Driving with a neurodegenerative disorder: an overview of the current literature

Parkinson's Disease and Driving Fitness: A Systematic Review of the Existing Guidelines

BACKGROUND

Motor/nonmotor symptomatology and antiparkinsonian drugs deteriorate the driving ability of Parkinson's disease (PD) patients.

OBJECTIVES

Treating neurologists are frequently asked to evaluate driving fitness of their patients and provide evidence-based consultation. Although several guidelines have been published, the exact procedure along with the neurologist's role in this procedure remains obscure.

METHODS

We systematically reviewed the existing guidelines, regarding driving fitness evaluation of PD patients. We searched MEDLINE and Google Scholar and identified 109 articles. After specified inclusion criteria were applied, 15 articles were included (nine national guidelines, five recommendation papers, and one consensus statement).

RESULTS

The treating physician is proposed as the initial evaluator in 8 of 15 articles (neurologist in 2 articles) and may refer patients for a second-line evaluation. The evaluation should include motor, cognitive, and visual assessment (proposed in 15, 13, and 8 articles, respectively). Specific motor tests are proposed in eight articles (cutoff values in four), whereas specific neuropsychological and visual tests are proposed in seven articles each (cutoff values in four and three articles, respectively). Conditional licenses are proposed in 11 of 15 articles, to facilitate driving for PD patients. We summarized our findings on a graphic of the procedure for driving fitness evaluation of PD patients.

CONCLUSIONS

Neurological aspects of driving fitness evaluation of PD patients are recognized in most of the guidelines. Motor, neuropsychological, visual, and sleep assessment and medication review are key components. Clear-cut instructions regarding motor, neuropsychological, and visual tests and relative cutoff values are lacking. Conditional licenses and periodical reevaluation of driving fitness are important safety measures.

Diagnosis of Alzheimer's dementia and vehicle driving restriction: a scoping review

There are doubts about vehicle driving restriction for patients with Alzheimer's disease. A scoping review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-ScR) methodology. Relevant databases were searched for articles published between 2000 and 2022 in English, Spanish, or Portuguese. Articles were included if they specifically addressed driving, risk of accidents, permission or licence to drive a motor vehicle in a context of important cognitive decline, or if addressed traffic legislation on driving and dementia. Twenty-three articles were selected for full reading, six of which were observational studies and only one with an interventionist method. All articles were carried out in high-income countries such as the UK, the US, and Australia. As a conclusion, there is no psychometric test in the literature sensitive enough to assess vehicle driving competence in older adults with cognitive deficits. Based on selected studies, there is no robust evidence to make recommendation for or against the cessation of vehicular driving for patients with mild cognitive decline or with mild dementia. In some situations, vehicle driving cessation can impact patients and their families. In addition, legal regulations regarding vehicle driving for older adults and people with dementia are scarce worldwide. Despite the scarcity of studies addressing the theme of vehicle driving in the context of dementia, there is some level of consensual reasoning that patients with moderate to severe dementia should halt driving activities, but the same does not apply for patients with mild levels of cognitive impairment, including mild dementia.

Driving Impairment in Movement Disorders

Background

Driving may be adversely affected by any movement disorder, but has been mostly studied in Parkinson's disease (PD). Few studies have addressed driving impairment in patients with Huntington's disease (HD); driving in other movement disorders such as dystonia, blepharospasm and Tourette syndrome (TS) has not been adequately evaluated.

Objectives

The aim of this review is to summarize the findings of driving impairment in movement disorders and evaluate the usefulness of clinical tools in guiding clinicians whether to refer patients for driving assessment.

Methods

A review of literature was performed on PubMed and articles on driving and movement disorders were identified using a Boolean phrase.

Results

We were able to identify 66 articles that fulfilled the target subject: impairment of driving in PD, cervical dystonia, blepharospasm, HD and TS. We also included articles discussing the role of driving rehabilitation in patients with movement disorders.

Conclusions

Driving is often impaired in patients with PD and other movement disorders not only due to motor symptoms but also because of cognitive and behavioral co-morbidities. Certain screening tools may be helpful in guiding the clinician in referring the patients for driving assessment.

