Driving scenes test of the Neuropsychological Assessment Battery (NAB) and on-road driving performance in aging and very mild dementia

Fit2Drive: Screening Older Drivers with Cognitive Concerns

OBJECTIVES

The purpose of this study was to identify the most parsimonious combination of cognitive tests that accurately predicts the likelihood of passing an on-road driving evaluation in order to develop a screening measure that can be administered as an in-office test.

DESIGN

This was a psychometric study of the new test's diagnostic accuracy.

SETTINGS AND PARTICIPANTS

The study was conducted at the Florida Atlantic University's Memory Center and Clinical Research Unit, both easily accessible to older drivers. Participants were older drivers who received a driving evaluation at the Memory Center and agreed to have their results included in the Driving Repository and community-based older drivers who volunteered to participate.

METHODS

Mini-Mental State Exam (MMSE), Trail Making Tests A and B, Clock Test, Hopkins Verbal Learning Test, and Driving Health Inventory results were compared with an on-road driving evaluation to identify those tests that best predict the ability to pass the on-road evaluation.

RESULTS

Altogether, 412 older drivers, 179 men and 233 women, were included in the analysis. Fifty-four percent of Driving Repository participants failed the on-road evaluation compared with 8% of the community sample. The highest correlation to the on-road evaluation was Trails B time in seconds r = -0.713 (P < .001). Variables with high multicollinearity and/or low correlation with the on-road evaluation were eliminated and sets of receiver operating characteristics curves were generated to assess the predictive accuracy of the remaining tests. A linear combination of Trails B in seconds and MMSE using the highest of the Serial 7s or WORLD spelled backward scores accounted for the highest area under the curve of 0.915. Finally, an algorithm was created to rapidly generate the prediction for an individual patient.

CONCLUSIONS AND IMPLICATIONS

The Fit2Drive algorithm demonstrated a strong 91.5% predictive accuracy. Usefulness in office-based patient consultations is promising but remains to be rigorously tested.

The Neuropsychological Assessment Battery Driving Scenes Test in a Dementia Clinic

OBJECTIVE

In dementia research, the Driving Scenes test from the Neuropsychological Assessment Battery has been shown to relate to memory, dementia diagnosis, and functional impairment. The aim of the current study was to examine Driving Scenes and its component scores, and their relationships with cognition and daily functioning, in a mixed dementia clinic sample.

METHOD

One hundred U.S. military veterans between the ages of 55 and 88 were administered a full neuropsychological protocol that included Driving Scenes.

RESULTS

The Driving Scenes score and its subscores were strongly related to memory skills, and there were additional subscore associations with language and visuospatial functions. Driving Scenes uniquely predicted reported bill payment difficulties and tendency to get lost while driving, which were not predicted by other performances across cognitive domains.

CONCLUSION

Driving Scenes is a clinically and functionally relevant measure of memory. Although the Driving Scenes total score remains useful in dementia evaluations, component scores and error scores contribute additional practical information.

Driving Assessment for Persons with Dementia: How and when?

Dementia is a progressive neurodegenerative disease leading to deterioration in cognitive and physical skills. Driving is an important instrumental activity of daily living, essential for independence. However, this is a complex skill. A moving vehicle can be a dangerous tool in the hand of someone who cannot maneuver it properly. As a result, the assessment of driving capacity should be part of the management of dementia. Moreover, dementia comprises of different etiologies and stages consisting of different presentations. As a result, this study aims to identify driving behaviors common in dementia and compare different assessment methods. A literature search was conducted using the PRISMA checklist as a framework. A total of forty-four observational studies and four meta-analyses were identified. Study characteristics varied greatly with regards to methodology, population, assessments, and outcome measures used. Drivers with dementia performed generally worse than cognitively normal drivers. Poor speed maintenance, lane maintenance, difficulty managing intersections and poor response to traffic stimuli were the most common behaviors in drivers with dementia. Naturalistic driving, standardized road assessments, neuropsychological tests, participant self-rating and caregiver rating were the most common driving assessment methods used. Naturalistic driving and on-road assessments had the highest predictive accuracy. Results on other forms of assessments varied greatly. Both driving behaviors and assessments were influenced by different stages and etiologies of dementia at varying degrees. Methodology and results in available research are varied and inconsistent. As a result, better quality research is required in this field.

Protocol for a randomized controlled trial of mindfulness-based stress reduction to improve attentional control in older adults (HealthyAgers trial)

BACKGROUND

Mindfulness meditation is a form of mind-body intervention that has increasing scientific support for its ability to reduce age-related declines in cognitive functioning, improve affective health, and strengthen the neural circuitry supporting improved cognitive and affective health. However, the majority of existent studies have been pilot investigations with small sample sizes, limited follow-up data, and a lack of attention to expectancy effects. Here, we present the study design of a Phase I/II, efficacy trial-HealthyAgers trial-that examines the benefits of a manualized mindfulness-based stress reduction program in improving attentional control and reducing mind-wandering in older adults.

METHODS

One hundred fifty older adults (ages 65-85 years) will be randomized into one of two groups: an eight-week mindfulness program or an eight-week, placebo-controlled, lifestyle education program. Behavioral and neuroimaging assessments are conducted before and after the training. Participants are then invited to booster sessions once every three months for a period of 12 months with post-intervention follow-up assessments conducted at 6-months and 12-months. The primary outcomes for the study are behavioral measures of attentional control and mind-wandering. Additional, secondary outcomes include network strength in an a priori defined neuromarker of attentional control, fluid and everyday cognition, emotion regulation strategy use, and markers of inflammation.

DISCUSSION

This study will establish the efficacy of a group-based, low-cost mind-body intervention for the inter-related facets of attentional control and mind-wandering in older adults. Strengths of this study include a well-designed, placebo-controlled comparison group, use of web/mobile application to track study adherence, and longitudinal follow-up.

TRIAL REGISTRATION

Clinicaltrials.gov (# NCT03626532 ). Registered August 4, 2018.

Development of a Web-Based Mini-Driving Scene Screening Test (MDSST) for Clinical Practice in Driving Rehabilitation

(1) Background: For the elderly and disabled, self-driving is very important for social participation. An understanding of changing driving conditions is essential in order to drive safely. This study aimed to develop a web-based Korean Mini-Driving Scene Screening Test (MDSST) and to verify its reliability and validity for clinical application. (2) Methods: We developed a web-based MDSST, and its content validity was verified by an expert group. The tests were conducted with 102 elderly drivers to verify the internal consistency and reliability of items, and the validity of convergence with the existing Korean-Safe Driving Behavior Measure (K-SDBM) and the Korean-Adelaide Driving Self-Efficacy Scale (K-ADSES) driving tests was also verified. The test–retest reliability was verified using 54 individuals who participated in the initial test. (3) Results: The average content validity index of MDSST was 0.90, and the average internal consistency of all items was 0.822, indicating high content validity and internal consistency. The exploratory factor analysis for construct validity, the KOM value of the data, was 0.658, and Bartlett’s sphericity test also showed a strongly significant result. The four factors were road traffic and signal perception, situation understanding, risk factor recognition, and situation prediction. The explanatory power was reliable at 61.27%. For the convergence validation, MDSST and K-SDBM showed r = 0.435 and K-ADSES showed r = 0.346, showing a moderate correlation. In the evaluation–reevaluation reliability verification, the reliability increased to r = 0.952. (4) Conclusions: The web-based MDSST test developed in this study is a useful tool for detecting and understanding real-world driving situations faced by elderly drivers. It is hoped that the MDSST test can be applied more widely as a driving ability test that can be used in the clinical field of driving rehabilitation.

