Intervention Development for Tailored Education for Aging and Cognitive Health (TEACH) for Dementia Prevention in Midlife Adults: Protocol for a Randomized Controlled Trial.

BACKGROUND: A total of 12 modifiable risk factors account for 40% of dementia cases globally, yet population adherence to health behaviors associated with these factors is low. Midlife is a critical window for dementia prevention, as brain pathology often begins to accumulate years or decades before the onset of symptoms. Although multidomain behavioral interventions have been efficacious in reducing the risk of cognitive decline, adherence is low. Intrapersonal factors, such as health beliefs, are known mediators of the relationship between knowledge and health behavior. OBJECTIVE: In keeping with stage I of the National Institutes of Health (NIH) Stage Model for Behavioral Intervention Development, this study will use mixed methods to (1) develop an enhanced health education intervention, including an explanatory method for communicating information about dementia risk and personal health beliefs, and (2) conduct a pilot randomized controlled trial (n=20 per intervention arm) over 8 weeks to assess the feasibility of delivering the enhanced intervention versus basic health education alone. METHODS: Phase 1 will involve focus groups and individual qualitative interviews. Focus groups will be analyzed using (1) a descriptive framework matrix analysis and (2) interpretive data review by the research team. Individual qualitative interviews will be coded using applied thematic analysis using a phenomenographic approach. Phase 2 will involve a pilot randomized controlled trial. Proximal outcomes (measured at baseline, 4 weeks, and 8 weeks) include the perceived threat of Alzheimer disease, dementia awareness, and self-efficacy. RESULTS: This project was funded in August 2022. Data collection began in 2023 and is projected to be completed in 2025. CONCLUSIONS: Study findings will reveal the feasibility of delivering an 8-week multidomain health education intervention for primary prevention of dementia in midlife and will provide preliminary evidence of mechanisms of change. TRIAL REGISTRATION: ClinicalTrials.gov NCT05599425; https://clinicaltrials.gov/study/NCT05599425. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/60395.

Experience from a Fast-Track Multidisciplinary Clinic Integrating Movement Disorders Neurologists in Normal Pressure Hydrocephalus Evaluation.

In this prospective observational cohort study, we provide preliminary findings from a same-day multidisciplinary fast-tracked normal pressure hydrocephalus (NPH) clinic; incorporating the expertise of movement disorders neurologists, emphasizing the clinical characteristics, consensus classification, and management of patients referred for suspected NPH. We evaluated 111 patients (male/female: 67/44) from April 2022 to May 2023. Based on the multidisciplinary team consensus, 52 (46.8%) were classified as "probable" idiopathic NPH (iNPH), 14 (12.6%) as "possible" NPH, 42 (37.8%) as "unlikely" NPH, and three (2.7%) as secondary NPH. While parkinsonian syndromes were recognized in 19.2% of "probable" iNPH patients (vs. 7.1% in "possible" and 26.2% in "unlikely" NPH), no significant group differences were noted in the scores of the UPDRS-III scale. Degenerative spine pathologies were prevalent across all NPH categories, affecting at least 50% of patients. In the "probable" iNPH group, 78.8% received programmable ventriculoperitoneal shunts, with clinical improvement identified in 87.8% at 12-month follow-up. Our findings underscore the high prevalence of overlapping and competing movement and spinal disorders in patients with suspected NPH. Further, our novel approach, incorporating movement disorder neurologists in NPH multidisciplinary evaluation, improved diagnostic precision and streamlined personalized plans, including further neurological workups, necessary spinal interventions, and medical management or rehabilitation.

Understanding Health Beliefs and Health Behaviors in Older Adults at Risk for Alzheimer's Disease.

