to 'foil' items unrelated to partial seizures indicated that high levels of symptom endorsement by ESD patients did not merely reflect a deviant response. Although ESD patients seldom present themselves at tertiary care epilepsy centers, the study of such patients is likely to be of relevance to mainstream epileptology.

Othello syndrome secondary to right cerebrovascular infarction.

The Othello syndrome, or delusional jealousy, occurs in idiopathic psychoses and in neurodegenerative diseases, but has rarely been described in patients with cerebrovascular infarction. A patient was observed to exhibit the delusion shortly after cerebral ischemic injury in the absence of other psychiatric symptoms. The underlying pathology was consistent with recent reports on content-specific delusions, implicating right hemisphere and frontal lobe involvement in the misinterpretation and misidentification of complex information. Psychological factors were hypothesized to shape the content of the delusional misinterpretations.

Liver function tests and neuropsychologic impairment in substance abusers.

The relationship between residual neuropsychologic dysfunction in alcoholics and subtle changes in liver function during acute phases of treatment was examined. Noncirrhotic alcoholics who exhibited extreme elevations in the liver enzyme gamma-glutamyl transferase (GGT) were found to have greater impairments in tasks of visuoperceptual and conceptual abilities when compared to alcoholics with normal or only mild elevations in GGT. The relationship between acute liver dysfunction and residual neuropsychologic impairment appeared to be independent of age and patterns of drinking. The implications of these findings in relation to treatment planning and prognosis of alcoholics are discussed.

Dichotic listening and complex partial seizures.

This study reports on 24 patients with multiple symptoms of untreated complex partial seizures (CPSz) who performed poorly at baseline assessment on a brief dichotic word listening task and subsequently improved following successful anticonvulsant therapy directed at treating seizure symptoms. These preliminary findings suggest that, in the absence of macroscopic structural lesions, dynamic electrophysiological dysfunction may interfere with the processing and transmission of simultaneously presented auditory information.