Use of the MMSE in the Prediction of Driving Fitness: Relevance of Specific Subtests.

OBJECTIVES: To examine the association between performance on subtests of the Mini-Mental State Examination (MMSE) and driving competence in people with cognitive impairment (CI) as well as those with no cognitive impairment (NCI). DESIGN: Retrospective observational study. SETTING: Participants referred for a DriveWise evaluation at Beth Israel Deaconess Medical Center in Boston, Massachusetts, were included in the study. PARTICIPANTS: A total of 419 participants referred for a DriveWise evaluation was studied. The average age of the sample was 77.69 years. In this study, people with an MMSE score lower than 25 were included in the CI group; 41% of participants had CI. MEASUREMENTS: All participants underwent mental status screening with the MMSE, and all underwent a 45-minute road test modeled after the Washington University Road Test adapted for use in Boston streets. RESULTS: In both groups, poor road test performance was associated with low scores on the MMSE. In drivers with CI, MMSE total score and performance on the attention subtest were significantly lower for those who failed the road test. In drivers with NCI, the MMSE total score and orientation subtests were significantly lower for those who failed the road test. CONCLUSIONS: Clinicians working with older people should know that the MMSE is an effective tool to screen for driving safety, but MMSE subtests are differentially sensitive to driving safety in people with and without CI. Poor performance on specific MMSE subtests may prompt further evaluation of driving competence with a road test. J Am Geriatr Soc 67:790-793, 2019.

Cognitive and Adaptive Outcomes After Proton Radiation for Pediatric Patients With Brain Tumors.

PURPOSE: Radiation therapy is integral in treatment of pediatric brain tumors, but it is associated with negative long-term sequelae. Proton beam radiation therapy (PRT), which enables better focusing of radiation on tumors, may entail fewer sequelae. This prospective study examined cognitive and adaptive functioning in children and young adults treated with PRT. METHODS AND MATERIALS: A total of 155 patients were assessed using age-appropriate measures for cognitive and adaptive functioning at start of or during PRT (baseline) and at follow-up. Mean age at baseline was 8.9 years; mean follow-up interval was 3.6 years. Diagnoses included medulloblastoma, craniopharyngioma, ependymoma, glial tumors, germ cell tumors, and others. The sample was divided by age at baseline (<6 years [N = 57, or 37%] and ≥6 years [N = 98, or 63%]) and by PRT field (craniospinal irradiation [CSI; 39%] and focal irradiation [61%]). RESULTS: Scores for mean intelligence quotient (IQ) and adaptive functioning skills were in the average range at baseline and follow-up. Overall, mean IQ scores declined from 105.4 to 102.5 (P = .005); however, only the younger CSI group showed significant decline. Patients receiving CSI, regardless of age, appeared particularly vulnerable in IQ, processing speed, and working memory. Adaptive skills were stable across the 4 age-by-treatment field groups. CONCLUSIONS: At a mean of 3.6 years after PRT, IQ declined slightly for the group, largely because of significant IQ decline in younger patients treated with CSI. No significant change was seen in patients <6 years treated with focal PRT or in older patients. Adaptive skills remained stable across age and treatment type.

Errors versus speed on the trail making test: Relevance to driving performance.

BACKGROUND/OBJECTIVES: Many studies have demonstrated that speed to complete items on the Trail Making Tests (TMT A and TMT B) is useful in the prediction of driving safety. However, there is no consensus regarding optimal "cut scores" to discriminate between safe and unsafe drivers. In this study, we examine TMT speed and errors in drivers referred for a road test. DESIGN: Retrospective analysis. SETTING: Patients referred for a DriveWise® evaluation at Beth Israel Deaconess Medical Center in Boston, Massachusetts. PARTICIPANTS: Drivers age 65 or older were included (total n = 373). Forty-five percent of the sample had been diagnosed with Cognitive Impairment (CI) whereas the remaining participants were in the No Cognitive Impairment (NCI) group. MEASUREMENTS: TMT Parts A & B, Folstein Mini Mental Status Examination, Washington University Road Test. RESULTS: CI drivers with TMT A speed exceeding 46 s were more likely to fail the road test whereas TMT B speed was not a sensitive metric in this group. In the No Cognitive Impairment (NCI) group, TMT B speed exceeding 131 s predicted driving impairment whereas TMT A speed was not sensitive. Error scores were not useful in the determination of driving fitness for either group. CONCLUSIONS: This study provides useful criteria for health providers working with older people in the determination of driving fitness. Results suggest that TMT speed, but not error rate, is associated with road test performance. Based on our work, we advocate that pre-existing dementia should be taken into consideration when using TMT performance as a screen for driving.

Validity of the mini-mental state examination and the montreal cognitive assessment in the prediction of driving test outcome.

OBJECTIVES: To evaluate the effectiveness of two cognitive screening measures, the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), in predicting driving test outcome for individuals with and without cognitive impairment. DESIGN: Retrospective cohort study. SETTING: A clinical driving evaluation program at a teaching hospital in the United States. PARTICIPANTS: Adult drivers who underwent assessment with the MMSE and MoCA as part of a comprehensive driving evaluation between 2010 and 2014 (N=92). MEASUREMENTS: MMSE and MoCA total scores were independent variables. The outcome measure was performance on a standardized road test. RESULTS: A preestablished diagnosis of cognitive impairment enhanced the validity of cognitive screening measures in the identification of at-risk drivers. In individuals with cognitive impairment there was a significant relationship between MoCA score and on-road outcome. Specifically, an individual was 1.36 times as likely to fail the road test with each 1-point decrease in MoCA score. No such relationship was detected in those without a diagnosis of cognitive impairment. CONCLUSION: For individuals who have not been diagnosed with cognitive impairment, neither the MMSE nor the MoCA can be reliably used as an indicator of driving risk, but for individuals with a preestablished diagnosis of cognitive impairment, the MoCA is a useful tool in this regard. A score on the MoCA of 18 or less should raise concerns about driving safety.

Nicotine levels after IV nicotine and cigarette smoking in men.

There has been considerable interest in the pharmacodynamics and pharmacokinetics of nicotine and the influence of different routes of administration. However, these variables are often examined in separate studies, and there is less information about the temporal relation between subjective reports and plasma nicotine levels. This study examined the time course and magnitude of plasma nicotine levels and reports of subjective "high" in nicotine-dependent men after 12 or more hrs of abstinence. The effects of two doses of IV nicotine and two doses of nicotine from cigarette smoking were compared, and samples were collected at 2-min intervals. Plasma nicotine levels after smoking a high-nicotine cigarette were significantly greater than after either dose of IV nicotine (p < .001). However, Visual Analog Scale (VAS) ratings of "high" after both doses of IV nicotine and smoking a high-nicotine cigarette did not differ significantly, and followed a similar time course. After smoking a low-nicotine cigarette, VAS ratings of "high" were significantly lower than after either IV nicotine dose or smoking a high-nicotine cigarette (p < .001). Peak levels of "high" were reported within 2 min after IV nicotine administration and the onset of cigarette smoking. Then "high" ratings abruptly decreased, while plasma nicotine rose to peak levels within 4 to 6 min after IV nicotine and 12 to 14 min during cigarette smoking. Plasma nicotine levels did not appear to determine the magnitude or time course of subjective effects under these conditions.