How effective is the Trail Making Test (Parts A and B) in identifying cognitively impaired drivers?

BACKGROUND: the medical community plays an important role in identifying drivers who may no longer be competent to drive due to illnesses such as dementia. Several office-based cognitive screening tools are currently used by the medical community, e.g. Mini-Mental State Examination, Trail Making Test (TMT), to assist in the identification of cognitively impaired (CI) at-risk drivers. However, the predictive validity of these tools is questionable. OBJECTIVE: to examine the predictive power of the TMT for on-road driving performance. METHODS: data from a prospective sample of CI and healthy older drivers were collected. TMT-A and -B (time and errors) served as predictor variables, with pass/fail on a scientifically based on-road assessment used as the criterion variable. Receiver operating characteristic (ROC) curve analysis was used to assess overall 'diagnostic' accuracy of TMT-A and -B for driving competency. Cut points from previous studies/guidelines were used to assess predictive power. FINDINGS: a total of 134 older drivers (mean age = 75.30; SD = 7.83) participated: 87 healthy controls and 47 CI individuals. All predictor variables, with the exception of TMT-A errors, were significantly correlated with driving outcome. However, results from ROC curve analyses indicated that only TMT-A and -B total time had moderate discriminative abilities. Results also indicate that the power of the TMT is the lowest where physicians need it most (e.g. identifying CI patients whose driving skills have declined to an unsafe level). CONCLUSION: TMT-A and -B outcomes are most likely to be inaccurate in those whose driving competency has declined to an unsafe level, resulting in risks to both individual and public safety.

Video programming for individuals with dementia: assessing cognitive congruence.

The effect of cognitively congruent video programming on attentional engagement, as measured by the average look duration and the proportion of the video viewed, was examined among long-term care facility residents with Alzheimer's disease. Over a 2-week period, 24 residents viewed 4 cognitively congruent videos and 1 control video (ie, a recorded episode of a local news program) at least once. Level of attentional engagement was significantly higher for cognitively congruent video programs compared to the News. Neither history of television viewing nor cognitive status was related to engagement. The results suggest that video programs with less cognitive complexity may be more engaging for individuals with Alzheimer's disease.

Prevalence and predictors of booster seat use in Alberta, Canada.

OBJECTIVE: To determine the prevalence of booster seat misuse in a Canadian province and identify determinants of non-use. METHODS: A cross-sectional study using parking lot interviews and in-vehicle restraint inspections by trained staff was conducted at 67 randomly selected childcare centres across Alberta. Only booster-eligible children were included in this analysis. Odds ratios (OR) and 95% confidence intervals (CI) are reported using unadjusted and adjusted logistic regression. RESULTS: Overall, 23% of children were not in a booster seat, and in 31.8% of cases there was evidence of at least one misuse. Non-use increased significantly by age, from 22.2% for children 2 years of age to 47.8% for children 7 years of age (p = 0.02). Children who were at significantly increased risk of booster seat non-use were those in vehicles with drivers who could not recall the booster seat to seatbelt transition point (OR: 4.54; 95% CI: 2.05-10.06) or drivers who were under the age of 30 (OR: 3.54; 95% CI: 1.45-8.62). A front row seating position was also associated with significantly higher risk of nonuse (OR: 18.00; 95% CI: 2.78-116.56). Children in vehicles with grandparent drivers exhibited significantly decreased risk of booster seat non-use (OR: 0.21; 95% CI: 0.05-0.85). CONCLUSION: Messaging should continue to stress that the front seat is not a safe place for any child under the age of 9 as well as remind drivers of the booster seat to seatbelt transition point, with additional emphasis placed on appealing to parents under the age of 30. Future research should focus on the most effective means of communicating booster seat information to this group. Enacting mandatory booster seat legislation would be an important step to increase both awareness and proper use of booster seats in Alberta.

Evaluation and management of the driver with dementia.

BACKGROUND: The number of older adult drivers with dementia is expected to increase over the next few decades. This increase raises public and personal safety concerns given the higher crash rates of drivers with a dementing illness. However, the identification of drivers with a dementia who may be at risk for a crash is difficult, particularly for those in the early stages of dementia. REVIEW SUMMARY: Studies examining the correlation of dementia with driving outcomes such as motor vehicle crashes are reviewed. The strengths and weaknesses of recent consensus statements, published to assist clinicians in evaluating drivers with a dementia, are discussed. The authors also review common practices currently in use by physicians to identify at-risk drivers, including mental status examinations, global dementia rating scales, specialist referral, medical evaluations, and the use of caregiver reports and other proxy measures. Legal issues, based on the role of the physician, are reviewed along with suggestions for driving cessation and education for the caregiver and family. CONCLUSIONS: In patients with mild to moderate dementia, the literature indicates that physicians would have difficulty in identifying which individuals should not drive. Performance-based measures of driving skills, such as on-road driving tests, are recommended as a means of assessing driving competency.

Geriatric core competencies for family medicine curriculum and enhanced skills: care of elderly.

