The Older Driver with Cognitive Impairment: Perceptions of Driving Ability and Results of a Behind the Wheel Test.

Older adult drivers with cognitive impairment pose a potential safety risk to themselves and others. Providers are often uncertain about when to request a formal evaluation of driving ability, leaving subjective reports of concerns by the patient or family as common initiators of objective driving evaluation referral. This observational study evaluated the correspondence of patient and caregiver report of driving concerns relative to objective behind-the-wheel (BTW) testing. Data were analyzed from occupational therapy driving evaluations of older adult U.S. Veterans referred from cognitive disorder specialty clinics between 2005 and 2015 (n = 151). Driving ability was evaluated with a pre-testing interview of the patient and a knowledgeable caregiver, followed by objective BTW testing. Patients referred had a mean age of 77.6 (SD = 8.1) years, were 97% male, and 98% white. Results demonstrated that most patients are evaluated for driving concerns far too late, with only 3% of the sample being evaluated as independent to drive without restrictions, and 38% recommended to retire from driving. Although both patients and caregivers denied specific driving concerns (obey signs and lights) relative to objective testing, caregiver concerns were greater than their respective patient's concerns (p < 0.001) and were associated with road test outcome (p = 0.001).

Dementia alters standing postural adaptation during a visual search task in older adult men.

This study investigated the effects of dementia on standing postural adaptation during performance of a visual search task. We recruited 16 older adults with dementia and 15 without dementia. Postural sway was assessed by recording medial-lateral (ML) and anterior-posterior (AP) center-of-pressure when standing with and without a visual search task; i.e., counting target letter frequency within a block of displayed randomized letters. ML sway variability was significantly higher in those with dementia during visual search as compared to those without dementia and compared to both groups during the control condition. AP sway variability was significantly greater in those with dementia as compared to those without dementia, irrespective of task condition. In the ML direction, the absolute and percent change in sway variability between the control condition and visual search (i.e., postural adaptation) was greater in those with dementia as compared to those without. In contrast, postural adaptation to visual search was similar between groups in the AP direction. As compared to those without dementia, those with dementia identified fewer letters on the visual task. In the non-dementia group only, greater increases in postural adaptation in both the ML and AP direction, correlated with lower performance on the visual task. The observed relationship between postural adaptation during the visual search task and visual search task performance--in the non-dementia group only--suggests a critical link between perception and action. Dementia reduces the capacity to perform a visual-based task while standing and thus, appears to disrupt this perception-action synergy.

Canonical correlation analysis of synchronous neural interactions and cognitive deficits in Alzheimer's dementia.

In previous work (Georgopoulos et al 2007 J. Neural Eng. 4 349-55) we reported on the use of magnetoencephalographic (MEG) synchronous neural interactions (SNI) as a functional biomarker in Alzheimer's dementia (AD) diagnosis. Here we report on the application of canonical correlation analysis to investigate the relations between SNI and cognitive neuropsychological (NP) domains in AD patients. First, we performed individual correlations between each SNI and each NP, which provided an initial link between SNI and specific cognitive tests. Next, we performed factor analysis on each set, followed by a canonical correlation analysis between the derived SNI and NP factors. This last analysis optimally associated the entire MEG signal with cognitive function. The results revealed that SNI as a whole were mostly associated with memory and language, and, slightly less, executive function, processing speed and visuospatial abilities, thus differentiating functions subserved by the frontoparietal and the temporal cortices. These findings provide a direct interpretation of the information carried by the SNI and set the basis for identifying specific neural disease phenotypes according to cognitive deficits.

The driver with dementia: a survey of physician attitudes, knowledge, and practice.

BACKGROUND: One of the most difficult issues physicians must address when caring for persons with dementia is fitness to drive. The purpose of this project was to investigate the attitudes, knowledge, and practices of physicians toward drivers with dementia. METHODS: A questionnaire that obtained perspectives about and experiences with drivers' with dementia was mailed to physicians from North Carolina and South Carolina. RESULTS: The sample was comprised of 239 physicians who worked with persons with dementia. Respondents who were aware of the Physician's Guide to Assessing and Counseling Older Drivers, had a strong perceived role regarding driving, were older, and believed it was important to address driving were more likely to engage in driving discussions. CONCLUSIONS: Concerns associated with the driver with dementia have implications for not only patient care but also public safety. We recommend that all physicians be encouraged to address the issue and utilize existing educational materials.