Clinical Tests Predicting On-Road Performance in Older Drivers with Cognitive Impairment

Background. The Trail Making Test Part B (Trails B) and Useful Field of View® (UFOV) can predict on-road outcomes in drivers with cognitive impairment (CI); however, studies have not included drivers referred for comprehensive driving evaluations (CDEs), who typically have more severe CI. Purpose. We determined the predictive ability of Trails B and UFOV on pass/fail on-road outcomes in drivers with CI (Montreal Cognitive Assessment <26) referred for CDEs. Method. Retrospective data collection from two driving assessments centers (N  =  100, mean age  =  76.2  ±  8.8 years). Findings. The Trails B (area under the curve [AUC]  =  .70) and UFOV subtests 2 (AUC  =  .73) and 3 (AUC  =  .76) predicted pass/fail outcomes. A cut-point ≥467 ms on UFOV subtest 3 better-predicted pass/fail outcomes with 78.9% sensitivity and 73.5% specificity. In comparison, a cut-point ≥3.58 min on Trails B had lower sensitivity (73.7%) and specificity (61.8%). Implications. The UFOV subtest 3 may be more useful than the Trails B for predicting pass/fail outcomes in drivers with more severe CI referred for CDEs.

Driving Errors Predicting Pass/Fail On-Road Assessment Outcomes Among Cognitively Impaired Older Drivers

Older drivers with cognitive impairment (CI)/dementia make significantly more driving errors than healthy controls; however, whether driving errors are predictive of pass/fail outcomes in older drivers with CI/dementia are unclear. This study determined the driving errors that predicted failing an on-road assessment in drivers with CI. We retrospectively collected comprehensive driving evaluation data of 80 participants (76.1 ± 9.3 years) from an Ontario driving assessment center. Adjustment to stimuli (area under the curve [AUC] = 0.88), lane maintenance (AUC = 0.84), and speed regulation errors (AUC = 0.85) strongly predicted pass/fail outcomes. Worse performance on the Trails B (time) and Useful Field of View® (Subtest 2, Subtest 3, and risk index) were significantly correlated with adjustment to stimuli (p < .05), lane maintenance (p < .05), and speed regulation errors (p < .05). Adjustment to stimuli, lane maintenance, and speed regulation errors may be critical indicators of failing an on-road assessment in older drivers with CI. Prioritizing these errors may help identify at-risk drivers.

Healthcare professionals' involvement in breaking bad news to newly diagnosed patients with motor neurodegenerative conditions: a qualitative study

PURPOSE

Research on breaking bad news (BBN) in healthcare has mostly focused on the doctor-patient interaction during a single consultation. However, it has been increasingly recognised that BBN is a wider process that also involves other healthcare professionals. This qualitative study explored non-medical¹ healthcare professionals' involvement in BBN to newly diagnosed patients with motor neurodegenerative conditions in the UK.

MATERIALS AND METHODS

19 healthcare professionals working with people with motor neurone disease, multiple sclerosis, Parkinson's disease or Huntington's disease took part in individual, semi-structured interviews which were analysed using thematic analysis.

RESULTS

Four themes were constructed: dealing with the diagnostic aftermath, unpacking the diagnosis, breaking bad news as a balancing act and empowering patients to regain control over their health and lives. Participants reported being broadly involved in BBN by supporting patients with negative diagnostic experiences, re-iterating diagnostic information and helping patients understand the impact of their condition. The challenges of effectively breaking bad news and how these difficult conversations could help empower patients were also emphasised.

CONCLUSIONS

BBN was a critical and challenging aspect of healthcare professionals' clinical work with newly diagnosed patients with motor neurodegenerative conditions. Besides providing information, BBN was perceived as a way to educate patients, encourage them to make decisions and prepare for the future.Implications for rehabilitationBreaking bad news is a potentially under-recognised but significant aspect in the neurorehabilitation of neurodegenerative conditions.Listening to patients' stories about a long and occasionally unsatisfactory diagnostic journey and allowing them to express their frustration can be critical in regaining patients' trust and building a relationship with them.Newly diagnosed patients have not always received adequate information about their condition at diagnosis or they might have not understood or retained that information. It is, therefore, essential that patients' understanding of their condition is assessed, misconceptions are cleared and appropriate information about the nature and impact of the diagnosis is provided.Irrespective of the length of experience, breaking bad news was perceived as a multi-faceted, challenging, stressful and emotionally demanding task.Formal support and specialised training on breaking the bad news that addresses the incurable, unpredictable and progressive nature of motor neurodegenerative conditions could help professionals with this challenging task.