Driving Performance in Older Adults: Current Measures, Findings, and Implications for Roadway Safety

Background and Objectives

Over 10,000 people a day turn 65 in the United States. For many older adults, driving represents an essential component of independence and is one of the most important factors in overall mobility. Recent survey studies in older adults suggest that up to 60% of older adult drivers with mild cognitive impairment, and up to 30% with dementia, continue to drive. The purpose of this review is to provide a comprehensive and detailed resource on the topics of cognition and driving for clinicians, researchers, and policymakers working on efforts related to older adult drivers.

Research Design and Methods

Publications on PubMed and Medline and discussions with experts working in geriatrics, technology, driving policy, psychology, and diverse aspects of driving performance were utilized to inform the current review.

Results

Research indicates that there is a complex and inverse correlation between multiple cognitive measures, driving performance, and risky driving behaviors. The fragmented nature of available peer-reviewed literature, and a reliance on correlative data, do not currently allow for the identification of the temporal and reciprocal nature of the interplay between cognition and driving endpoints.

Discussion and Implications

There are currently no widely accepted definitions, conceptual models, or uniform set of analyses for conducting geriatric research that is focused on driving. Establishing conventions for conducting research that harmonizes the fields of geriatrics, cognition, and driving research is critical for the development of the evidence base that will inform clinical practice and road safety policy.

Predictors of Caregiver Burden in Huntington's Disease

OBJECTIVE

Huntington's disease (HD) is a genetic neurodegenerative condition that is characterized by cognitive, motor, and psychiatric dysfunction. The purpose of this study was to explore which disease characteristics influence caregiver burden in HD.

METHODS

Fifty participants with HD and 50 of their caregivers participated in the study at the University of South Florida. Participants were administered a neuropsychological battery, the Unified Huntington's Disease Rating Scale (UHDRS) motor exam, and the Frontal Systems Behavior Scale (FrSBe) self-report. Caregivers completed the Caregiving Appraisal Scale and the FrSBe family-report.

RESULTS

There were significant correlations between caregiver burden and caregiver age and sex, UHDRS motor scores, cognitive functioning, and self and caregiver-reported FrSBe scores. The significant variables were entered into a regression model and explained 63.1% of the variance in caregiver burden scores. Caregiver age, cognitive functioning, and caregiver-reported FrSBe scores continued to be significant predictors of caregiver burden, whereas the other variables were no longer significant.

CONCLUSIONS

There were significant relationships between caregiver burden, cognitive functioning, and frontally mediated behaviors, but not motor scores. The results suggest that possible interventions for caregivers may include education to caregivers on how to cope with apathy/executive dysfunction and cognitive decline. Caregiver age was associated with burden, with younger age being associated with increased burden when controlling for symptom severity. This has implications for this population in that HD typically has a younger age of onset than other neurodegenerative diseases and therefore, these caregivers may be particularly at risk for caregiver burden.

Regional Gray Matter Volume Identifies High Risk of Unsafe Driving in Healthy Older People

In developed countries, the number of traffic accidents caused by older drivers is increasing. Approximately half of the older drivers who cause fatal accidents are cognitively normal. Thus, it is important to identify older drivers who are cognitively normal but at high risk of causing fatal traffic accidents. However, no standardized method for assessing the driving ability of older drivers has been established. We aimed to establish an objective assessment of driving ability and to clarify the neural basis of unsafe driving in healthy older people. We enrolled 32 healthy older individuals aged over 65 years and classified unsafe drivers using an on-road driving test. We then utilized a machine learning approach to distinguish unsafe drivers from safe drivers based on clinical features and gray matter volume data. Twenty-one participants were classified as safe drivers and 11 participants as unsafe drivers. A linear support vector machine classifier successfully distinguished unsafe drivers from safe drivers with 87.5% accuracy (sensitivity of 63.6% and specificity of 100%). Five parameters (age and gray matter volume in four cortical regions, including the left superior part of the precentral sulcus, the left sulcus intermedius primus [of Jensen], the right orbital part of the inferior frontal gyrus, and the right superior frontal sulcus), were consistently selected as features for the final classification model. Our findings indicate that the cortical regions implicated in voluntary orienting of attention, decision making, and working memory may constitute the essential neural basis of driving behavior.

Off-road assessment of cognitive fitness to drive

Road safety is a major issue in every society. The assessment of driving ability with a real vehicle is a lengthy and costly process; therefore, there is a growing need for the development of a neuropsychological battery that can provide a fast and reliable evaluation of a person's cognitive fitness to drive. In the present study, we examined the relationship of an off-road lab-type test, namely, the Driving Scenes test, with performance on a driving simulator, as well as the influence of cognitive factors on driving ability as evaluated by Driving Scenes. Our results demonstrated a relationship between Driving Scenes and driving simulator performance. They also showed that some cognitive factors (namely, selective attention and verbal memory), were predictive of driving ability (as determined by the Driving Scenes test), but not others (namely visuospatial perception/memory, working memory, and visuospatial recognition). In addition, age strongly predicted performance on this test (younger age was associated with better performance). The conclusions derived from the present study highlight the need to identify off-road tools with high predictive value in assessing driving ability.

Machine-learning approach to predict on-road driving ability in healthy older people

AIM

In Japan, fatal traffic accidents due to older drivers are on the rise. Considering that approximately half the older drivers who have caused fatal accidents are cognitively normal healthy people, it has been required to detect older drivers who are cognitively normal but at high risk of having fatal traffic accidents. However, a standardized method for assessing the driving ability of older drivers has not yet been established. We thus aimed to identify a new sensing method for the evaluation of the on-road driving ability of healthy older people on the basis of vehicle behaviors.

METHODS

We enrolled 33 healthy older individuals aged over 65 years and utilized a machine-learning approach to dissociate unsafe drivers from safe drivers based on cognitive assessments and a functional visual acuity test.

RESULTS

The linear support vector machine classifier successfully dissociated unsafe drivers from safe drivers with accuracy of 84.8% (sensitivity of 66.7% and specificity of 95.2%). Five clinical parameters, namely age, the first trial of the Rey Auditory Verbal Learning Test immediate recall, the delayed recall of the Rey-Osterrieth Complex Figure Test, the result of the free-drawn Clock Drawing Test, and maximal visual acuity, were consistently selected as essential features for the best classification model.