Background: There are significant public health benefits to delaying the onset of Alzheimer's disease (AD) in individuals at risk. However, adherence to brain healthy behaviors is low. The Health Belief Model proposes that specific beliefs are mediators of behavior change. Objective: To characterize health belief measures from the Science of Behavior Change Research Network (SBCRN) in an older adult population and associations between health beliefs, AD risk, and current health behaviors. Methods: A total of 172 individuals from the Rhode Island AD Prevention Registry participated. SBCRN health belief measures included assessments of future time perspective, self-efficacy, deferment of gratification, and consideration of future consequences. Outcome measures included individual AD risk index score, dementia risk awareness, and lifestyle behaviors including physical, cognitive, and social activity. Results: Participants who were older had higher scores for AD risk, lower future time perspective, and lower generalized self-efficacy (all at p < 0.001). Higher generalized self-efficacy was related to increased physical activity (p < 0.010). Higher future time perspective (p < 0.001) and generalized self-efficacy (p = 0.48) were associated with lower AD risk score. Subjective cognitive decline (SCD) was associated with lower self-efficacy, ability to delay gratification, and a less expansive future time perspective. Conclusions: Greater self-efficacy and perceived future time remaining were associated with lower AD risk and greater engagement in physical activity. SCD was associated with health beliefs that may negatively affect engagement in positive brain health behaviors. Assessment of and psychoeducation about these intrapersonal health belief constructs may be important targets for behavioral interventions to reduce AD risk.

Anticholinergic and sedative medication use in older patients with cognitive concerns.

BACKGROUND: Anticholinergic (AC) and sedative medications are a risk factor for cognitive impairment. This study sought to characterize AC and sedative use in older patients seen for outpatient neuropsychological evaluation and evaluate their associations with different cognitive domains. We hypothesized that AC and sedative use would be associated with worse attention/processing speed (AP), executive functioning (EF), and memory. METHODS: We conducted a cross-sectional chart review of 392 patients (mean [M] age = 72 ± 7.7 years, range = 54-91). Medications were characterized by number of AC medications (≥1 on the Anticholinergic Cognitive Burden Scale [ACB]), number of sedative medications, and polypharmacy (≥5 daily medications). Demographically adjusted composites were calculated for AP, EF, and memory. Bivariate Pearson correlations assessed relationships between medication use and cognition. Multivariate linear regressions evaluated significant medication-cognition associations, controlling for total medications, medical comorbidities, and estimated premorbid cognitive functioning. RESULTS: Polypharmacy was common (80%; n = 314). Most patients (70%; n = 275) used ≥1 sedative medications (range = 0-9). Over half (63%; n = 248) used ≥1 AC drugs (range = 0-7), yet ACB scores were ≤2 in 74% of patients. Sedative use was negatively correlated with AP (r = -0.134, p = 0.008) and EF (r = -0.105, p = 0.04). ACB scores were negatively correlated with AP (r = -0.106, p = 0.037). Sedatives and a priori covariates significantly predicted AP performance (R2 = 0.127, p < 0.001); using more sedative medications was uniquely associated with worse AP (ß = -0.426, p = 0.049). No significant associations were found with memory. CONCLUSION: AC and sedative medications and polypharmacy were prevalent in this sample of older patients. Though both drug classes had negative relationships with AP and EF, sedatives had a particularly negative association with AP. Contrary to our hypotheses, memory was not associated with medication use; however, anticholinergic burden was low within the sample, and AP and EF deficits may masquerade as memory problems.

Medication management error types: Associations with mild cognitive impairment subtype.

Objective: Medication management errors are suspected to be prevalent among older adults with mild cognitive impairment (MCI). This study examined types of simulated medication-taking errors in cognitively normal older adults (CN; n = 131), single domain amnestic MCI (sdMCI, n = 91), and multi-domain MCI (mdMCI, n = 44). Errors were measured using the medication management ability assessment (MMAA). Methods: 266 participants seen for neuropsychological evaluation (94.4% White, 57.9% female, average age = 72, average education = 14 years) completed the MMAA (version 4.1), a performance-based task of medication management. Group differences in MMAA total scores, accuracy, and error types were evaluated using Kruskall-Wallis H tests. This study was the first to explore a newly operationalized error, perseverations, caused by taking a specific dose ≥2 times during the simulation. Results: CN and sdMCI groups had higher MMAA total scores than individuals with mdMCI, indicating better overall performance. The mdMCI group made a higher number of omission errors (missed pills) than other groups, but no differences were found for commission errors (extra pills). The sdMCI group made more perseverative errors compared to the CN group. Conclusions: Individuals with mdMCI made more simulated medication management errors than CN and sdMCI groups, indicating that they may be most vulnerable to difficulties in medication management. In contrast, sdMCI individuals were more likely to make perseverative errors, which may reflect a tendency towards overcompensation of memory loss. Future studies should assess whether MMAA performance is associated with patterns of real-world medication-taking in more diverse samples of older adults.