Symbol digit modalities test predicts decline of off-road driving ability in Japanese patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic progressing neurological disease with exacerbations and remissions. Patients with MS can show a variety of neurological symptoms. Cognitive decline is noticed as one of them and is related with deterioration of daily life quality in a clinical practice. Driving a car is one of the common activities required in daily life and is also an important issue in MS patients.

METHODS

To clarify the relationship between cognitive function and driving ability in MS patients, the symbol digit modalities test (SDMT) and a driving simulator were evaluated. We enrolled 24 patients with MS (5 males, 19 females, 39.04 ± 8.27 years old) and age- and sex-matched 24 healthy controls (5 males, 19 females, 40.54 ± 9.78 years old) in this study. They underwent the SDMT and also used a driving simulator to measure a total of 12 response values related to driving ability. In order to evaluate the relationship between SDMT and driving ability, MS patients were divided into two groups according to the median SDMT score: group A (SDMT 51 or more) and group B (SDMT less than 51). The data were statistically analyzed among control group, MS group A, and MS group B using Jonkheere-Terpstra trend test and Bonferroni's multiple comparison test.

RESULTS

The group with higher scores on the SDMT tended to have significantly higher driving performance. Multiple comparison analysis among three groups showed that the reaction values for speed of response behavior were significantly higher in MS group B than control group.

CONCLUSION

This study revealed a relationship between driving abilities and SDMT scores. Clinical evaluation using the SDMT may help to detect cognitive decline and to make a decision on driving a car in patients with MS.

Driving ability and predictors for driving performance in Multiple Sclerosis: A systematic review

OBJECTIVE

To provide an overview of the evidence on driving ability in persons with multiple sclerosis (PwMS), specifically to (i) study the impact of MS impairment on driving ability and (ii) evaluate predictors for driving performance in MS.

METHODS

To identify relevant studies, different electronic databases were screened in accordance with PRISMA guidelines; this includes reference lists of review articles, primary studies, and trial registers for protocols. Furthermore, experts in the field were contacted. Two reviewers independently screened titles, abstracts, and full-texts to identify relevant articles targeting driving in people with MS that investigated driving-related issues with a formal driving assessment (defined as either an on-road driving assessment; or naturalistic driving in a car equipped with video cameras to record the driving; or a driving simulator with a steering wheel, a brake pedal, and an accelerator).

RESULTS

Twenty-four publications, with 15 unique samples (n = 806 PwMS), were identified. To assess driving ability, on-road tests (14 papers) and driving simulators (10 papers) were used. All studies showed moderate to high study quality in the CASP assessment. About 6 to 38% of PwMS failed the on-road tests, showing difficulties in different areas of driving. Similarly, PwMS showed several problems in driving simulations. Cognitive and visual impairment appeared to most impact driving ability, but the evidence was insufficient and inconsistent.

CONCLUSION

There is an urgent need for more research and standardized guidelines for clinicians as one in five PwMS might not be able to drive safely. On-road tests may be the gold standard in assessing driving ability, but on-road protocols are heterogeneous and not infallible. Driving simulators assess driving ability in a standardized way, but without standardized routes and driving outcomes, comparability between studies is difficult. Different aspects, such as cognitive impairment or vision problems, impact driving ability negatively and should be taken into consideration when making decisions about recommending driving cessation.

SYSTEMATIC REVIEW REGISTRATION

Identifier [10.17605/OSF.IO/WTG9J].

Development of the Colorado posterior cortical questionnaire within an Alzheimer's disease study cohort

INTRODUCTION

Non-amnestic presentations of neurodegenerative dementias, including posterior- and visual-predominant cognitive forms, are under-recognized. Specific screening measures for posterior cortical symptoms could allow for earlier, more accurate diagnosis and directed treatment.