Mandatory testing of drivers on the basis of age and degenerative diseases: stakeholder opinions.

Concerns about the driving competence of older drivers have led to policy discussions about mandatory aged-based and disorder-based assessments. This study explored the attitudes, beliefs, and preferences of older adults, law enforcement officers, and licensing authorities toward reexamination of driving skills for persons with Alzheimer's disease (AD) and Parkinson's disease (PD) and at varying ages. With few exceptions, participants across all groups supported retesting drivers with AD. Moderate support was given for further evaluation of 90-year-olds and those with PD. Least endorsement was given for reassessment of 70-year-old drivers. Findings have implications for legislative changes to address drivers with AD and PD and at older ages.

Fluorodeoxyglucose positron emission tomography of mild cognitive impairment with clinical follow-up at 3 years.

BACKGROUND: Alzheimer's disease (AD) is the most common dementing illness. Development of effective treatments directed at AD requires an early diagnosis. Mild cognitive impairment (MCI) often heralds AD. Thus, characterizing MCI is fundamental to the early diagnosis of AD. METHODS: 19 MCI patients referred from a memory loss clinic and 27 healthy subjects, all followed up for 3 years. Metabolism scans (MCI minus controls) were compared voxel-wise after anatomic normalization and were examined both visually and with a computerized classifier. RESULTS: Agreement between raters as to whether the individual scans were normal or abnormal was high. Agreement between raters of the eventual clinical diagnosis and baseline metabolic pattern was poor. A computerized classifier was unsuccessful at classifying MCI from normal; however, its performance improved when using only prototypic AD-like MCI scans, indicating the classifier worked well when shared patterns existed in the data. Outcomes on follow-up were nine of 19 AD, five of 19 remained MCI, and five of 19 developed dementias other than AD. Both MCI cases of early Lewy body dementia (LBD) showed an AD-like metabolic pattern. CONCLUSIONS: Visual inspection proved reliable in determining normal from abnormal scans, but it proved unreliable at predicting diagnosis on follow-up. Computerized classification of MCI by using an AD-like metabolic template (such as derived from the averaged MCI images) showed potential to identify patients who will develop AD. However, the metabolic pattern in early LBD did not differ from that in AD.

Patient age influences recognition of Alzheimer's disease.

BACKGROUND: This study evaluated whether patient age influences recognition of Alzheimer's disease (AD) as assessed by referrals to a specialty clinic. METHODS: The age and Mini-Mental State Exam (MMSE) at the initial visit to a memory loss clinic of all patients with a diagnosis of AD (n = 533; 88.7%) or amnestic Mild Cognitive Impairment (n = 68; 11.3%) seen from 1992 through 2004 were examined. Only patients seen at least twice were considered so that the potentially confounding effects of age on rate of decline could be examined. RESULTS: There was a significant inverse correlation between age and MMSE score at initial visit (Spearman rho = -0.10, p =.016). Mixed-model regression analyses revealed significant effects of age and calendar year at initial visit on initial MMSE score and estimated the annual rate of decline on the MMSE at 1.58 points per year. Age at initial visit was not related to the rate of MMSE decline over time. CONCLUSIONS: Recognition of symptoms of AD is delayed as patients age. This delay is not explained by a difference in the rate of decline with age. Even though AD incidence increases dramatically with age, older patients were found to be more advanced in their disease at the time of referral to a dementia clinic.

Synchronous neural interactions assessed by magnetoencephalography: a functional biomarker for brain disorders.