Compensatory Strategy Intervention: What Older Patients Want and Why.

OBJECTIVE: Compensatory strategies can improve performance of instrumental activities of daily living in people with cognitive impairment. This study investigated patient interest in compensatory strategy interventions and preference for various intervention formats. METHODS: Semi-structured qualitative interviews with 38 older adults with cognitive impairment queried motivation to improve strategy use and interest in intervention formats/delivery methods. Two coders used thematic analysis to determine rates of interest in each intervention type and explore patient-reported barriers and facilitators to motivation and intervention models. RESULTS: Most of the samples reported motivation to enhance compensatory strategy use. Degree of motivation was driven by current experiences with strategy use, perceived benefit of potential changes, intrinsic desire to improve life and self, and current perceived need. The vast majority were interested in hour-long, multi-session, instructor-led interventions. Just over half of the sample was interested in a self-directed virtual program, and just under half was interested in involving family/friends. Facilitators and barriers to interest in intervention formats and delivery methods varied based on participants' previous experiences, preferred learning style, content, and time commitment of the intervention, and perceived current need for intervention. One-fifth of the sample expressed no interest in any intervention type, though they expressed openness to assistance in the future as needed. CONCLUSIONS: Older adults with cognitive impairment are generally motivated to enhance their compensatory strategy use. Clinicians/researchers designing compensatory strategy interventions should consider instructor-led formats, present individualized benefits of interventions, and demonstrate the benefits of both preventative and remedial intervention to optimize patient engagement.

Association between neuropsychological assessment and amyloid status in a clinical setting.

OBJECTIVE: Large research cohorts show robust associations between neuropsychological tests and Alzheimer's disease (AD) biomarkers, but studies in clinical settings are limited. The increasing availability of AD biomarkers to the practicing clinician makes it important to understand the relationship between comprehensive clinical neuropsychological assessment and biomarker status. This study examined concordance between practicing clinical neuropsychologists' diagnostic impressions and AD biomarker status in patients seen at an outpatient medical center, with a secondary aim of defining the characteristics of discordant cases. METHOD: Participants (N = 79) seen for clinical neuropsychological assessment who subsequently underwent lumbar puncture or amyloid positron emission tomography imaging were identified via retrospective chart review. Concordance between clinical neuropsychological diagnosis (non-AD, indeterminate, possible/probable AD) and AD biomarker status (negative, indeterminate, positive) was determined. Individual test score data were used to examine between-group differences based on amyloid status. RESULTS: AD biomarker positive and negative patients did not differ on individual neuropsychological tests after correcting for multiple comparisons, though the small number of AD biomarker indeterminate individuals performed better than biomarker positive patients. However, there was 76.7% concordance between neuropsychologists' diagnostic impressions and AD biomarker status (88% sensitivity and 55% specificity of neuropsychological assessment in detecting AD biomarker status). AD biomarker negative patients diagnosed as possible/probable AD (discordant) versus non-AD (concordant) had significantly lower Neuropsychological Assessment Battery Story Delayed Recall, higher Wechsler Adult Intelligence Scale-Fourth Edition Coding, and higher Trail-Making A (i.e., an amnestic memory profile). CONCLUSIONS: Comprehensive neuropsychological assessment showed modest concordance with AD biomarker status in patients seen in an outpatient medical center for routine clinical care. Low specificity for the clinical diagnosis of AD could be explained by the multiplicity of etiologies that cause memory impairment (i.e., TAR DNA-binding protein 43, suspected non-AD pathology). (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Medication self-management in predominantly African American and Caribbean American people with epilepsy: The role of medication beliefs and epilepsy knowledge.