METHODS

Based on clinical experience with posterior cortical atrophy evaluations, high-yield screening questions were collected and organized into a 15-item self-report questionnaire, titled the Colorado Posterior Cortical Questionnaire (CPC-Q). The CPC-Q was then piloted within a longitudinal cohort of cognitive aging, including 63 older adults, including healthy older adults (n = 33) and adults with either amnestic Alzheimer's disease (n = 21) or posterior cortical atrophy (PCA, n = 9).

RESULTS

The CPC-Q demonstrated acceptable psychometric properties (internal consistency, α = 0.89; mean item-total correlation = 0.62), correlated strongly with visuospatial measures on cognitive testing (p < 0.001), and could distinguish PCA from non-PCA groups (p < 0.001; AUC 0.95 (95% CI 0.88, 1.0)).

CONCLUSIONS

The CPC-Q captured posterior cortical symptoms in older adults, using a gold standard of expert consensus PCA diagnosis. Future studies will validate the CPC-Q in a larger cohort, with recruitment of additional PCA participants, to evaluate its convergent and discriminant validity more thoroughly. As a short, self-report tool, the CPC-Q demonstrates potential to improve detection of non-amnestic neurodegenerative dementias in the clinical setting.

M, Michelle. H, Anna. D, Reuben. R, Greg. K, Andre. JJ, Leslie L, Thomas. M, GF. TK. Impact of HIV on Cognitive Performance in Professional Drivers

BACKGROUND

The intellectually demanding modern workplace is often dependent on good cognitive health, yet there is little understanding of how neurocognitive dysfunction related to HIV presents in employed individuals working in high-risk vocations such as driving. HIV-associated neurocognitive impairment is also associated with poorer long-term cognitive, health, and employment outcomes.

SETTING

This study, set in Cape Town, South Africa, assessed the effects of HIV on neuropsychological test performance in employed male professional drivers.

METHOD

We administered a neuropsychological test battery spanning 7 cognitive domains and obtained behavioral data, anthropometry, and medical biomarkers from 3 groups of professional drivers (68 men with HIV, 55 men with cardiovascular risk factors, and 81 controls). We compared the drivers' cognitive profiles and used multiple regression modeling to investigate whether between-group differences persisted after considering potentially confounding sociodemographic and clinical variables (ie, income, home language, depression, and the Framingham risk score).

RESULTS

Relative to other study participants, professional drivers with HIV performed significantly more poorly on tests assessing processing speed (P < 0.003) and attention and working memory (P = 0.018). Group membership remained a predictor of cognitive performance after controlling for potential confounders. The cognitive deficits observed in men with HIV were, however, largely characterized as being mild or asymptomatic. Consistent with this characterization, their relatively poor performance on neuropsychological testing did not generalize to self-reported impairment on activities of daily living.

CONCLUSION

Drivers with HIV may be at risk of poorer long-term health and employment outcomes. Programs that monitor and support their long-term cognitive health are needed.

Clinical Factors Predicting Voluntary Driving Cessation among Patients with Parkinson’s Disease

Factors that influence the decision of voluntary driving cessation in patients living with Parkinson’s disease (PD) are still unclear. We aimed to reveal the factors affecting the decision of voluntary driving cessation in patients with PD. This hospital-based cross-sectional study recruited consecutive outpatients with PD. Data on sociodemographic and clinical characteristics and medication use were collected from the patients using semistructured interviews. Cognitive function was evaluated using the Japanese version of the Montreal Cognitive Assessment (MoCA-J). We excluded patients with dementia or motor impairment ( $\text{Hoehn}-\text{Yahr}\text{stage}>3$ ). We divided the patients into two groups, with and without voluntary driving cessation (D: driver; RD: retired driver), and conducted investigations using multivariate logistic regression analyses. Of the 40 patients, 8 (20.0%) voluntarily retired from driving. Patients who decided on driving cessation had a higher prevalence of freezing of gait (FOG) (D vs. RD, 25.0% vs. 87.5%; $P=0.001$ ) and tended to have lower scores for attention in the MoCA-J (D vs. RD, $5.0\pm 1.2$ vs. $4.1\pm 1.4$ ; $P=0.086$ ). Multivariable analysis showed that FOG was independently associated with driving cessation (odds ratio: 14.46, 95% confidence interval: 1.91–303.74). FOG was associated with voluntary driving cessation in patients with PD without dementia or severe motor impairment. Physicians should consider providing extensive social support to maintain patients’ mobility and independence, especially if the patients have these clinical factors.

