Optimizing Clock Drawing Scoring Criteria: Development of the West Haven-Yale Clock Drawing Test.

BACKGROUND/OBJECTIVES: The Clock Drawing Test (CDT) is a widely used measure, which has been included as a recommended cognitive screen for driving evaluations. This study aimed to develop an optimized scoring method-the West Haven-Yale CDT (WHY-CDT)-based on the scoring methods of Freund and Royall's CLOX, the latter of which is significantly associated with executive control functions. DESIGN: Retrospective cohort study. SETTING: Greater New Haven, Connecticut, area. PARTICIPANTS: A total of 237 adults, aged 70 years and older, who had a current driver's license and drove at least once a month. MEASUREMENTS: Clock drawings were independently scored using both scoring systems, as well as a qualitative-based 5-point gestalt score. Interrater reliability was calculated using Light's κ for dichotomous variables and intraclass correlations for continuous variables. A categorical principal component analysis was conducted to determine which items from the Freund and Royall scoring systems should be retained in the modified system, with the Kuder-Richardson test used to assess internal consistency (reliability). RESULTS: The majority of the quantitative scoring items had moderate to almost perfect interrater reliability, with excellent interrater reliability for the qualitative gestalt score. The final scoring method retained seven items from the Freund and Royall versions, of which over 85% were from the latter. Internal consistency was fair to acceptable for the WHY-CDT's two dichotomously scored subscales, but poor for both the Freund and Royall scoring methods. CONCLUSIONS: The WHY-CDT is a simple scoring method that combines elements of the Freund and Royall methods, as well as an overall gestalt score, and has strong interrater reliability. Future directions for use of this modified system are discussed. J Am Geriatr Soc 67:2129-2133, 2019.

A randomized trial of a physical conditioning program to enhance the driving performance of older persons.

BACKGROUND: As the number of older drivers increases, concern has been raised about the potential safety implications. Flexibility, coordination, and speed of movement have been associated with older drivers' on road performance. OBJECTIVE: To determine whether a multicomponent physical conditioning program targeted to axial and extremity flexibility, coordination, and speed of movement could improve driving performance among older drivers. DESIGN: Randomized controlled trial with blinded assignment and end point assessment. Participants randomized to intervention underwent graduated exercises; controls received home, environment safety modules. PARTICIPANTS: Drivers, 178, age > or = 70 years with physical, but without substantial visual (acuity 20/40 or better) or cognitive (Mini Mental State Examination score > or =24) impairments were recruited from clinics and community sources. MEASUREMENTS: On-road driving performance assessed by experienced evaluators in dual-brake equipped vehicle in urban, residential, and highway traffic. Performance rated three ways: (1) 36-item scale evaluating driving maneuvers and traffic situations; (2) evaluator's overall rating; and (3) critical errors committed. Driving performance reassessed at 3 months by evaluator blinded to treatment group. RESULTS: Least squares mean change in road test scores at 3 months compared to baseline was 2.43 points higher in intervention than control participants (P = .03). Intervention drivers committed 37% fewer critical errors (P = .08); there were no significant differences in evaluator's overall ratings (P = .29). No injuries were reported, and complaints of pain were rare. CONCLUSIONS: This safe, well-tolerated intervention maintained driving performance, while controls declined during the study period. Having interventions that can maintain or enhance driving performance may allow clinician-patient discussions about driving to adopt a more positive tone, rather than focusing on driving limitation or cessation.

A randomized trial of an education program to enhance older driver performance.

BACKGROUND: This study was designed to determine whether an education program consisting of classroom and on-road training could enhance driving performance. METHODS: This randomized controlled trial with blinded endpoint assessment enrolled 126 community-living drivers 70 years old or older who were recruited from clinic and community sources. Treatment assignment was concealed until eligibility was established. Participants randomized to intervention underwent two 4-hour classroom and two 1-hour on-road sessions focused on common problem areas of older drivers. Controls received modules directed at vehicle, home, and environmental safety. A knowledge test and driving performance were assessed at baseline and 8 weeks. On-road driving performance was assessed by an experienced evaluator in a dual-brake-equipped vehicle in urban, residential, and highway traffic. Driving performance was rated on a 36-item scale with potential scores from 0 to 72 (higher score better). The knowledge test included 20 road knowledge and eight road sign questions, scored from 0 to 28 correct. RESULTS: The least squares mean change in road test score relative to baseline was 2.87 points higher in the intervention than in the control group (p =.001). The least squares mean change in knowledge test scores relative to baseline was 3.45 points higher in the intervention than in the control group (p <.001). CONCLUSIONS: An education program consisting of classroom and on-road training targeted to common errors of older drivers enhanced performance on knowledge and on-road tests. Such interventions offer older drivers the potential to continue driving safely longer and to maintain their out-of-home mobility.

Age-Related Differences in Sleep-Wake Symptoms of Adults Undergoing Polysomnography.