INTRODUCTION: Suboptimal medication adherence is common in people with epilepsy (PWE) and disproportionally prevalent among racially/ethnically diverse patients. Understanding reasons and risks of suboptimal adherence is critical to developing interventions that reduce negative health outcomes. This cross-sectional study characterized common barriers to medication self-management, prevalence of negative medication beliefs, and gaps in epilepsy knowledge among predominantly African American and Caribbean American PWE and examined their interrelationships. MATERIALS AND METHODS: Sixty-three PWE (Age = 42.1 ± 13.2; 60% female; 79% Black; 19% Hispanic/Latino) completed validated self-report questionnaires about medication self-management, medication beliefs, and epilepsy knowledge. Correlations and t-tests examined interrelationships. RESULTS: Four barriers to medication self-management were common, including not taking antiseizure medications at the same time every day, forgetting doses, not planning refills before running out, and spreading out doses when running low. More than half the sample believed medications were overused by prescribers. Nearly one-third believed medications were harmful, and nearly a quarter believed their antiseizure medications were minimally necessary with almost half reporting elevated concerns about negative consequences of antiseizure medications. Poorer medication self-management was associated with stronger beliefs that medications in general are harmful/overused by prescribers. Individuals who were "accepting" of their antiseizure medications (i.e., high perceived necessity, low concerns) were less likely to spread out time between doses when running low compared to non-accepting counterparts. Knowledge gaps related to the cause of seizures/epilepsy, chronicity of epilepsy treatment, and seizure semiology/diagnosis were common. Nevertheless, epilepsy knowledge was unrelated to medication self-management and medication beliefs. CONCLUSIONS: In these PWE, the most prevalent reasons for suboptimal medication self-management were behaviorally mediated and potentially modifiable. Negative medication beliefs and misconceptions about epilepsy and its treatment were common. Results further suggest that interventions addressing negative medication beliefs will be more effective than knowledge-based psychoeducation alone to improve medication self-management in this patient population.

A comparison of cognitive performances based on differing rates of DNA methylation GrimAge acceleration among older men and women.

Cognitive heterogeneity increases with age rendering sex differences difficult to identify. Given established sex differences in biological aging, we examined whether comparisons of men and women on neuropsychological test performances differed as a function of age rate. Data were obtained from 1921 adults enrolled in the 2016 wave of the Health and Retirement Study. The residual from regressing the DNA methylation GrimAge clock on chronological age was used as the measure of aging rate. Slow and fast age rates were predefined as 1 standard deviation below or above the sex-specific mean rates, respectively. ANCOVAs were used to test group differences in test performances. Pairwise comparisons revealed that slow aging men outperformed fast aging women (and vice versa) on measures of executive function/speed, visual memory and semantic fluency; however, when groups were matched by aging rates, no significant differences remained. In contrast, women, regardless of their aging rates, education or depressive symptoms maintained their advantage on verbal learning and memory. Implications for research on sex differences in cognitive aging are discussed.

The complementary utility of cognitive testing and the medication management ability assessment in older adults.

OBJECTIVE: Older adults are susceptible to cognitive declines that may limit independence. Though neuropsychologists opine about risk of functional decline, the degree to which cognitive testing and in-office simulations approximate everyday behavior is unclear. We assessed the complementary utility of cognitive testing and the face-valid Medication Management Ability Assessment (MMAA) to predict medication management among older adults. METHOD: This was a retrospective study of 234 older adults (age = 72 ± 7.7 years; 59% women) who completed the MMAA during outpatient neuropsychological evaluations. Based on comprehensive clinical assessment, most participants (n = 186) were independent in medication management, while 48 received assistance. Demographically adjusted composite scores were derived for attention/processing speed (A/PS), executive functioning (EF), visuospatial/constructional ability (VC), language, and memory domains. Univariate differences in cognition were examined across Assisted versus Independent groups. Logistic regression assessed which cognitive domains independently predicted group status. The incremental value of the MMAA was assessed, holding uniquely associated cognitive test scores constant. RESULTS: Those receiving assistance with medication management performed worse across all neurocognitive domains and the MMAA compared with independent counterparts. EF was the only unique cognitive predictor of medication management status. When modeled alone, EF and MMAA performance correctly classified 79.5% and 80.8% of cases, respectively. When modeled together, both were independently associated with medication management status and correctly classified 83.3% of cases. CONCLUSIONS: EF uniquely predicted medication management status beyond other cognitive domains. The MMAA provided complementary predictive utility. Concurrent interpretation of executive functioning and MMAA performance is advised when assessing older adults suspected of medication mismanagement. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Verbal memory is associated with adherence to COVID-19 protective behaviors in community dwelling older adults.