CONCLUSION

Our findings improve our understanding of clinical risk factors leading to unsafe driving and may provide insight into a new intervention that prevents fatal traffic accidents caused by healthy older people.

Multimethod assessment of driving in older adults using a novel driving simulator

Driving simulators may be an effective means of assessing driving performance, however many are cost-prohibitive. The present pilot study examined whether a novel, cost-effective driving simulator (Assetto Corsa (AC)) may be useful in the evaluation of older adults' driving performance, and explore associations among various driving safety indicators. A community sample of older adults completed a battery of cognitive measures, several self-reported driving measures, and a novel driving simulator task (AC). Simple attention, executive functioning, and processing speed were associated with simulator performance variables. Lower self-rated driving safety was associated with slower simulated driving. Additionally, several cognitive domains were associated with perceptions about driving-related safety and driving-related legal repercussions (e.g., traffic tickets). Findings suggested that associations between cognitive tests with AC were less robust than those found in other simulator studies. Novel associations between cognitive performance and self-reported driving were identified; however, given the small sample size of this study, such associations should be explored further.

Alzheimer Disease Biomarkers and Driving in Clinically Normal Older Adults: Role of Spatial Navigation Abilities

PURPOSE

Older adults experience impaired driving performance, and modify their driving habits, including limiting amount and spatial extent of travel. Alzheimer disease (AD)-related pathology, as well as spatial navigation difficulties, may influence driving performance and driving behaviors in clinically normal older adults. We examined whether AD biomarkers [cerebrospinal fluid (CSF) concentrations of Aβ42, tau, and ptau181] were associated with lower self-reported spatial navigation abilities, and whether navigation abilities mediated the relationship of AD biomarkers with driving performance and extent.

METHODS

Clinically normal older adults (n=112; aged 65+) completed an on-road driving test, the Santa Barbara Sense of Direction scale (self-report measure of spatial navigation ability), and the Driving Habits Questionnaire for an estimate of driving extent (composite of driving exposure and driving space). All participants had a lumbar puncture to obtain CSF.

RESULTS

CSF Aβ42, but not tau or ptau181, was associated with self-reported navigation ability. Lower self-reported navigation was associated with reduced driving extent, but not driving errors. Self-reported navigation mediated the relationship between CSF Aβ42 and driving extent.

CONCLUSIONS

Findings suggest that cerebral amyloid deposition is associated with lower perceived ability to navigate the environment, which may lead older adults with AD pathology to limit their driving extent.

Evaluation of a performance-rating method to assess awareness of cognitive functioning in Huntington's disease

Objective: Anosognosia, or lack of awareness of symptoms, is commonly observed in Huntington's disease (HD) using patient/informant-report discrepancy methods. The purpose of this study was to examine the utility of a performance-rating method for assessing awareness of cognitive performance in HD.Method: Persons with manifest HD (n = 54) rated their performance on the daily living tests from the Neuropsychological Assessment Battery (NAB) using a bell curve. We also examined patient/informant-report discrepancies of executive functioning (FrSBe) in a subset (n = 47) of patients and their informants.Results: Patients were able to reliably use our method of categorizing their performance as evidenced by significant correlations between verbal descriptions of their performance and the percentile ratings they indicated on the bell curve. Patients across the range of observed Unified HD Rating Scale motor scale scores rated their performance on the NAB tasks significantly higher than actual performance for both pretest prediction and posttest evaluation ratings. Only patients with more severe motor impairment underestimated their problems relative to informant report on the FrSBe.Conclusions: This is the first study to use a performance-rating method for examining awareness in HD. Patients could reliably use this performance-based bell curve method to provide accurate estimations of their performance and as a group they tended to overestimate performance as has been demonstrated in previous studies. Unlike previous studies using self-report methodology, we also demonstrated decreased awareness in the persons with HD with less severe motor impairment using the performance-rating method, suggesting the two methods may measure different constructs of awareness.

Subcortical Ischemic Change as a Predictor of Driving Cessation in the Elderly

OBJECTIVE

Motor, perceptual, and cognitive functions are known to affect driving competence. Subcortical ischemic changes on brain magnetic resonance imaging (MRI) can reflect reduction in cognitive and motor performance. However, few studies have reported the relationship between subcortical ischemic changes and driving competence of the elderly. Thus, the objective of this study was to investigate the association between subcortical ischemic changes on MRI and driving abilities of the elderly.

METHODS

Participants (n=540) were drawn from a nationwide, multicenter, hospital-based, longitudinal cohort. Each participant underwent MRI scan and interview for driving capacity categorized into 'now driving' and 'driving cessation (driven before, not driving now)'. Participants were divided into three groups (mild, n=389; moderate, n=116; and severe, n=35) depending on the degree of white matter hyperintensity (WMH) on MRI at baseline. Driving status was evaluated at follow-up. Statistical analyses were conducted using χ2 test, analysis of variance (ANOVA), structured equation model (SEM), and generalized estimating equation (GEE).

RESULTS

In SEM, greater baseline degree of WMH was directly associated with driving cessation regardless of cognitive or motor dysfunction (β=-0.110, p<0.001). In GEE models after controlling for age, sex, education, cognitive, and motor dysfunction, more severe change in the degree of WMH was associated with faster change from 'now driving' state to 'driving cessation' state over time in the elderly (β=-0.508, p<0.001).

CONCLUSION

In both cross-sectional and longitudinal results, the degree of subcortical ischemic change on MRI might predict driving cessation in the elderly.

Clinical Utility of Select Neuropsychological Assessment Battery Tests in Predicting Functional Abilities in Dementia

OBJECTIVE

Neuropsychological test performance can provide insight into functional abilities in patients with dementia, particularly in the absence of an informant. The relationship between neuropsychological measures and instrumental activities of daily living (IADLs) is unclear due to hetereogeneity in cognitive domains assessed and neuropsychological tests administered. Practical and ecologically valid performance-based measures of IADLs are also limited. The Neuropsychological Assessment Battery (NAB) is uniquely positioned to provide a dual-purpose assessment of cognitive and IADL function, as it includes Daily Living tests that simulate real-world functional tasks. We examined the utility of select NAB tests in predicting informant-reported IADLs in mild cognitive impairment and dementia.

METHODS

The sample of 327 participants included 128 normal controls, 97 individuals with mild cognitive impairment, and 102 individuals with Alzheimer's disease dementia from the Boston University Alzheimer's Disease Center research registry. Informants completed the Lawton Brody Instrumental Activities of Daily Living Scale, and study participants were administered selected NAB tests that were complementary to the existing protocol.

RESULTS

ROC curves showed strongest prediction of IADL (AUC > 0.90) for memory measures (List Learning delayed recall and Daily Living Memory delayed recall) and Daily Living Driving Scenes. At a predetermined level of specificity (95%), List Learning delayed recall (71%) and Daily Living Memory delayed recall (88%) were the most sensitive. The Daily Living Memory and Driving Scenes tests strongly predicted IADL status, and the other Daily Living tests contributed unique variance.

CONCLUSIONS

NAB memory measures and Daily Living Tests may have clinical utility in detecting informant-rated functional impairment in dementia.