BACKGROUND: There is a growing mandate for Family Medicine residency programs to directly assess residents' clinical competence in Care of the Elderly (COE). The objectives of this paper are to describe the development and implementation of incremental core competencies for Postgraduate Year (PGY)-I Integrated Geriatrics Family Medicine, PGY-II Geriatrics Rotation Family Medicine, and PGY-III Enhanced Skills COE for COE Diploma residents at a Canadian University. METHODS: Iterative expert panel process for the development of the core competencies, with a pre-defined process for implementation of the core competencies. RESULTS: Eighty-five core competencies were selected overall by the Working Group, with 57 core competencies selected for the PGY-I/II Family Medicine residents and an additional 28 selected for the PGY-III COE residents. The core competencies follow the CanMEDS Family Medicine roles. Both sets of core competencies are based on consensus. CONCLUSIONS: Due to demographic changes, it is essential that Family Physicians have the required skills and knowledge to care for the frail elderly. The core competencies described were developed for PGY-I/II Family Medicine residents and PGY-III Enhanced Skills COE, with a focus on the development of geriatric expertise for those patients that would most benefit.

The Introduction of a New Screening Tool for the Identification of Cognitively Impaired Medically At-Risk Drivers: The SIMARD A Modification of the DemTect.

UNLABELLED: The number of drivers with a cognitive impairment due to dementia or other age-associated pathologies will increase significantly over the next 3 decades. Physicians are well placed to identify medically at-risk drivers, but are hampered by the lack of a valid, easy to administer screening tool. This research develops and validates a brief screening tool for use in the primary care setting to identify drivers with cognitive impairment with or without dementia. Initial Study Participants: A cohort of 146 consecutive referrals from community-based family physicians, diagnosed with an undifferentiated cognitive impairment or dementia, as well as 35 community dwelling healthy controls. Validation Study: A cohort of 192 consecutive referrals carrying the same diagnosis as above and 52 community dwelling healthy controls. Criterion Measure: Pass/fail on an On-Road evaluation. Predictor Measures: Subtests of the DemTect, a screening test for cognitive impairment or dementia developed by Kalbe and colleagues.(1) Initial Study: Three of the DemTect measures predicted On-Road outcomes (R(2) = .262). Regression results were used to develop a simple scoring algorithm, with cut-points then derived by identifying those most at risk for failing and passing the On-Road assessment, and those needing a driving assessment for determination of driving competency. 89 individuals scored in the indeterminate range, with 49 and 43 predicted to fail and pass, respectively-86% and 84% of those predicted to fail and pass did subsequently fail and pass. Validation Study: 123 individuals scored in the indeterminate range, with 66 and 55 predicted to fail and pass, respectively-80% and 87% of those predicted to fail and pass did subsequently fail and pass. CONCLUSIONS: The SIMARD A Modification of the DemTect ( S creen for the I dentification of cognitively impaired M edically A t- R isk D rivers) is a brief paper and pencil screening tool with a high degree of accuracy that can be used for immediate decisions in the clinical setting.

Aging baby boomers--a blessing or challenge for driver licensing authorities.

INTRODUCTION: In less than 5 years, the first wave of baby boomers will begin turning 65, with the last wave of boomers entering their senior years in January 2029. Currently, boomers make up a significant percentage of the population in Canada, the United States, and other developed countries. The baby boom generation has had a profound impact on our society over the last six decades, and this large cohort will continue to exert its influence for several decades to come. Central to this article is the rapid growth in the number of persons 65 years of age and older, beginning in 2011, with a corresponding increase in the number of older drivers. The demographic shift has important implications for licensing authorities, the regulatory bodies charged with licensing and 'fitness to drive' decisions. OBJECTIVES: The objectives of this paper are to summarize the published scientific literature on licensing policies and procedures currently in use for older drivers, discuss their limitations, and provide recommendations for meeting the upcoming challenges of an aging baby boomer population of drivers. METHOD: Online searches were conducted using the following databases: PsycINFO, MEDLINE, Scopus, and TRIS. Google and Google Scholar also were searched for scientific articles. References identified from database and online searches were examined for relevant articles. RESULTS: A number of studies have investigated the utility of different licensing policies and procedures for identifying older drivers who may be at risk for impaired driving performance. Overall, results suggest that current policies and procedures are ineffective in identifying high-risk older drivers. The results also emphasize the need for a different approach for the identification of high risk older drivers by licensing agencies. Recommendations to assist with that goal are provided. CONCLUSIONS: The aging of the baby boomer population, combined with the projected high crash rates for this cohort of drivers as it moves through the senior years, underscores the need for cost-effective, accurate, and efficient methods for identifying and assessing the subgroup of older drivers whose driving has declined to an unsafe level. That subgroup consists of individuals with medical conditions (and treatments) affecting driving performance. The demographic shift has been a blessing for licensing authorities in that it has created awareness of the need for a reexamination of licensing policies and procedures designed to identify those older drivers who may no longer be safe to drive. If that awareness becomes translated into effective policies and procedures that appropriately target the medically at-risk/impaired older driver rather than the older driver per se, the result will be an increase in the safety and mobility of the older driving population and increased public safety overall. However, a continued focus on older drivers rather than medically at-risk drivers will result in a costly, ineffective, and overburdened system.