Assessing Fitness to Drive in Patients With Different Types of Dementia.

Dementia is a risk factor for unsafe driving. Therefore, an assessment strategy has recently been developed for the prediction of fitness to drive in patients with the Alzheimer disease (AD). The aim of this study was to investigate whether this strategy is also predictive of fitness to drive in patients with non-AD dementia, that is, vascular dementia, frontotemporal dementia, and dementia with Lewy bodies. Predictors were derived from 3 types of assessment: clinical interviews, neuropsychological tests, and driving simulator rides. The criterion was the pass-fail outcome of an official on-road driving assessment. About half of the patients with non-AD dementia (n=34) failed the on-road driving assessment. Neuropsychological assessment [area under the curve (AUC)=0.786] was significantly predictive of fitness to drive in patients with non-AD dementia, however, clinical interviews (AUC=0.559) and driving simulator rides (AUC=0.404) were not. The fitness-to-drive assessment strategy with the 3 types of assessment combined (AUC=0.635) was not found to significantly predict fitness to drive in non-AD dementia. Different types of dementia require different measures and assessment strategies.

Adherence to driving cessation advice given to patients with cognitive impairment and consequences for mobility.

BACKGROUND: Driving is related to social participation; therefore older drivers may be reluctant to cease driving. Continuation of driving has also been reported in a large proportion of patients with cognitive impairment. The aim of this study is to investigate whether patients with cognitive impairment adhere to driving cessation advice after a fitness-to-drive assessment and what the consequences are with regard to mobility. METHODS: Patients with cognitive impairment (n = 172) participated in a fitness-to-drive assessment study, including an on-road driving assessment. Afterwards, patients were advised to either continue driving, to follow driving lessons, or to cease driving. Approximately seven months thereafter, patients were asked in a follow-up interview about their adherence to the driving recommendation. Factors influencing driving cessation were identified using a binary logistic regression analysis. Use of alternative transportation was also evaluated. RESULTS: Respectively 92 and 79% of the patients adhered to the recommendation to continue or cease driving. Female gender, a higher Clinical Dementia Rating-score, perceived health decline, and driving cessation advice facilitated driving cessation. Patients who ceased driving made use of less alternative modes of transportation than patients who still drove. Nonetheless, around 40% of the patients who ceased driving increased their frequency of cycling and/or public transport use. CONCLUSIONS: Adherence to the recommendations given after the fitness-to-drive assessments was high. Female patients were in general more likely to cease driving. However, a minority of patients did not adhere to driving cessation advice. These drivers with dementia should be made aware of the progression of their cognitive impairment and general health decline to facilitate driving cessation. There are large differences in mobility between patients with cognitive impairment. Physicians should discuss options for alternative transportation in order to promote sustained safe mobility of patients with cognitive impairment.

Difficulties in Daily Life Reported by Patients With Homonymous Visual Field Defects.

BACKGROUND: Homonymous visual field defects (HVFD) are common after postchiasmatic acquired brain injury and may have a significant impact on independent living and participation in society. Vision-related difficulties experienced in daily life are usually assessed using questionnaires. The current study 1) links the content of 3 of these questionnaires to the International Classification of Functioning, Disability and Health (ICF) and 2) provides analyses of vision-related difficulties reported by patients with HVFD and minimal comorbidities. METHODS: Fifty-four patients with homonymous hemianopia or quadrantanopia were asked about difficulties experienced in daily life because of their HVFD. This was performed during a structured interview including 3 standardized questionnaires: National Eye Institute Visual Functioning Questionnaire, Independent Mobility Questionnaire, and Cerebral Visual Disorders Questionnaire. The reported difficulties were linked to the ICF according to the ICF linking rules. Main outcome measures were presence or absence of experienced difficulties. RESULTS: The ICF linking procedure resulted in a classification table that can be used in future studies of vision-related difficulties. Besides well-known difficulties related to reading, orientation, and mobility, a high proportion of patients with HVFD reported problems that previously have not been documented in the literature, such as impaired light sensitivity, color vision, and perception of depth. CONCLUSIONS: A systematic inventory of difficulties experienced in daily life by patients with HVFD was performed using the ICF. These findings have implications for future study, assessment and rehabilitation of patients with HVFD.