Cross-Tissue Exploration of Genetic and Epigenetic Effects on Brain Gray Matter in Schizophrenia

Closely linking genetics and environment factors, epigenetics has been of increasing interest in psychiatric disease studies. In this work, we integrated single nucleotide polymorphisms (SNPs), DNA methylation of blood and saliva, and brain gray matter (GM) measures to explore the role of genetic and epigenetic variation to the brain structure changes in schizophrenia (SZ). By focusing on the reported SZ genetic risk regions, we applied a multi-stage multivariate analysis to a discovery dataset (92 SZ patients and 110 controls, blood) and an independent replication dataset (93 SZ patients and 99 controls, saliva). Two pairs of SNP-methylation components were significantly correlated (r = .48 and .35) in blood DNA, and replicated (r = .46 and .29) in saliva DNA, reflecting cross-tissue SNP cis-effects. In the discovery data, both SNP-related methylation components were also associated with one GM component primarily located in cerebellum, caudate, and thalamus. Additionally, another methylation component in NOSIP gene with significant SZ patient differences (P = .009), was associated with 8 GM components (7 with patient differences) including superior, middle, and inferior frontal gyri, superior, middle, and inferior temporal gyri, cerebellum, insula, cuneus, and lingual gyrus. Of these, 5 methylation-GM associations were replicated (P < .05). In contrast, no pairwise significant associations were observed between SNP and GM components. This study strongly supports that compared to genetic variation, epigenetics show broader and more significant associations with brain structure as well as diagnosis, which can be cross-tissue, and the potential in explaining the mechanism of genetic risks in SZ.

A Systematic Review and Meta-Analysis of On-Road Simulator and Cognitive Driving Assessment in Alzheimer's Disease and Mild Cognitive Impairment

BACKGROUND

Many individuals with Alzheimer's disease (AD) and mild cognitive impairment (MCI) are at an increased risk of driving impairment. There is a need for tools with sufficient validity to help clinicians assess driving ability.

OBJECTIVE

Provide a systematic review and meta-analysis of the primary driving assessment methods (on-road, cognitive, driving simulation assessments) in patients with MCI and AD.

METHODS

We investigated (1) the predictive utility of cognitive tests and domains, and (2) the areas and degree of driving impairment in patients with MCI and AD. Effect sizes were derived and analyzed in a random effects model.

RESULTS

Thirty-two articles (including 1,293 AD patients, 92 MCI patients, 2,040 healthy older controls) met inclusion criteria. Driving outcomes included: On-road test scores, pass/fail classifications, errors; caregiver reports; real world crash involvement; and driving simulator collisions/risky behavior. Executive function (ES [95% CI]; 0.61 [0.41, 0.81]), attention (0.55 [0.33, 0.77]), visuospatial function (0.50 [0.34, 0.65]), and global cognition (0.61 [0.39, 0.83]) emerged as significant predictors of driving performance. Trail Making Test Part B (TMT-B, 0.61 [0.28, 0.94]), TMT-A (0.65 [0.08, 1.21]), and Maze test (0.88 [0.60, 1.15]) emerged as the best single predictors of driving performance. Patients with very mild AD (CDR = 0.5) mild AD (CDR = 1) were more likely to fail an on-road test than healthy control drivers (CDR = 0), with failure rates of 13.6%, 33.3% and 1.6%, respectively.

CONCLUSION

The driving ability of patients with MCI and AD appears to be related to degree of cognitive impairment. Across studies, there are inconsistent cognitive predictors and reported driving outcomes in MCI and AD patients. Future large-scale studies should investigate the driving performance and associated neural networks of subgroups of AD (very mild, mild, moderate) and MCI (amnestic, non-amnestic, single-domain, multiple-domain).

The association between Tai Chi exercise and safe driving performance among older adults: An observational study

BACKGROUND

Age-related cognitive and physical decline can impair safe driving performance. Tai Chi exercise benefits cognitive and physical function and may influence safe driving performance in older adults. The primary aim of this observational study was to compare cognitive processes and physical function related to safe driving performance among older adult Tai Chi practitioners to normative reference values. Secondary aims were to examine relationships between Tai Chi exercise habits, cognitive processes, and physical function related to safe driving performance and to explore potential predictors of safe driving performance.

METHODS

The DrivingHealth Inventory, the Driving Scenes Test, other driving-related cognitive and physical measures, and self-reported measures including the Mindful Attention Awareness Scale (MAAS) and the Vitality Plus Scale (VPS) were collected from current Tai Chi practitioners (n = 58; age 72.9 ± 5.9 years, mean ± SD) with median >3 years Tai Chi practice.

RESULTS

Compared to normative reference values, participants performed better on numerous cognitive measures including the Driving Scenes Test (p < 0.001, d = 1.63), maze navigation (p = 0.017, d = 0.27), the Useful Field of View Test (p < 0.001, r = 0.15), and on physical measures including the Rapid Walk Test (p < 0.001, r = 0.20), and the Right Foot Tapping Test, (p < 0.001, r = 0.35). Participants scored higher than normative reference values on MAAS and VPS (p < 0.001, d = 0.75; p = 0.002, d = 0.38, respectively). Statistically significant correlations were found between several study measures. The digit span backward test was the strongest predictor of safe driving performance (β = 0.34, p = 0.009).

CONCLUSION

Tai Chi exercise has the potential to impact cognitive processes and physical function related to safe driving performance. Further study using randomized controlled trials, structured Tai Chi exercise doses, and driving simulator or on-road driving performance as outcome measures are warranted.

Update on the Risk of Motor Vehicle Collision or Driving Impairment with Dementia: A Collaborative International Systematic Review and Meta-Analysis

Guidelines that physicians use to assess fitness to drive for dementia are limited in their currency, applicability, and rigor of development. Therefore, we performed a systematic review to determine the risk of motor vehicle collisions (MVCs) or driving impairment caused by dementia, in order to update international guidelines on driving with dementia. Seven literature databases (MEDLINE, CINAHL, Embase, etc.) were searched for all research studies published after 2004 containing participants with mild, moderate, or severe dementia. From the retrieved 12,860 search results, we included nine studies in this analysis, involving 378 participants with dementia and 416 healthy controls. Two studies reported on self-/informant-reported MVC risk, one revealing a four-fold increase in MVCs per 1,000 miles driven per week in 3 years prior, and the other showing no statistically significant increase over the same time span. We found medium to large effects of dementia on driving abilities in six of the seven recent studies that examined driving impairment. We also found that persons with dementia were much more likely to fail a road test than healthy controls (RR: 10.77, 95% CI: 3.00-38.62, z = 3.65, p < 0.001), with no significant heterogeneity (χ² = 1.50, p = 0.68, I² = 0%) in a pooled analysis of four studies. Although the limited data regarding MVCs are equivocal, even mild stages of dementia place patients at a substantially higher risk of failing a performance-based road test and of demonstrating impaired driving abilities on the road.

