Diagnostic criteria for apathy in neurocognitive disorders.

INTRODUCTION: Apathy is common in neurocognitive disorders (NCD) but NCD-specific diagnostic criteria are needed. METHODS: The International Society for CNS Clinical Trials Methodology Apathy Work Group convened an expert group and sought input from academia, health-care, industry, and regulatory bodies. A modified Delphi methodology was followed, and included an extensive literature review, two surveys, and two meetings at international conferences, culminating in a consensus meeting in 2019. RESULTS: The final criteria reached consensus with more than 80% agreement on all parts and included: limited to people with NCD; symptoms persistent or frequently recurrent over at least 4 weeks, a change from the patient's usual behavior, and including one of the following: diminished initiative, diminished interest, or diminished emotional expression/responsiveness; causing significant functional impairment and not exclusively explained by other etiologies. DISCUSSION: These criteria provide a framework for defining apathy as a unique clinical construct in NCD for diagnosis and further research.

Computer-Based Driving in Dementia Decision Tool With Mail Support: Cluster Randomized Controlled Trial.

BACKGROUND: Physicians often find significant challenges in assessing automobile driving in persons with mild cognitive impairment and mild dementia and deciding when to report to transportation administrators. Care must be taken to balance the safety of patients and other road users with potential negative effects of issuing such reports. OBJECTIVE: The aim of this study was to assess whether a computer-based Driving in Dementia Decision Tool (DD-DT) increased appropriate reporting of patients with mild dementia or mild cognitive impairment to transportation administrators. METHODS: The study used a parallel-group cluster nonblinded randomized controlled trial design to test a multifaceted knowledge translation intervention. The intervention included a computer-based decision support system activated by the physician-user, which provides a recommendation about whether to report patients with mild dementia or mild cognitive impairment to transportation administrators, based on an algorithm derived from earlier work. The intervention also included a mailed educational package and Web-based specialized reporting forms. Specialists and family physicians with expertise in dementia or care of the elderly were stratified by sex and randomized to either use the DD-DT or a control version of the tool that required identical data input as the intervention group, but instead generated a generic reminder about the reporting legislation in Ontario, Canada. The trial ran from September 9, 2014 to January 29, 2016, and the primary outcome was the number of reports made to the transportation administrators concordant with the algorithm. RESULTS: A total of 69 participating physicians were randomized, and 36 of these used the DD-DT; 20 of the 35 randomized to the intervention group used DD-DT with 114 patients, and 16 of the 34 randomized to the control group used it with 103 patients. The proportion of all assessed patients reported to the transportation administrators concordant with recommendation did not differ between the intervention and the control groups (50% vs 49%; Z=-0.19, P=.85). Two variables predicted algorithm-based reporting-caregiver concern (odds ratio [OR]=5.8, 95% CI 2.5-13.6, P<.001) and abnormal clock drawing (OR 6.1, 95% CI 3.1-11.8, P<.001). CONCLUSIONS: On the basis of this quantitative analysis, in-office abnormal clock drawing and expressions of concern about driving from caregivers substantially influenced physicians to report patients with mild dementia or mild cognitive impairment to transportation administrators, but the DD-DT tool itself did not increase such reports among these expert physicians. TRIAL REGISTRATION: ClinicalTrials.gov NCT02036099; https://clinicaltrials.gov/ct2/show/NCT02036099 (Archived by WebCite at http://www.webcitation.org/6zGMF1ky8).

Development of a decision-making tool for reporting drivers with mild dementia and mild cognitive impairment to transportation administrators.

BACKGROUND: Driving in persons with dementia poses risks that must be counterbalanced with the importance of the care for autonomy and mobility. Physicians often find substantial challenges in the assessment and reporting of driving safety for persons with dementia. This paper describes a driving in dementia decision tool (DD-DT) developed to aid physicians in deciding when to report older drivers with either mild dementia or mild cognitive impairment to local transportation administrators. METHODS: A multi-faceted, computerized decision support tool was developed, using a systematic literature and guideline review, expert opinion from an earlier Delphi study, as well as qualitative interviews and focus groups with physicians, caregivers of former drivers with dementia, and transportation administrators. The tool integrates inputs from the physician-user about the patient's clinical and driving history as well as cognitive findings, and it produces a recommendation for reporting to transportation administrators. This recommendation is translated into a customized reporting form for the transportation authority, if applicable, and additional resources are provided for the patient and caregiver. CONCLUSIONS: An innovative approach was needed to develop the DD-DT. The literature and guideline review confirmed the algorithm derived from the earlier Delphi study, and barriers identified in the qualitative research were incorporated into the design of the tool.

Developing physician consensus on the reporting of patients with mild cognitive impairment and mild dementia to transportation authorities in a region with mandatory reporting legislation.

OBJECTIVE: To establish consensus among dementia experts about which patients with mild cognitive impairment (MCI) or mild dementia should be reported to transportation authorities. METHODS: We conducted a literature review of predictors of driving safety in patients with dementia and combined these into 26 case scenarios. Using a modified Delphi technique, case scenarios were reviewed by 38 dementia experts (geriatric psychiatrists, geriatricians, cognitive neurologists and family physicians with expertise in elder care) who indicated whether or not they would report the patient in each scenario to regional transportation authorities and recommend a specialized on-road driving test. Scenarios were presented up to five times to achieve consensus, defined as 85% agreement, and discrepancies were discussed anonymously online. RESULTS: By the end of the fifth iteration, there was cumulative consensus on 18 scenarios (69%). The strongest predictors of decision to report were the combination of caregiver concern about the patient's driving and abnormal Clock Drawing Test, which accounted for 62% of the variance in decision to report at the same time as or without a road test (p <0.01). Based on these data, an algorithm was developed to guide physician decision-making about reporting patients with MCI or mild dementia to transportation authorities. CONCLUSION: This study supports existing international guidelines that recommend specialized on-road testing when driving safety is uncertain for patients with MCI and emphasizes the importance of assessing executive dysfunction and caregiver concern about driving.

The effects of donepezil on computer-simulated driving ability among healthy older adults: a pilot study.

The purpose of the present pilot study was to examine the effect of donepezil on simulated driving among healthy older adults. Twenty participants with a mean age of 72 years were randomized to take 5 mg of donepezil or placebo for 2 weeks. All participants were assessed at baseline and 2 weeks later on measures of attention, global cognition, and simulated driving on the York driving simulator. Driving measures included speed deviation, deviation of road position, reaction time to wind gusts, and collisions. Groups were compared using analysis of covariance, controlling for baseline values. There were no differences between the groups on attentional measures, number of collisions, or composite simulator measures. The placebo group fared approximately 0.5 second better in reaction time to wind gusts and showed a nonsignificant tendency toward less deviation of road position, compared with the donepezil group. This analysis does not support the use of donepezil to extend the period of safe driving among older adults, but further study is needed regarding its role among patients with cognitive disorders.