BACKGROUND: Adherence to protective behaviors is central to limiting the spread of COVID-19 and associated risk of serious illness and mortality in older populations. Whether cognition predicts adherence to protective behaviors has not been examined in older adults. AIMS: To examine whether specific cognitive abilities predict adherence to COVID-19 protective behaviors in older adults, independent of other relevant factors. METHODS: Data from 431 older adults (i.e., ≥ 65 years) who took part in the COVID-19 module of the Health and Retirement Study were included in the present study. Separate binary logistic regression models were used to examine whether performance on measures of immediate and delayed recall and working memory predicted adherence to COVID-19 protective behaviors, controlling for demographics, level of COVID-19 concern, depressive symptoms, and medical conditions. RESULTS: For every unit increase in immediate and delayed recall, the probability of adhering to COVID-19 protective behaviors increased by 47% and 69%, respectively. There was no association between the measure of working memory and adherence. DISCUSSION: It is of public interest to understand the factors that reduce adherence to protective behaviors so that we can better protect those most vulnerable and limit community spread. Our findings demonstrate that reduced memory predicts non-adherence to COVID-19 protective behaviors, independent of virus concern, and other relevant demographic and health factors. CONCLUSIONS: Public health strategies aimed at increasing adherence to COVID-19 protective behaviors in community dwelling older adults, should account for the role of reduced cognitive function in limiting adherence.

Adding cognition to AT(N) models improves prediction of cognitive and functional decline.

INTRODUCTION: This study sought to determine whether adding cognition to a model with Alzheimer's disease biomarkers based on the amyloid, tau, and neurodegeneration/neuronal injury-AT(N)-biomarker framework predicts rates of cognitive and functional decline in older adults without dementia. METHODS: The study included 465 participants who completed amyloid positron emission tomography, cerebrospinal fluid phosphorylated tau, structural magnetic resonance imaging, and serial neuropsychological testing. Using the AT(N) framework and a newly validated cognitive metric as the independent variables, we used linear mixed effects models to examine a 4-year rate of change in cognitive and functional measures. RESULTS: The inclusion of baseline cognitive status improved model fit in predicting rate of decline in outcomes above and beyond biomarker variables. Specifically, those with worse cognitive functioning at baseline had faster rates of memory and functional decline over a 4-year period, even when accounting for AT(N). DISCUSSION: Including a newly validated measure of baseline cognition may improve clinical prognosis in non-demented older adults beyond the use of AT(N) biomarkers alone.

Video feedback intervention for cognitively impaired older drivers: A randomized clinical trial.

INTRODUCTION: This clinical trial aimed to determine whether in-car video feedback about unsafe driving events (UDE) to cognitively impaired older drivers and family members leads to a reduction in such driving behaviors. METHODS: We randomized 51 cognitively impaired older drivers to receive either (1) a weekly progress report with recommendations and access to their videos, or (2) video monitoring alone without feedback over 3 months. RESULTS: UDE frequency/1000 miles was reduced by 12% in feedback (rate ratio [RR] = 0.88, 95% confidence interval [CI] = .58-1.34), while remaining constant with only monitoring (RR = 1.01, 95% CI = .68-1.51). UDE severity/1000 miles was reduced by 37% in feedback (RR = 0.63, 95% CI = .31-1.27), but increased by 40% in monitoring (RR = 1.40, 95% CI = .68-2.90). Cognitive impairment moderated intervention effects (P = .03) on UDE frequency. DISCUSSION: Results suggest the potential to improve driving safety among mild cognitively impaired older drivers using a behavior modification approach aimed at problem behaviors detected in their natural driving environment.

The Clinical Utility and Ecological Validity of the Medication Management Ability Assessment in Older Adults with and without Dementia.