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

Driving is important for employment, social activities, and for the feeling of independence. The decision to cease driving affects the quality of life and has been associated with reduced mobility, social isolation, and sadness. Patients with neurodegenerative disorders can experience difficulties while driving due to their cognitive, motor, and behavioral impairments. The aim of this review is to summarize the available literature on changes in driving competence and behavior in patients with neurodegenerative disorders, with a particular focus on Huntington's (HD), Parkinson's (PD), and Alzheimer's disease (AD). A systematic literature search was conducted in the PubMed/Medline database. Studies using on-road or simulated driving assessments were examined in this review. In addition, studies investigating the association between cognitive functioning and driving were included. The review identified 70 studies. Only a few publications were available on HD (n = 7) compared to PD (n = 32) and AD (n = 31). This review revealed that driving is impaired in patients with neurodegenerative disorders on all levels of driving competence. The errors most commonly committed were on the tactical level including lane maintenance and lane changing. Deficits in executive functioning, attention, and visuospatial abilities can partially predict driving competence, and the performance on neuropsychological tests might be useful when discussing potential driving cessation. Currently, there is no gold standard to assess driving ability using clinical measures such as neuropsychological assessments, so more studies are necessary to detect valid screening tools and develop useful and reliable evidence-based guidelines.

Office-Based Assessment of At-Risk Driving in Older Adults With and Without Cognitive Impairment

BACKGROUND

A multitest approach is optimal for the identification of at-risk driving among older adults. This study examined the predictive validity of a combination of office-based screening tests for on-road driving performance in older adults with and without mild cognitive impairment (MCI)/dementia.

METHODS

Forty-four normal control, 20 participants with MCI, and 20 participants with dementia completed a battery of office-based assessments. On-road driving evaluation classified participants as not at-risk (n = 65) or at-risk drivers (n = 19).

RESULTS

Logistic regression revealed age and 2 tests of visual attention abilities (Useful Field of View [UFOV] Divided Attention and Neuropsychological Assessment Battery [NAB] Driving Scenes) best predicted at-risk drivers ( C statistic = 0.90); no cutoff score had both sensitivity and specificity >80%.

CONCLUSIONS

Future research on larger and more clinically representative neurological samples will improve understanding of the utility of the UFOV Divided Attention and NAB Driving Scenes in detecting at-risk older adult drivers in the clinic.

Neuropsychological Assessment of Driving Capacity

Clinicians are increasingly requested to make determinations regarding patients' driving capacity in the context of neurological injury/conditions and a growing cohort of older drivers. The capability to drive safely involves a number of cognitive, physical, and sensorimotor abilities that may be impacted by injury, illness, or substances that influence alertness. Neuropsychological measures are an important component of a multidisciplinary approach for evaluation of driving capacity. Clinicians should become familiar with measures that have the best predictive validity so they may incorporate a patient's neurocognitive strengths and weaknesses in decisions about driving ability.

Interrater Reliability of the Record of Driving Errors (RODE)

The Record of Driving Errors (RODE) is a novel standardized tool designed to quantitatively document the specific types of driving errors that occur during a standardized performance-based road test. The purpose of this study was to determine interrater reliability between two occupational therapy driver rehabilitation specialists who quantitatively scored specific driving errors using the RODE in a sample of older adults diagnosed with dementia (n=24). Intraclass correlation coefficients of major driving error and intervention categories indicated almost perfect agreement between raters. Using raters with adequate training and similar professional backgrounds, it is possible to have good interrater reliability using the RODE on a standardized road test.

Comparing caregiver and clinician predictions of fitness to drive in people with Alzheimer's disease

This observational study investigated family caregiver and clinician ratings of 75 drivers with Alzheimer's disease against scores on a standardized road test and a naturalistic driving evaluation. Clinician ratings by a physician specialized in dementia were significantly associated with road test error scores (r=.25, p=.03) but not naturalistic driving errors or global ratings of road test and naturalistic driving performance. Caregiver ratings were unrelated to either driving assessment, with two exceptions; adult child ratings of driving ability were correlated with road test error scores (r=.43, p=.02), and spousal ratings were inversely correlated with global ratings. Clinician ratings of driving competence were modestly correlated with road test performance, but caregiver ratings were more complex. Adult children may be more accurate reporters of driving ability than spouses, possibly because of less personal bias, but the reasons behind this discrepancy need further investigation.

An integrative review: understanding driving retirement decisions for individuals living with a dementia

AIM

To synthesise primary research exploring decision making practices used to determine the time to retire from driving for individuals living with a dementia.

BACKGROUND

Driving requires complex cognitive and physical skills potentially compromised due to the progressive nature of dementia. Whilst on-road assessments are considered reliable indicators of driving capacity by clinicians, drivers with dementia disagree.

DESIGN

Integrative literature review informed by Whittemore & Knafl (2005).

DATA SOURCES

Electronic database search of Medline, CINAHL, Web of Science, Google Scholar 1997-2012; and incremental hand search.

REVIEW METHODS

Primary studies published in peer reviewed journals were appraised against quality assessment criteria using CASP methodological assessment tools.

RESULTS

A total of 43 studies were retained for synthesis. Key findings were abstracted and a themes matrix was generated to identify patterns of meaning. Six themes emerged: (i) dementia may compromise the complex task of driving; (ii) defining onset and severity of dementia is problematic; (iii) symptom progression impacts on driving skills; (iv) assessment of fitness to drive remains subjective; (v) some drivers are reluctant to accept negative assessment outcomes; and (vi) the search for effective strategies to enhance acceptance of driver retirement continues.

CONCLUSION

This integrative literature review identified a large body of knowledge exploring the issues of driving cessation for drivers with dementia. However a challenge remains for practitioners, drivers and their family carers regarding how best to address this highly emotive issue. Findings could inform a structured approach to address this sensitive topic in a timely manner.

Test validity and performance validity: considerations in providing a framework for development of an ability-focused neuropsychological test battery

Literature on test validity and performance validity is reviewed to propose a framework for specification of an ability-focused battery (AFB). Factor analysis supports six domains of ability: first, verbal symbolic; secondly, visuoperceptual and visuospatial judgment and problem solving; thirdly, sensorimotor skills; fourthly, attention/working memory; fifthly, processing speed; finally, learning and memory (which can be divided into verbal and visual subdomains). The AFB should include at least three measures for each of the six domains, selected based on various criteria for validity including sensitivity to presence of disorder, sensitivity to severity of disorder, correlation with important activities of daily living, and containing embedded/derived measures of performance validity. Criterion groups should include moderate and severe traumatic brain injury, and Alzheimer's disease. Validation groups should also include patients with left and right hemisphere stroke, to determine measures sensitive to lateralized cognitive impairment and so that the moderating effects of auditory comprehension impairment and neglect can be analyzed on AFB measures.