Caregiver Prediction of Driving Fitness in Older Adults with Dementia

Objectives: To determine whether caregiver opinion of fitness to drive and the level of assistance needed for functional activities are useful in determining the need for a Comprehensive Driving Evaluation.Methods: This study examined a sample (N = 179) of drivers with dementia. Caregivers completed a questionnaire that included caregiver opinion of driving fitness and the Functional Assessment Questionnaire (FAQ). A univariate simple logistic regression model was used to examine the relationship of road test failure with caregiver opinion of driving fitness and FAQ scores. From the significant predictive variables from the univariate test, multiple logictic regression models were used to examine possible combination of variables as predictors of road test failure.Results: The combination of caregiver opinion of driving fitness and the FAQ sub-item for memory were found to have modest ability in predicting failure on a standardized on-road driving assessment (AUC 0.727).Conclusions: Caregiver opinion of driving fitness and most individual higher order activities of daily living were found to be independent predictors of failure on a standardized road test.Clinical Implications: Caregiver opinion of driving fitness and ratings of functional activities may be useful for families and clinicians in considering whether an adult with dementia should be more carefully assessed for fitness to drive.

Driving and Alzheimer's dementia or mild cognitive impairment: a systematic review of the existing guidelines emphasizing on the neurologist's role

BACKGROUND

Driving is a complex task requiring the integrity and the cooperation of cognition, motor, and somatosensory skills, all of which are impacted by neurological diseases.

OBJECTIVE

Identification of neurologist's role when assessing fitness to drive of cognitively impaired individuals.

METHODS

We performed a systematic review of the guidelines/recommendations (G/Rs) regarding the evaluation of driving fitness of patients with mild cognitive impairment (MCI) and/or dementia. Emphasis was put on the neurological and neuropsychological aspects of the evaluation.

RESULTS

Eighteen G/Rs were included in the review (9 national guidelines, 5 recommendation papers, 3 consensus statements, and 1 position paper). All G/Rs referred to drivers with dementia and 9/18 referred to drivers with MCI. A common approach among G/Rs is the initial trichotomization of patients in safe to drive, unsafe to drive, and undetermined cases, which are referred to a second-line evaluator. First-line evaluators are general practitioners in 10/18 G/Rs; second-line evaluators are neurologists in 7/18 G/Rs. Specific neuropsychological tests are proposed in 11/18 G/Rs and relative cut-off values in 7/18. The most commonly used tests are the MMSE, TMT, and CDT. A thorough neurological examination is proposed in only 1/18 G/R.

CONCLUSION

Although extensive multi-disciplinary research has provided useful information for driving behavior of cognitively impaired individuals, we are still far from a widely accepted approach of driving ability evaluation in this increasing population. A comprehensive assessment from a multi-disciplinary team in which the neurologist plays a critical role seems to be required, although this has not yet been implemented in any G/Rs.

The Impact of HIV-Associated Neurocognitive Impairment on Driving Performance in Commercial Truck Drivers

Driving ability can be diminished amongst people with HIV with associated neurocognitive impairment (NCI). We explore the relationship between HIV status, NCI and driving ability in professional truck drivers. Forty male professional drivers (20 HIV-positive; mean age = 39.20 ± 7.05) completed a neuropsychological test battery, two driving simulator tasks that assessed driving ability, and a driving history and habits questionnaire. A higher proportion of HIV-positive drivers exhibited impaired overall cognitive performance (p ≤ 0.001). Overall, drivers with NCI (defined as z ≤ 1.00) were more likely than those without NCI to crash (p = 0.002). There were no significant between-group (HIV-positive versus HIV-negative) differences with regard to self-reported on-road driving events. Professional drivers with NCI, as measured on a driving simulator, are at increased risk of making driving errors under high-risk conditions compared to their neurocognitively normal counterparts. These data should inform driver health management with regard to annual medical screening and surveillance.