OBJECTIVES: To evaluate age-related differences in sleep-wake symptoms. DESIGN: Cross-sectional. SETTING: Technologist-attended, laboratory-based polysomnography (PSG). PARTICIPANTS: Community-dwelling adults aged 20 to 89 (N = 201): 52 aged 18 to 39, 72 aged 40 to 59, and 77 aged 60 and older. MEASUREMENTS: Medical burden (Charlson Comorbidity Index, medications, health status), PSG-defined sleep disorders (sleep-disordered breathing (SDB), sleep-associated hypoxemia, periodic limb movements in sleep (PLMS)), sleep-wake symptoms (Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), fatigue (Facit-F Scale)). RESULTS: Medical burden increased significantly with age (Charlson Comorbidity Index and number of medications, P < .001; health status, P = .005). Severity of sleep disorders also increased significantly with age (SDB and hypoxemia, P < .001; PLMS, P = .008). Conversely, sleep-wake symptoms decreased with age (daytime drowsiness (ESS ≥ 10), P = .02; insomnia (ISI ≥ 8), P = .04; fatigue, P < .001). In adjusted models, a 1-year increase in age was significantly associated with a 4% decrease in the odds of having daytime drowsiness (odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.93-0.98). Similarly, but only in those with mild SDB, a 1-year increase in age was significantly associated with a 5% decrease in the odds of having insomnia (OR = 0.95, 95% CI = 0.92-0.99). CONCLUSION: Older age was characterized by less-severe sleep-wake symptoms (daytime drowsiness, insomnia, fatigue), despite an age-related increase in disease severity (medical burden, sleep disorders). Because the increase in disease severity included well-established risk factors for having sleep-wake symptoms, the age-related decrease in sleep-wake symptoms may reflect a decrease in symptom awareness.

Identification of strategies used to cope with chronic pain in older persons receiving primary care from a Veterans Affairs Medical Center.

OBJECTIVES: To identify the strategies used by older persons to cope with chronic noncancer pain, determine the perceived effectiveness of the strategies, and ascertain factors associated with their use. DESIGN: Cross-sectional telephone survey. SETTING: Primary care practice located at a Veterans Affairs Medical Center in New England. PARTICIPANTS: Two hundred forty-five patients (aged 65-90) with chronic pain. MEASUREMENTS: Qualitative methods were used to ascertain participants' coping strategies, and their effectiveness was determined using a five-category response scale (1=not at all effective to 5=extremely effective). In multivariate analyses, associations between participants' demographic, medical, psychosocial, and pain characteristics and prevalent coping strategies were assessed. RESULTS: Participants had a mean age+/-standard deviation of 75+/-5.1; 84% were male. Overall, 240 (98%) participants had employed at least one coping strategy in the previous month; the mean number used per participant was 2.8+/-1.4. Prevalent coping strategies included analgesic medications (used by 187/240=78% participants), exercise (35%), cognitive methods (37%), religious activities (21%), and activity restriction (20%). The proportion of participants who used a given strategy and rated it quite a bit or extremely effective exceeded 50% for only five of the 15 identified strategies. Women were more likely than men to use cognitive coping methods (odds ratio (OR)=3.2, 95% confidence interval (CI)=1.5-6.8) and religious activities (OR=2.6, 95% CI=1.2-5.7). Participants with chronic pain due to a musculoskeletal cause were more likely to use analgesic medications than those with pain due to all other causes (OR=3.2, 95% CI=1.6-6.4), whereas those with trauma-related pain were less likely to use exercise than those with pain due to all other causes (OR=0.2, 95% CI=0.1-0.7). CONCLUSION: Older primary care patients use a broad variety of coping strategies to cope with chronic pain. Studies are needed to confirm these findings in other older populations and to characterize the longitudinal effects of the coping strategies. Given the finding that the perceived effectiveness of most coping strategies was modest, efforts to increase their effectiveness in older persons are indicated.

Sleep disturbances and driving practices of older drivers.

OBJECTIVES: To evaluate the associations between sleep disturbances and driving practices, including driving cessation and trajectories of daily driving mileage (change over time), in older drivers. DESIGN: Longitudinal. SETTING: New Haven, Connecticut. PARTICIPANTS: Four hundred thirty older drivers, mean age 78.5, recruited from clinic and community sites. MEASUREMENTS: Baseline measures included medical history, daily driving mileage, Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Sleep Apnea Clinical Score (SACS). Longitudinal outcomes included at least one episode of driving cessation and trajectories of miles driven per day, as recorded every 6 months over 2 years. RESULTS: At baseline, participants drove an average of 22.2 miles per day; 26.0% (112/430) had insomnia (ISI ≥ 8), 19.3% (83/430) had daytime drowsiness (ESS ≥ 10), and 19.9% (84/422) had high sleep apnea risk (SACS > 15). The sleep-based predictors of insomnia (risk ratio (RR) = 1.20, 95% confidence interval (CI) = 0.65-2.20), daytime drowsiness (RR = 0.94, 95% CI = 0.46-1.95), and high sleep apnea risk (RR = 0.62, 95% CI = 0.27-1.42) did not confer a significantly greater risk of driving cessation. Insomnia was the only sleep-based predictor that conferred a significant change in driving mileage, yielding an average decrease of 4.5 miles per day over 2 years (P = .01). In the insomnia model, covariates that were associated with less driving mileage were polypharmacy (≥ 4 medications) and each year of additional age, yielding an average decrease of 8.3 (P = .01) and 0.4 miles per day (P = .02), respectively, over 2 years. CONCLUSION: In a cohort of older drivers, insomnia and the covariates of polypharmacy and advancing age were longitudinally associated with less daily driving mileage. Because reductions in driving mileage in older persons often occur in response to reductions in driving capacity, these results support a clinical approach that considers insomnia-based cognitive-behavioral therapy and reduced polypharmacy as strategies for improving driving capacity in older persons.