When family looks strange and strangers look normal: a case of impaired face perception and recognition after stroke.

We describe a patient (JS) with impaired recognition and distorted visual perception of faces after an ischemic stroke. Strikingly, JS reports that the faces of family members look distorted, while faces of other people look normal. After neurological and neuropsychological examination, we assessed response accuracy, response times, and skin conductance responses on a face recognition task in which photographs of close family members, celebrities and unfamiliar people were presented. JS' performance was compared to the performance of three healthy control participants. Results indicate that three aspects of face perception appear to be impaired in JS. First, she has impaired recognition of basic emotional expressions. Second, JS has poor recognition of familiar faces in general, but recognition of close family members is disproportionally impaired compared to faces of celebrities. Third, JS perceives faces of family members as distorted. In this paper we consider whether these impairments can be interpreted in terms of previously described disorders of face perception and recent models for face perception.

[Safety measures in traffic; how risk compensation affects our behaviour]. / Veiligheidsmaatregelen in het verkeer.

In 2020, more than 600 people died as a result of a traffic crash in the Netherlands and 6,500 were hospitalized after they had sustained a serious injury (MAIS 3+). These numbers are much lower than those in the beginning of the seventies of the last century, when there were more than 3,000 road fatalities. To reduce the number of fatalities, many measures have been taken to avoid road crashes and reduce injury severity. By road design that makes it impossible for road users to collide, by improving the safety of vehicles, and by educating road users. Traffic psychologists often warn for behavioural adaptations that nullify the expected effect of road safety measures (risk compensation). Numerous studies have shown examples of risk compensation in traffic. What is the psychological mechanism behind risk compensation? Which factors enhance risk compensation? And are there any advantages of risk compensation?

Conscious and unconscious processing of fear after right amygdala damage: a single case ERP-study.

In this study, we describe a 58-year-old male patient (FZ) with a right-amygdala lesion after temporal lobe infarction. FZ is unable to recognize fearful facial expressions. Instead, he consistently misinterprets expressions of fear for expressions of surprise. Employing EEG/ERP measures, we investigated whether presentation of fearful and surprised facial expressions would lead to different response patterns. We also measured ERPs to aversively conditioned and unconditioned fearful faces. We compared ERPs elicited by supraliminally and subliminally presented conditioned fearful faces (CS+), unconditioned fearful faces (CS-) and surprised faces. Despite FZ's inability to recognize fearful facial expressions in emotion recognition tasks, ERP components showed different response patterns to pictures of surprised and fearful facial expressions, indicating that covert or implicit recognition of fear is still intact. Differences between ERPs to CS+ and CS- were only found when these stimuli were presented subliminally. This indicates that intact right amygdala function is not necessary for aversive conditioning. Previous studies have stressed the importance of the right amygdala for discriminating facial emotional expressions and for classical conditioning. Our study suggests that the right amygdala is necessary for explicit recognition of fear, while implicit recognition of fear and classical conditioning may still occur following lesion of the right amygdala.

Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life.

A multicenter randomized control trial (RCT) was conducted to evaluate the effects of a treatment for dysexecutive problems after acquired brain injury (ABI) on daily life functioning. Seventy-five ABI patients were randomly allocated to either the experimental treatment, multifaceted strategy training for executive dysfunction, or a control treatment, computerized cognitive function training. Assessment took place before, directly after, and 6 months post-treatment. The primary outcome measure, the Role Resumption List (RRL), and two other follow-up measures, the Treatment Goal Attainment (TGA) and the Executive Secretarial Task (EST), were indications of daily life executive functioning. The experimental group improved significantly more over time than the controls on the RRL and attained significantly higher scores on the TGA and EST. We conclude that our treatment has resulted in significant improvements of executive functioning in daily life, lasting at least 6 months post-treatment. Although control patients' satisfaction and subjective well-being were at the same level, the experimental group had better abilities to set and accomplish realistic goals, to plan, initiate, and regulate a series of real-life tasks, and to resume previous roles with respect to work, social relations, leisure activities, and mobility.

Cognitive dysfunction in non-demented Parkinson's disease patients: controlled and automatic behavior.