Cognitive approaches to early Alzheimer's disease diagnosis

In this article, cognitive measures in the screening of individuals at risk for Alzheimer disease (AD) are reviewed. Use of cognitive tasks in identifying clinical cases of AD is considered, as well as methods for detecting those in the prodromal stages of the disease, including cognitive screening instruments. Traditional assessments, such as the mini-mental state examination, as well as contemporary computerized screening instruments, are examined. Areas of cognition for investigation in the detection of prodromal AD are recommended. The prospects for general cognitive screening are reviewed, and more engaging technologies to tests individuals at risk for developing AD are recommended.

The Judgment Test of the Neuropsychological Assessment Battery (NAB): psychometric considerations in an assisted-living sample

A total of 82 older adults recruited from assisted-living facilities completed the Judgment subtest of the Neuropsychological Assessment Battery. The internal consistency reliability of Judgment scores in this sample, as estimated by Cronbach's α, was .83. Significant and strong Judgment score correlations with measures of general cognitive functioning and instrumental activities of daily living provided evidence of construct validity. Furthermore, participants who exhibited the capacity to consent to the evaluation performed significantly better on the Judgment subtest than did participants who did not exhibit consent capacity. Finally, Judgment scores predicted a significant proportion of variance in both instrumental and basic activities of daily living over and above the variance accounted for by scores on measures of general cognitive functioning and executive functioning. This study presents promising preliminary evidence of the incremental validity of Judgment subtest scores for predicting both basic and instrumental activities of daily living in an assisted-living sample.

Zur deutschen Adaptation der Neuropsychological Assessment Battery (NAB)

Standardisierte Testverfahren bilden einen wichtigen Bestandteil neuropsychologischer Diagnostik. Im deutschsprachigen Raum besteht ein großer Bedarf für eine einheitlich normierte neuropsychologische Testbatterie. Die Neuropsychological Assessment Battery (NAB) ist ein in den USA entwickeltes Verfahren zur Beurteilung der neuropsychologischen Funktionen bei Erwachsenen (Alter 18 – 97 Jahre). Die NAB besteht aus zwei äquivalenten Parallelformen, die jeweils in sechs Module untergliedert sind: Screening, Aufmerksamkeit, Sprache, Gedächtnis, Wahrnehmung und Exekutive Funktionen. Das Verfahren ermöglicht eine umfangreiche, psychometrisch fundierte und ökologisch valide Diagnostik. Die NAB wird im Hinblick auf die Entstehungsgeschichte, psychometrische Güte und bisherige Rezeption präsentiert. Die Autorengruppe arbeitet zurzeit an der deutschen Adaptation und Normierung der NAB.

The influence of cognitive impairment with no dementia on driving restriction and cessation in older adults

Cognitively impaired older adults may be at increased risk of unsafe driving. Individuals with insight into their own impairments may minimize their risk by restricting or stopping driving. The purpose of this study was to examine the influence of cognitive impairment on driving status and driving habits and intentions. Participants were classified as cognitively impaired, no dementia single (CIND-single), CIND-multiple, or not cognitively impaired (NCI) and compared on their self-reported driving status, habits, and intentions to restrict or quit driving in the future. The groups differed significantly in driving status, but not in whether they restricted their driving or reduced their driving frequency. CIND-multiple group also had significantly higher intention to restrict/stop driving than the NCI group. Reasons for restricting and quitting driving were varied and many individuals reported multiple reasons, both external and internal, for their driving habits and intentions. Regardless of cognitive status, none of the current drivers were seriously thinking of restricting or quitting driving in the next 6 months. It will be important to determine, in future research, how driving practices change over time and what factors influence decisions to restrict or stop driving for people with cognitive impairment.

Road test and naturalistic driving performance in healthy and cognitively impaired older adults: does environment matter?

OBJECTIVES

To relate the standardized road test to video recordings of naturalistic driving in older adults with a range of cognitive impairment.

DESIGN

Cross-sectional observational study.

SETTING

Academic medical center memory disorders clinic.

PARTICIPANTS

One hundred three older drivers (44 healthy, 59 with cognitive impairment) who passed a road test.

MEASUREMENTS

Error rate and global ratings of safety (pass with and without recommendations, marginal with restrictions or training, or fail) made by a professional driving instructor.

RESULTS

There was fair agreement between global ratings on the road test and naturalistic driving. More errors were detected in the naturalistic environment, but this did not affect global ratings. Error scores between settings were significantly correlated, and the types of errors made were similar. History of crashes corrected for miles driven per week was related to road test error scores but not naturalistic driving error scores. Global cognition (Mini-Mental State Examination) was correlated with road test and naturalistic driving errors. In healthy older adults, younger age was correlated with fewer errors on the road test and more errors in naturalistic driving.

CONCLUSION

Road test performance is a reasonable proxy for estimating fitness to drive in older individuals' typical driving environments, but differences between performance assessed using these two methods remain poorly understood and deserve further study.

Predicting road test performance in adults with cognitive or visual impairment referred to a Veterans Affairs Medical Center driving clinic

OBJECTIVES

To develop a screening battery for office-based clinicians that would assist with the prediction of impaired driving performance and deciding who should proceed to road testing in a sample of adults with cognitive or visual deficits.

DESIGN

Prospective observational study.

SETTING

Driving evaluation clinic at a Veterans Affairs Medical Center (VAMC) in St. Louis, Missouri.

PARTICIPANTS

Seventy-seven individuals aged 23 to 91 with diagnoses of cognitive or visual impairment or both referred to an occupational therapy based driving clinic by VAMC providers because of concerns regarding driving safety.

MEASUREMENTS

Predictor variables included tests of visual and cognitive functioning and activities of daily living. The major outcome was pass or fail on a standardized performance-based on-road driving test.

RESULTS

Thirty percent of the referrals failed the road test. The best predictors of driving performance were the Trail-Making Test Part A and the Mazes Test from the Neuropsychological Assessment Battery.

CONCLUSION

Measures of visual search, psychomotor speed, and executive functioning accurately predicted road test performance in a significant number of participants. These brief tests may assist clinicians in deciding who should proceed with a road test in a driver rehabilitation clinic or perhaps to whom it should be recommended to cease driving.

Judgment in Mild Cognitive Impairment and Alzheimer's disease

Judgment is the capacity to make decisions after considering available information, contextual factors, possible solutions and probable outcomes. Our aim was to investigate previous research studies regarding assessment of judgment in older adults with different degrees of cognitive impairment. To this end, a search of Pubmed and Lilacs electronic databases for studies published from January 1990 until August 2011 in English, Spanish and Portuguese was carried out. The terms used were "judgment" combined with the terms "dementia" or "Mild Cognitive Impairment" (MCI) or "Alzheimer's disease" (AD). Some studies showed that MCI and AD patients had impaired judgment. There is a lack of specific methods to measure judgment capacity, and data on judgment abilities in older adults with MCI and dementia are scarce. No studies with specific measures of judgment capacity in other dementias were found.

Assessing executive function in relation to fitness to drive: a review of tools and their ability to predict safe driving

BACKGROUND/AIM

The assessment of executive functions is an integral component in determining fitness to drive. A structured review was conducted to identify assessment tools used to measure executive function in relation to driving and to describe these tools according to: (i) specific executive function components assessed; (ii) the tool's validity in predicting safe driving; and (iii) clinical utility.