OBJECTIVE: Older adults are susceptible to medication nonadherence, which may signify functional decline. Thus, performance-based proxies of medication-taking behavior may help diagnose dementia. We assessed the Medication Management Ability Assessment's (MMAA) clinical utility and ecological validity. METHOD: This was a retrospective chart review of 180 outpatients (age = 72 ± 8 years) who completed the MMAA during clinical evaluations. Forty-seven were cognitively normal (CN), 103 had mild cognitive impairment (MCI), and 30 had dementia. Most (136) were independent in medication management, whereas 28 were assisted and 16 were dependent. Kruskal-Wallis tests assessed whether MMAA scores differed by diagnosis and independence. Receiver operating characteristic (ROC) analyses identified diagnostic cut-offs. Classification accuracy estimates were derived. RESULTS: MMAA performance differed across diagnosis as expected (p's < .001). Those who were independent in medication management outperformed assisted and dependent counterparts (p's < .001). Assisted and dependent cases were no different. At a cut-off = 23, the MMAA was good-to-strong in distinguishing dementia from CN cases (Sn = 0.96, Sp = 0.83), dementia from MCI (Sn = 0.70, Sp = 0.83), and dementia from functionally unimpaired cases (Sn = 0.78, Sp = 0.83). At a cut-off = 27, it had good sensitivity but weaker specificity when distinguishing both MCI and all cognitively impaired patients (MCI and dementia) from CN cases (Sn = 0.81, Sp = 0.66 and Sn = 0.81, Sp = 0.72, respectively). CONCLUSIONS: The MMAA has ecological validity and clinical utility in identifying dementia. Its inclusion in neuropsychological practice may be especially useful when medication mismanagement is suspected.

Evaluation of Naturalistic Driving Behavior Using In-Vehicle Monitoring Technology in Preclinical and Early Alzheimer's Disease.

Cognitive impairment is a significant risk factor for hazardous driving among older drivers with Alzheimer's dementia, but little is known about how the driving behavior of mildly symptomatic compares with those in the preclinical, asymptomatic phase of Alzheimer's disease (AD). This study utilized two in-car technologies to characterize driving behavior in symptomatic and preclinical AD. The goals of this pilot study were to (1) describe unsafe driving behaviors in individuals with symptomatic early AD using G-force triggered video capture and (2) compare the driving habits of these symptomatic AD drivers to two groups of cognitively normal drivers, those with and those without evidence of cerebral amyloidosis (CN/A+ and CN/A-) using a global positioning system (GPS) datalogger. Thirty-three drivers (aged 60+ years) were studied over 3 months. G-force triggered video events captured instances of near-misses/collisions, traffic violations, risky driver conduct, and driving fundamentals. GPS data were sampled every 30 s and all instances of speeding, hard braking, and sudden acceleration were recorded. For the early AD participants, video capture identified driving unbelted, late response, driving too fast for conditions, traffic violations, poor judgment, and not scanning intersections as the most frequently occurring safety errors. When evaluating driving using the GPS datalogger, hard breaking events occurred most frequently on a per trip basis across all three groups. The CN/A+ group had the lowest event rate across all three event types with lower instances of speeding. Slower psychomotor speed (Trail Making Part A) was associated with fewer speeding events, more hard acceleration events, and more overall events. GPS tracked instances of speeding were correlated with total number of video-captured near-collisions/collisions and driving fundamentals. Results demonstrate the utility of electronic monitoring to identify potentially unsafe driving events in symptomatic and preclinical AD. Results suggest that drivers with preclinical AD may compensate for early, subtle cognitive changes by driving more slowly and cautiously than healthy older drivers or those with cognitive impairment. Self-regulatory changes in driving behavior appear to occur in the preclinical phase of AD, but safety concerns may not arise until symptoms of cognitive impairment emerge and the ability to self-monitor declines.

Evaluation of the Driving Safety of Visually Impaired Bioptic Drivers Based on Critical Events in Naturalistic Driving.