Emotion Recognition and Traffic-Related Risk-Taking Behavior in Patients with Neurodegenerative Diseases

OBJECTIVES

Neurodegenerative diseases (NDDs), such as Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies, and Huntington's disease, inevitably lead to impairments in higher-order cognitive functions, including the perception of emotional cues and decision-making behavior. Such impairments are likely to cause risky daily life behavior, for instance, in traffic. Impaired recognition of emotional expressions, such as fear, is considered a marker of impaired experience of emotions. Lower fear experience can, in turn, be related to risk-taking behavior. The aim of our study was to investigate whether impaired emotion recognition in patients with NDD is indeed related to unsafe decision-making in risky everyday life situations, which has not been investigated yet.

METHODS

Fifty-one patients with an NDD were included. Emotion recognition was measured with the Facial Expressions of Emotions: Stimuli and Test (FEEST). Risk-taking behavior was measured with driving simulator scenarios and the Action Selection Test (AST). Data from matched healthy controls were used: FEEST (n = 182), AST (n = 36), and driving simulator (n = 18).

RESULTS

Compared to healthy controls, patients showed significantly worse emotion recognition, particularly of anger, disgust, fear, and sadness. Furthermore, patients took significantly more risks in the driving simulator rides and the AST. Only poor recognition of fear was related to a higher amount of risky decisions in situations involving a direct danger.

CONCLUSIONS

To determine whether patients with an NDD are still fit to drive, it is crucial to assess their ability to make safe decisions. Measuring emotion recognition may be a valuable contribution to this judgment.

The Drives for Driving Simulation: A Scientometric Analysis and a Selective Review of Reviews on Simulated Driving Research

Driving behaviors and fitness to drive have been assessed over time using different tools: standardized neuropsychological, on-road and driving simulation testing. Nowadays, the great variability of topics related to driving simulation has elicited a high number of reviews. The present work aims to perform a scientometric analysis on driving simulation reviews and to propose a selective review of reviews focusing on relevant aspects related to validity and fidelity. A scientometric analysis of driving simulation reviews published from 1988 to 2019 was conducted. Bibliographic data from 298 reviews were extracted from Scopus and WoS. Performance analysis was conducted to investigate most prolific Countries, Journals, Institutes and Authors. A cluster analysis on authors' keywords was performed to identify relevant associations between different research topics. Based on the reviews extracted from cluster analysis, a selective review of reviews was conducted to answer questions regarding validity, fidelity and critical issues. United States and Germany are the first two Countries for number of driving simulation reviews. United States is the leading Country with 5 Institutes in the top-ten. Top Authors wrote from 3 to 7 reviews each and belong to Institutes located in North America and Europe. Cluster analysis identified three clusters and eight keywords. The selective review of reviews showed a substantial agreement for supporting validity of driving simulation with respect to neuropsychological and on-road testing, while for fidelity with respect to real-world driving experience a blurred representation emerged. The most relevant critical issues were the a) lack of a common set of standards, b) phenomenon of simulation sickness, c) need for psychometric properties, lack of studies investigating d) predictive validity with respect to collision rates and e) ecological validity. Driving simulation represents a cross-cutting topic in scientific literature on driving, and there are several evidences for considering it as a valid alternative to neuropsychological and on-road testing. Further research efforts could be aimed at establishing a consensus statement for protocols assessing fitness to drive, in order to (a) use standardized systems, (b) compare systematically driving simulators with regard to their validity and fidelity, and (c) employ shared criteria for conducting studies in a given sub-topic.

Validity and Reliability of the Traffic Sign Naming Test (TSNT) and Written Exam for Driving Decisions (WEDD) as Measures of Fitness to Drive Among Older Adults

IMPORTANCE

Occupational therapists need valid and reliable tools to help determine fitness to drive of older drivers with medical conditions such as dementia.

OBJECTIVE

To establish the validity and reliability of the Traffic Sign Naming Test (TSNT) and Written Exam for Driving Decisions (WEDD) as measures of fitness to drive of adults with and without dementia.

DESIGN

Cross-sectional.

SETTING

Washington University Medical School in St. Louis in collaboration with the Rehabilitation Institute of St. Louis.