METHODS

Sixty-nine articles were reviewed, identifying 53 executive function tools/assessments used in driving research. Each tool was critically appraised and the findings were compiled in a Driving Executive Function Tool Guide.

RESULTS

Among the 53 tools, there were 27 general assessments of cognition, 19 driving-specific and seven activities of daily living/instrumental activities of daily living assessments. No single tool measured all executive function components: working memory was the most common (n = 20/53). Several tools demonstrated strong predictive validity and clinical utility. For example, tools, such as the Trail Making Test and the Maze Task, have the shortest administration time (i.e. often less than 10 minutes) and the most easily accessible method of administration (i.e. pen and paper or verbal). Driving-specific tools range from short questionnaires, such as the 10-minute Manchester Driving Behaviour Questionnaire, to more complex tools requiring about 45 minutes to administer. CONCLUSIONS AND SIGNIFICANCE OF THE STUDY: The appropriateness of a tool depends on the individual being assessed and on practical constraints of the clinical context. The Driving Executive Function Tool Guide provides useful information that should facilitate decision-making and selection of appropriate executive function tools in relation to driving.

Performance-based everyday functioning after stroke: relationship with IADL questionnaire and neurocognitive performance

Neuropsychologists frequently are asked to comment on everyday functioning, but the research relies mostly on questionnaire-based assessment of daily functioning. While performance-based assessment of everyday functioning has many advantages over commonly used questionnaires, there are few empirically validated comprehensive performance-based measures. We present data here on a performance-based battery of daily living skills, the Functional Impact Assessment (FIA) in 47 unilateral stroke patients and 37 matched healthy controls. The FIA was validated by comparing it to performance on the self- and informant-report version of the Functional Activities Questionnaire (FAQ). We also examined the relationship between the FIA and cognitive functioning using the Neuropsychological Assessment Battery (NAB). The stroke group's performance on the FIA, FAQ (self and informant), and NAB (total and domain scores) was significantly (d's ≥ .80) lower than the control group. The NAB total score and all domain scores were highly correlated with the FIA in the stroke group (r's > .7), and only one NAB domain score (visuospatial) was a unique predictor. This may be due to the fact that most of the NAB domains have a statistical problem of multicollinearity, which may explain why only the spatial domain was a unique predictor. While the informant FAQ was significantly correlated with FIA total score (r = .48, p < .01), the NAB total score was a significantly better predictor (r = .83, p < .001) than the informant FAQ. NAB total scaled score of less than 86 predicted impairment on the FIA with 92% sensitivity and 84% specificity. Our findings argue that the FIA is sensitive to deficits associated with stroke and is highly associated with all neuropsychological domains (attention, executive functions, language and spatial skills, and memory).

Older drivers: On-road and off-road test results

Eighty-five volunteer drivers, 65-85 years old, without cognitive impairments impacting on their driving were examined, in order to investigate driving errors characteristic for older drivers. In addition, any relationships between cognitive off-road and on-road tests results, the latter being the gold standard, were identified. Performance measurements included Trail Making Test (TMT), Nordic Stroke Driver Screening Assessment (NorSDSA), Useful Field of View (UFOV), self-rating driving performance and the two on-road protocols P-Drive and ROA. Some of the older drivers displayed questionable driving behaviour. In total, 21% of the participants failed the on-road assessment. Some of the specific errors were more serious than others. The most common driving errors embraced speed; exceeding the speed limit or not controlling the speed. Correlations with the P-Drive protocol were established for NorSDSA total score (weak), UFOV subtest 2 (weak), and UFOV subtest 3 (moderate). Correlations with the ROA protocol were established for UFOV subtest 2 (weak) and UFOV subtest 3 (weak). P-Drive and self ratings correlated weakly, whereas no correlation between self ratings and the ROA protocol was found. The results suggest that specific problems or errors seen in an older person's driving can actually be "normal driving behaviours".

Neuropsychological assessment of fitness to drive following acquired cognitive impairment

PRIMARY OBJECTIVE

The study evaluated a neuropsychological assessment battery used to assess fitness to drive in cognitively impaired individuals and hypothesized that the battery would be associated with on-road outcome measures. A secondary aim was to explore the relationships between individual neuropsychological tests and driving performance.

RESEARCH DESIGN

The study used a cross-sectional design in which a sample of individuals with various types of cognitive impairment completed the test battery and an on-road driving test.

METHODS AND PROCEDURES

Performance on the test battery was compared to on-road driving performance in 104 individuals with acquired cognitive impairment.

MAIN OUTCOMES AND RESULTS

The battery had 73% sensitivity and 76% specificity in terms of agreement with the 'pass/fail' classification of the on-road driving test. Scores on the battery accounted for 18% of the variance in the total number of corrective interventions performed by a driving instructor during the on-road test. Most tests correlated significantly with driving test outcomes. While one test, the Rey Complex Figure Test, emerged as an independent predictor of driving performance in multiple regression analyses, the variance explained by this single test was small.

CONCLUSIONS

The results provide support for the use of a battery approach to assess fitness to drive.

Utility of the Neuropsychological Assessment Battery in detecting cognitive impairment after unilateral stroke

This study evaluated the clinical utility of the Neuropsychological Assessment Battery (NAB) in a stroke sample by examining the NAB's ability to differentiate a chronic stroke group with radiologically confirmed unilateral damage (n = 42) and a demographically matched healthy control (HC) group (n = 36). The stroke group performed more poorly than the control group across NAB Total score and all five Domain scores. Receiver operator curves (ROC) were derived and area under the curve (AUC) showed moderate diagnostic effectiveness (AUC .70 to .90) for NAB Total score, all five Domain scores, a motor composite, and a Global Deficit Score (GDS) that has been shown to closely approximate clinical ratings of neuropsychological impairment. The NAB Total, GDS, and motor composite had comparable clinical utility, whereas the Attention and Executive domain scores demonstrated better classification utility compared with the Memory domain. Because 90.5% of our stroke sample had middle cerebral artery territory strokes, the comparison of motor and cognitive classification utility may be biased. However, follow-up analyses showed that the NAB accounted for additional variance even when motor composite was included in the model. Sensitivity, specificity, and odds ratios at various clinical cutoffs are provided. These results suggest that the NAB is a useful clinical tool for detection of cognitive deficits in individuals with chronic unilateral stroke, although lenient clinical cutoffs appear warranted to maximize sensitivity.