Purpose: Visually impaired people may be allowed to drive if they wear bioptic telescopes. Bioptic driving safety is debatable, especially given that the telescopes are seldom used by most bioptic drivers. This preliminary study examined bioptic safety based on critical events that occurred in naturalistic daily driving. Methods: Daily driving activities were recorded using in-car video recorders in 20 bioptic drivers (median age 55, visual acuity, 20/60-160) and 19 control subjects (median age 74) for two to eight weeks. In a secondary analysis, these subjects were compared with 44 cognitively impaired drivers with normal vision (median age 75). Results: In 292 hours of driving by bioptic drivers and 169 hours by control drivers, seven bioptic drivers and three control drivers had eight and four near-collisions, respectively. Near-collision survival times were not significantly different between the two groups (hazard ratio [HR] = 1.93, P = 0.591) according to Cox hazards regression. Even without compensation for bioptic drivers' longer driving exposure, their odds ratio (OR) was not statistically significant (OR = 2.88, P = 0.18). When including cognitively impaired drivers with normal vision, cognition was a significant predictor of near collisions (HR = 3.86, P = 0.036), but vision loss was not (HR = 0.47, P = 0.317). Conclusions: This preliminary study failed to find any evidence suggesting that bioptic drivers were more prone to near-collision than healthy drivers. Vision might be a less-significant factor than cognition. Translational Relevance: Given that bioptic drivers use the telescope for less than 2% of the driving time, this study suggests that driving safety might not be substantially affected even when visual acuity is in the low vision range.

Driving Safety of Cognitively-Impaired Drivers Based on Near Collisions in Naturalistic Driving.

BACKGROUND: Controlled naturalistic driving for examining impacts of cognitive impairment on driving safety is rare. OBJECTIVE: Evaluating the safety among drivers with mild cognitive impairment based on near collision incidents using naturalistic driving, and investigating its correlation with cognitive measures. METHODS: Frequency of near collisions of 44 cognitively impaired [Age = 75.1(±6.7), MMSE = 25.5(±2.5)] and 19 control group drivers [Age = 72.5(±7.8), MMSE = 29.3(±0.8)] were obtained from two weeks of recorded driving. Survival time free of predicted collision based on a previously established near-collision to collision estimate ratio of 11 : 1, for 140 hours of driving exposure was calculated. Participants were also tested using Mini-Mental Status Examination (MMSE), Trail A, and Trail B. Spearman correlation and Cox survival analysis were conducted. RESULTS: Near collision frequency per driving hour was correlated with MMSE (r = -0.258, p = 0.041). Survival analyses showed that cognitively impaired drivers might be prone to higher probability of having collision (p = 0.056) with a hazard ratio of 5.78 (p = 0.092). When all participants were combined, there was a significant difference (p < 0.017) in all the three cognitive measures between drivers with and without predicted collision, which were not significant within patient or control group alone (p > 0.186). Cox regression analysis showed MMSE as the only significant factor (p < 0.025) for survival time of predicted collision, but not age, gender, or driving experience. CONCLUSION: The association between driving critical events and cognitive measures suggests that some drivers with mild cognitive impairment might have an elevated driving collision risk compared to control drivers. Standard clinical cognitive measures may be reasonable predictors.

Discrepancy-Based Evidence for Loss of Thinking Abilities (DELTA): Development and Validation of a Novel Approach to Identifying Cognitive Changes.

OBJECTIVE: To develop and validate the Discrepancy-based Evidence for Loss of Thinking Abilities (DELTA) score. The DELTA score characterizes the strength of evidence for cognitive decline on a continuous spectrum using well-established psychometric principles for improving detection of cognitive changes. METHODS: DELTA score development used neuropsychological test scores from the Alzheimer's Disease Neuroimaging Initiative (ADNI) cohort (two tests each from Memory, Executive Function, and Language domains). We derived regression-based normative reference scores using age, gender, years of education, and word-reading ability from robust cognitively normal ADNI participants. Discrepancies between predicted and observed scores were used for calculating the DELTA score (range 0-15). We validated DELTA scores primarily against longitudinal Clinical Dementia Rating-Sum of Boxes (CDR-SOB) and Functional Activities Questionnaire (FAQ) scores (baseline assessment through Year 3) using linear mixed models and secondarily against cross-sectional Alzheimer's biomarkers. RESULTS: There were 1359 ADNI participants with calculable baseline DELTA scores (age 73.7 ± 7.1 years, 55.4% female, 100% white/Caucasian). Higher baseline DELTA scores (stronger evidence of cognitive decline) predicted higher baseline CDR-SOB (ΔR2 = .318) and faster rates of CDR-SOB increase over time (ΔR2 = .209). Longitudinal changes in DELTA scores tracked closely and in the same direction as CDR-SOB scores (fixed and random effects of mean + mean-centered DELTA, ΔR2 > .7). Results were similar for FAQ scores. High DELTA scores predicted higher PET-Aß SUVr (ρ = 324), higher CSF-pTau/CSF-Aß ratio (ρ = .460), and demonstrated PPV > .9 for positive Alzheimer's disease biomarker classification. CONCLUSIONS: Data support initial development and validation of the DELTA score through its associations with longitudinal functional changes and Alzheimer's biomarkers. We provide several considerations for future research and include an automated scoring program for clinical use.