We report on a test to assess the dynamic brain function at high temporal resolution using magnetoencephalography (MEG). The essence of the test is the measurement of the dynamic synchronous neural interactions, an essential aspect of the brain function. MEG signals were recorded from 248 axial gradiometers while 142 human subjects fixated a spot of light for 45-60 s. After fitting an autoregressive integrative moving average (ARIMA) model and taking the stationary residuals, all pairwise, zero-lag, partial cross-correlations (PCC(ij)(0)) and their z-transforms (z(ij)(0)) between i and j sensors were calculated, providing estimates of the strength and sign (positive, negative) of direct synchronous coupling at 1 ms temporal resolution. We found that subsets of z(ij)(0) successfully classified individual subjects to their respective groups (multiple sclerosis, Alzheimer's disease, schizophrenia, Sjögren's syndrome, chronic alcoholism, facial pain, healthy controls) and gave excellent external cross-validation results.

The older driver with dementia: an updated literature review.

INTRODUCTION: At some point during their illness, drivers with dementia pose a public safety risk. METHOD: To address the issue of determining driving competence in drivers with dementia, the authors reviewed 11 studies. RESULTS: When comparing different driving assessments, the authors found that while road tests, simulators, and neuropsychological tests are important, each has limitations. CONCLUSION: Neuropsychological tests that highlighted visual spatial skills, attention, and reaction time provided the most meaningful correlations with driving performance. Furthermore, the authors recommend that patients with MMSE scores of 24 or less have a driving evaluation, and that driving evaluations be repeated at six month intervals or more frequently if a noticeable decline is observed. IMPACT: Because many older adults with dementia continue to drive, competence must be addressed.

Driving habits and patterns in older men with glaucoma.

Glaucoma, an eye disorder that gradually decreases peripheral vision, affects millions of older adults. Consequences of glaucoma can mean changes in the ability to perform familiar tasks, including driving an automobile. We surveyed older drivers with glaucoma and a control comparison group in order to learn more about their driving habits and expectations about driving cessation. Findings indicate that compared to the control group, drivers with glaucoma are significantly more likely to change their driving habits with regard to driving at night (p=0.003), on freeways (p=0.05), and in unfamiliar areas (p=0.01). Drivers with glaucoma were also significantly more likely to report family concern about their driving (p=0.01). However, the drivers with glaucoma did not anticipate that their disease would force them to discontinue driving. Social workers play a pivotal role in coordinating the complex care needs of visually impaired elders. When driving skills are affected, social workers must address transportation, housing as well as quality of life concerns.

Change in the mini-mental state exam in Alzheimer's disease over 2 years: the experience of a dementia clinic.

The decline in the Mini-Mental State Exam (MMSE) over 2 years was assessed in males with Alzheimer's disease (AD; N = 136) seen in a dementia clinic. The average initial MMSE was 21.0 (SD+/-3.9; range 14--29) and declined 2.8 points (+/-4.7; range -17 to +6) over 2 years. The mode for change on the MMSE was 0 (N = 22) while the median fell between 2 and 3 points lost. Fifty-five of 136 patients (39.7%) had unchanged or better scores. There was no significant correlation between the initial MMSE and rate of change (r = -0.16; p = 0.06). While the progression of AD is quite variable from patient to patient, our data indicate that in most it is associated with little if any change in the MMSE even over 2 years. The MMSE is not an adequate tool to monitor change in the individual patient with AD.

The influence of age and gender on the driving patterns of older adults.

The purpose of this study was to investigate the influences of age and gender on the driving patterns of 300 older adults. Odds of driving less than every day increased significantly with age and female gender. However, no differences were found in the reduction of overall driving. Females were more likely than men to have stopped or reduced driving under certain adverse conditions and for elective purposes. The driving patterns of today's cohort of older females suggest that the gender gap may be narrowing. Social and cultural issues such as security, safety, and identity with driving may explain existing gender differences.

The Driver With Dementia: A Review of the Literature.

The authors review 10 studies of driving and dementia. They found poor agreement among the researchers with regard to the stage at which a patient with dementia should discontinue driving and the appropriate tools to be used for an assessment of driving skills. They make recommendations for a comprehensive driving assessment and for the clinical management of drivers with dementia. Because the impaired driver is a medical as well as a public safety concern, clinicians and policymakers must work together to address the many problems associated with this issue.