PARTICIPANTS

Older drivers diagnosed with dementia (n = 130) and without dementia (n = 34). Drivers with dementia required a physician referral indicating a medical need for a driving evaluation, a diagnosis of dementia, and an Alzheimer Detection 8 score of 2. Drivers without dementia were required to be age 55 yr or older and not meet criteria for dementia.

OUTCOMES AND MEASURES

Participants completed a comprehensive driving evaluation (CDE) that included clinical measures of vision, motor, and cognition; TSNT; and WEDD. The outcome measure was performance on a standardized on-road assessment.

RESULTS

The TSNT's interrater reliability was determined to be strong (κ = .80). The TSNT and WEDD demonstrated convergent validity with cognitive measures (p < .001) and discriminant validity with visual and motor measures in the CDE. The TSNT (area under the curve [AUC] = .74) and WEDD (AUC = .71) had fair ability to predict failure on a standardized on-road assessment.

CONCLUSION AND RELEVANCE

TSNT and WEDD are recommended for use by occupational therapists in combination with other performance measures when determining fitness to drive or need for a CDE.

WHAT THIS ARTICLE ADDS

The TSNT and WEDD can be included as screening tools (in addition to other performance measures) to assist clinicians in determining which clients need to be referred for a CDE. The TSNT and WEDD can also be included as part of a CDE to assist driving rehabilitation specialists in making final recommendations regarding fitness to drive. The scores generated from the TSNT and WEDD address driving knowledge in a way that may be more understandable to clients and more relatable to skills needed to actually drive.

Pyrola incarnata demonstrates neuroprotective effects against β-amyloid-induced memory impairment in mice

This study aims to investigate the neuroprotective effects of Pyrola incarnata against β-amyloid-induced memory impairment in mice. Ethanol extract of Pyrola incarnata (EPI) was obtained and led to eleven phytochemicals successfully by isolation and purification, which were elucidated by spectroscopic analysis (¹H NMR, ¹³C NMR and HR-ESI-MS). Thereinto, ursolic acid was gained as most abundant monomer. C57BL/6 mice were intracerebroventricular injected with aggregated Aβ_25-35. Open-field test, Barnes maze test and Morris water maze were conducted for evaluating cognition processes of EPI and ursolic acid. EPI significantly improved learning and memory deficits, attenuated the Aβ_25-35 level of deposition immunohistochemically. Further studies revealed that ursolic acid as bioactive phytochemical of P. incarnata improved spatial memory performance and ameliorated Aβ_25-35 accumulation by activating microglia cells and up-regulating Iba1 level in the hippocampus. These findings suggest P. incarnata could improve the cognition of mice and be a promising natural source for the treatment of neurodegenerative disease.

The MMSE should not be the sole indicator of fitness to drive in mild Alzheimer's dementia

Since Alzheimer’s disease may affect driving performance, patients with Alzheimer’s disease are assessed on fitness to drive. On-road driving assessments are widely used, and attempts have also been made to develop strategies to assess fitness to drive in a clinical setting. Preferably, a first indication of fitness to drive is obtained quickly after diagnosis using a single test such as the Mini-Mental State Examination (MMSE). The aim of this study is to investigate whether the MMSE can be used to predict whether patients with Alzheimer’s disease will pass or fail an on-road driving assessment. Patients with Alzheimer’s disease (n = 81) participated in a comprehensive fitness-to-drive assessment which included the MMSE as well as an on-road driving assessment [PLoS One 11(2):e0149566, 2016]. MMSE cutoffs were applied as suggested by Versijpt and colleagues [Acta Neurol Belg 117(4):811–819, 2017]. All patients with Alzheimer’s disease who scored below the lower cutoff (MMSE ≤ 19) failed the on-road driving assessment. However, a third of the patients with Alzheimer’s disease who scored above the upper cutoff (MMSE ≥ 25) failed the on-road driving assessment as well. We conclude that the MMSE alone has insufficient predictive value to correctly identify fitness to drive in patients with very mild-to-mild Alzheimer’s disease implicating the need for comprehensive assessments to determine fitness to drive in a clinical setting.