The Screening Utility and Ecological Validity of the Neuropsychological Assessment Battery Bill Payment Subtest in Older Adults with and without Dementia.

OBJECTIVE: The Neuropsychological Assessment Battery Bill Payment subtest has shown strong diagnostic accuracy in dementia due to Alzheimer's disease (AD) versus non-AD. Its relationship to mild cognitive impairment (MCI) or all-cause dementia has not been fully examined nor has its ecological validity as a proxy of financial independence. METHOD: We describe 270 women (63%) and men (age = 72 ± 8.39) who completed Bill Payment during outpatient neuropsychological evaluation. Seventy-one were cognitively normal (CN), 160 had MCI, and 39 had Dementia. Two hundred fourteen were independent in money management, 31 were assisted (had oversight/some help), and 25 were dependent (relied on others). Receiver operating characteristic (ROC) curves tested Bill Payment's utility as a dementia screen. Kruskal-Wallis tests examined whether Bill Payment differed by levels of financial independence. RESULTS: At a cutoff of 17, Bill Payment had strong sensitivity (0.87) and specificity (0.80) for dementia versus CN cases. A cutoff of 15 distinguished dementia from MCI (Sn = 0.64, Sp = 0.85), whereas a cutoff of 16 distinguished dementia from functionally unimpaired cases (MCI + CN) with greater sensitivity and similar specificity (Sn = 0.74, Sp = 0.81). Sensitivity attenuated in MCI versus CN cases (Sn = 0.46, Sp = 0.83). Those who were independent in money management had higher scores than assisted and dependent cases (p ≤ 0.046). Assisted and dependent cases were no different (p > 0.05). CONCLUSIONS: Bill Payment is a valid screen of all-cause dementia. Lower Bill Payment scores may mark subtle functional decline beyond cognitive impairment alone. Specifically, results provide preliminary evidence of Bill Payment's ecological validity as a measure related to financial independence. It may prove useful when impaired financial abilities are suspected but unreported.

Detection of Risky Driving Behaviors in the Naturalistic Environment in Healthy Older Adults and Mild Alzheimer's Disease.

Analyzing naturalistic driving behavior recorded with in-car cameras is an ecologically valid method for measuring driving errors, but it is time intensive and not easily applied on a large scale. This study validated a semi-automated, computerized method using archival naturalistic driving data collected for drivers with mild Alzheimer's disease (AD; n = 44) and age-matched healthy controls (HC; n = 16). The computerized method flagged driving situations where safety concerns are most likely to occur (i.e., rapid stops, lane deviations, turns, and intersections). These driving epochs were manually reviewed and rated for error type and severity, if present. Ratings were made with a standardized scoring system adapted from DriveCam®. The top eight error types were applied as features to train a logistic model tree classifier to predict diagnostic group. The sensitivity and specificity were compared among the event-based method, on-road test, and composite ratings of two weeks of recorded driving. The logistic model derived from the event-based method had the best overall accuracy (91.7%) and sensitivity (97.7%) and high specificity (75.0%) compared to the other methods. Review of driving situations where risk is highest appears to be a sensitive data reduction method for detecting cognitive impairment associated driving behaviors and may be a more cost-effective method for analyzing large volumes of naturalistic data.