The older adult driver with cognitive impairment: "It's a very frustrating life"

Although automobiles remain the transportation of choice for many older adults, late-life cognitive impairment and dementia often impair the ability to drive safely. However, there is no commonly used method of assessing dementia severity in relation to driving, no consensus on the assessment of older drivers with cognitive impairment, and no gold standard for determining driving fitness. Yet clinicians are called on by patients, their families, other health professionals, and often their state's Department of Motor Vehicles to assess their patients' fitness to drive and to make recommendations about driving privileges. This article describes the challenges of driving with cognitive impairment for both the patient and caregiver, summarizes the literature on dementia and driving, discusses evidence-based assessment of fitness to drive, and addresses important ethical and legal issues. It also describes the role of physician assessment, referral for neuropsychological testing, screening for functional ability, tools to assess dementia severity, driving evaluation clinics, and Department of Motor Vehicles referrals that may assist with evaluation. Lastly, it discusses mobility counseling (eg, exploration of transportation alternatives), because health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance patients' social connectedness and quality of life while meeting their psychological and medical needs and maintaining personal and public safety.

Test Acceptability and Confidence Levels in Older Adults Referred for Fitness-to-Drive Evaluations

In this study, we examined confidence and face validity or client acceptability of tests used in a Veterans Affairs Medical Center driving clinic. The clinic used evidence-based off-road tests and adopted the Washington University Road Test (WURT) as a performance-based on-road examination. Forty-three clients consented to participate in the study; most were male with an average age of 78.2 years (standard deviation = 12.6). In general, a trend existed toward higher client acceptability of tests adopted from the Neuropsychological Assessment Battery (Stern & White, 2003) and the WURT than of other off-road measures. Confidence decreased after administration of the psychometric test battery, yet it increased after the on-road evaluations despite a 47% failure rate in the sample. Additional study is needed on test acceptability because it may have the potential to increase understanding, compliance, or both with driving recommendations. Additional research is also needed to examine client confidence levels and their potential impact on performance during the driving evaluation process.

How does dementia affect driving in older patients?

Driving is a complex activity that always becomes impaired at some point in older adults with degenerative dementia. Over time, disruption of the visual processing circuits of the brain that link the occipital and prefrontal regions, particularly in the right hemisphere, leads to increasing degrees of driving impairment that ultimately preclude safe driving. Neuropsychological tests of visuospatial ability, executive function and attention that tap into the integrity of these brain regions provide the clinician with important information regarding the need for a formal determination of driving competence. Enhancement of cognitive function in these domains through anti-dementia therapy and exercise may partially mitigate risk; however, all drivers with dementia must ultimately retire from driving when dementia becomes moderately severe, and often in earlier stages of the illness. Future efforts to improve screening tests for hazardous driving and to develop interventions to help prolong the time that drivers with mild dementia can continue to drive safely are needed for our increasingly aged and mobile population.

Anxiety of Alzheimer's disease patients before and after a standardized on-road driving test

BACKGROUND

A large number of licensed elderly drivers are demented or are likely to become demented. On-road driving tests, a method often used to assess driver competency, are likely anxiety-provoking for elderly individuals. This article examines the relationship between anxiety and driving performance in a mildly demented and elderly control (EC) sample.

METHODS

Anxiety ratings of fear and tension, as assessed by visual analog scales, of 84 patients clinically diagnosed with mild Alzheimer's disease (AD) (68 safe/marginal and 16 unsafe drivers) were compared with those of 44 age- and education-equated safe/marginal EC participants, both before and after a standardized on-road driving test.

RESULTS

Analyses revealed significant positive correlations between AD patients' pre-road test and post-road test tension and post-road test fear ratings and total road test score. Subsequent analyses of variance showed no significant pre-road test differences in fear ratings between the three groups but significantly higher levels of tension among the unsafe AD participants. After adjusting for baseline group differences, unsafe AD drivers experienced stable or higher anxiety levels after road test, whereas both the EC and safe/marginal AD drivers endorsed a significant reduction in anxiety.

DISCUSSION

Unlike their safe EC and safe AD driver counterparts, unsafe AD patients reported continued elevated levels of fear and tension after the road test. Given these findings, we suggest that the most appropriate time for driving instructors to counsel patients regarding their driving skills might be directly after the road test.

Ecological validity of the neuropsychological assessment battery screening module in post-acute brain injury rehabilitation

PRIMARY OBJECTIVE

To assess the ecological validity of the Screening Module of the Neuropsychological Assessment Battery (NAB-SM) using the Functional Independence Measure (FIM).

METHOD

Seventy individuals with moderate-to-severe traumatic brain injury at a residential post-acute rehabilitation facility were administered the FIM instrument and the NAB-SM upon admission. Hierarchical regression analysis was used to examine the relationship between the variables from these two assessment measures.

RESULTS

Hierarchical models revealed that (1) the NAB-SM Total score was significantly associated with the FIM instrument Total score as well as the Motor and Cognition sub-scale scores, above and beyond the contribution of demographic variables, (2) the NAB-SM Language, Memory and Spatial domain scores were significantly associated with of the FIM instrument Cognition sub-scale score and (3) the NAB-SM Spatial domain score was significantly associated with of the FIM instrument Total and Motor sub-scale scores.

CONCLUSIONS

The current findings support previous research and provide strong evidence for the ecological validity of the NAB-SM with regard to functional abilities as assessed by the FIM instrument.

A longitudinal study of drivers with Alzheimer disease

OBJECTIVE

The goal of this study was to define the natural progression of driving impairment in persons who initially have very mild to mild dementia.

METHODS

We studied 128 older drivers, including 84 with early Alzheimer disease (AD) and 44 age-matched control subjects without cognitive impairment. Subjects underwent repeated assessments of their cognitive, neurologic, visual, and physical function over 3 years. Self-reports of driving accidents and traffic violations were supplemented by reports from family informants and state records. Within 2 weeks of the office evaluation, subjects were examined by a professional driving instructor on a standardized road test.

RESULTS

At baseline, subjects with AD had experienced more accidents and performed more poorly on the road test, compared to controls. Over time, both groups declined in driving performance on the road test, with subjects with AD declining more than controls. Survival analysis indicated that while the majority of subjects with AD passed the examination at baseline, greater severity of dementia, increased age, and lower education were associated with higher rates of failure and marginal performance.

CONCLUSIONS

This study confirms previous reports of potentially hazardous driving in persons with early Alzheimer disease, but also indicates that some individuals with very mild dementia can continue to drive safely for extended periods of time. Regular follow-up assessments, however, are warranted in those individuals.

Frequency of abnormal scores on the Neuropsychological Assessment Battery Screening Module (S-NAB) in a mixed neurological sample

The Neuropsychological Assessment Battery (NAB; Stern & White, 2003; White & Stern, 2003) is a comprehensive, modular battery of tests comprised of the following six modules: (a) Screening, (b) Attention, (c) Language, (d) Memory, (e) Spatial, and (f) Executive Functions. The Screening Module is an abbreviated version of the full NAB. The purpose of this descriptive study was to present index and primary test score information for the Screening Module in a mixed sample of patients with known neurological conditions. Participants were 37 outpatients with clear evidence of neurological damage or disease. Performance decrements were found on the Attention Index, most notably on the Numbers and Letters tests. Decrements were also found on the Executive Functions Index, most notably on the Word Generation test. Somewhat surprisingly, patients performed well across most of the individual test scores. This mixed clinical sample showed less neuropsychological compromise than the clinical samples presented in the NAB manual.