Altered driving performance of symptomatic Huntington's disease gene carriers in simulated road conditions

OBJECTIVE

In clinical practice, patients with Huntington's disease (HD) often decide to solely drive in their own familiar neighborhoods and not on a motorway or in an unknown area. The aim of the study was to identify differences in driving performance between HD gene carriers and healthy individuals in simulated urban and motorway environments.

METHODS

This cross-sectional study included 87 participants (28 premanifest HD, 30 manifest HD, 29 controls). All participants were active drivers and were assessed using a driving simulator, a driving history questionnaire, and the Unified Huntington's Disease Rating Scale. The driving simulator session included urban and motorway scenarios. Analysis of variance and Kruskal-Wallis tests were used to compare urban and motorway driving across all 3 groups.

RESULTS

Manifest HD drove slower compared to controls and premanifest HD when speed limits increased (80 and 100 km/h) and they had a less steady speed compared to premanifest HD on the motorway and in a 30 km/h zone. Manifest HD also had a larger standard deviation of the lateral position (i.e., more weaving of the car/less vehicle control) compared to controls and premanifest HD on the motorway.

CONCLUSIONS

Manifest HD drive more cautious in a driving simulator when speed limits increase compared to premanifest HD and controls and they have less vehicle control on the motorway. The driving simulator parameters are able to discriminate between manifest HD and healthy individuals, so a driving simulator seems a feasible tool to use when investigating changes in driving in manifest HD.

Driving impairment and crash risk in Parkinson disease: A systematic review and meta-analysis

OBJECTIVES

To provide the best possible evidence base for guiding driving decisions in Parkinson disease (PD), we performed a meta-analysis comparing patients with PD to healthy controls (HCs) on naturalistic, on-the-road, and simulator driving outcomes.

METHODS

Seven major databases were systematically searched (to January 2018) for studies comparing patients with PD to HCs on overall driving performance, with data analyzed using random-effects meta-analysis.

RESULTS

Fifty studies comprising 5,410 participants (PD = 1,955, HC = 3,455) met eligibility criteria. Analysis found the odds of on-the-road test failure were 6.16 (95% confidence interval [CI] 3.79-10.03) times higher and the odds of simulator crashes 2.63 (95% CI 1.64-4.22) times higher for people with PD, with poorer overall driving ratings also observed (standardized mean differences from 0.50 to 0.67). However, self-reported real-life crash involvement did not differ between people with PD and HCs (odds ratio = 0.84, 95% CI 0.57-1.23, p = 0.38). Findings remained unchanged after accounting for any differences in age, sex, and driving exposure, and no moderating influence of disease severity was found.

CONCLUSIONS

Our findings provide persuasive evidence for substantive driving impairment in PD, but offer little support for mandated PD-specific relicensure based on self-reported crash data alone, and highlight the need for objective measures of crash involvement.

The visual cortex and visual cognition in Huntington's disease: An overview of current literature

The processing of visual stimuli from retina to higher cortical areas has been extensively studied in the human brain. In Huntington's disease (HD), an inherited neurodegenerative disorder, it is suggested that visual processing deficits are present in addition to more characteristic signs such as motor disturbances, cognitive dysfunction, and behavioral changes. Visual deficits are clinically important because they influence overall cognitive performance and have implications for daily functioning. The aim of this review is to summarize current literature on clinical visual deficits, visual cognitive impairment, and underlying visual cortical changes in HD patients. A literature search was conducted using the electronic database of PubMed/Medline. This review shows that changes of the visual system in patients with HD were not the primary focus of currently published studies. Still, early atrophy and alterations of the posterior cerebral cortex was frequently observed, primarily in the associative visual cortical areas such as the lingual and fusiform gyri, and lateral occipital cortex. Changes were even present in the premanifest phase, before clinical onset of motor symptoms, suggesting a primary region for cortical degeneration in HD. Although impairments in visuospatial processing and visual perception were reported in early disease stages, heterogeneous cognitive batteries were used, making a direct comparison between studies difficult. The use of a standardized battery of visual cognitive tasks might therefore provide more detailed information regarding the extent of impairments in specific visual domains. Further research could provide more insight into clinical, functional, and pathophysiological changes of the visual pathway in HD.