The evidence with regard to impaired automatic and controlled information processing in non-demented patients with Parkinson's disease (PD) is critically discussed. We use a comprehensive mental schema framework of executive functioning, that is the planning and regulation of behavior in complex everyday tasks (International Classification of Functioning - ICF - activity level). In this framework monitoring, inhibition, mental effort, planning, working memory and flexibility are important elements of controlled processing (supervisory attentional control) and controlled processing can only influence performance by modulating automatic processes. The striatum plays an important role in the interface between controlled and automatic processes. It is wel documented that PD patients show impairments applying and achieving automaticities. With sustained cortical control of task performance during both automatic and controlled processing, not showing the transition to striatal control, which is normal in the case of skill learning. In addition, PD patients have been shown to be limited in executive functioning. Many authors have interpreted this as evidence for impaired executive functions (ICF body level). But the question must be asked to what extent these limitations are an indirect effect of impaired automatic processing. To answer this question, studies on executive functioning are critically assessed with regard to the control they have provided for impaired automaticity. It is concluded that only for cognitive flexibility and working memory, the evidence for impairments is convincing because significant limitations have also been shown in tasks with very low automatic processing demands. Impairments in other executive functions, such as monitoring, inhibition and planning have not been convincingly shown in non-demented PD patients and are likely to be due to treatment strategies and factors such as fatigue.

Driving Difficulties Among Patients with Alzheimer's Disease and Other Neurodegenerative Disorders.

BACKGROUND/OBJECTIVE: Neurodegenerative disorders impact fitness to drive of older drivers, but on-road driving studies investigating patients with different neurodegenerative disorders are scarce. A variety of driving errors have been reported in patients with Alzheimer's disease (AD), but it is unclear which types of driving errors occur most frequently. Moreover, patients with other neurodegenerative disorders than AD typically present with different symptoms and impairments, therefore different driving errors may be expected. METHODS: Patients with AD (n = 80), patients with other neurodegenerative disorders with cognitive decline (i.e., vascular dementia, frontotemporal dementia, dementia with Lewy bodies/Parkinson's disease, n = 59), and healthy older drivers (n = 45) participated in a fitness-to-drive assessment study including on-road driving. RESULTS: Patients with AD performed significantly worse than healthy older drivers on operational, tactical, visual, and global aspects of on-road driving. In patients with AD, on-road measures were significantly associated with 'off-road' measures. Patients with neurodegenerative disorders other than AD showed large overlap in the types of driving errors. Several driving errors were identified that appear to be characteristic for patients with particular neurodegenerative disorders. CONCLUSION: Patients from each group of neurodegenerative disorders commonly display tactical driving errors regarding lane positioning, slow driving, observation of the blind spot, and scanning behavior. Several other tactical and operational driving errors, including not communicating with cyclists and unsteady steering, were more frequently observed in patients with non-AD neurodegenerative disorders. These findings have implications for on-road and 'off-road' fitness-to-drive assessments for patients with neurodegenerative disorders with cognitive decline.

Mobility scooter driving ability in visually impaired individuals.

PURPOSE: To investigate how well visually impaired individuals can learn to use mobility scooters and which parts of the driving task deserve special attention. MATERIALS AND METHODS: A mobility scooter driving skill test was developed to compare driving skills (e.g. reverse driving, turning) between 48 visually impaired (very low visual acuity = 14, low visual acuity = 10, peripheral field defects = 11, multiple visual impairments = 13) and 37 normal-sighted controls without any prior experience with mobility scooters. Performance on this test was rated on a three-point scale. Furthermore, the number of extra repetitions on the different elements were noted. RESULTS: Results showed that visually impaired participants were able to gain sufficient driving skills to be able to use mobility scooters. Participants with visual field defects combined with low visual acuity showed most problems learning different skills and needed more training. Reverse driving and stopping seemed to be most difficult. CONCLUSIONS: The present findings suggest that visually impaired individuals are able to learn to drive mobility scooters. Mobility scooter allocators should be aware that these individuals might need more training on certain elements of the driving task. Implications for rehabilitation Visual impairments do not necessarily lead to an inability to acquire mobility scooter driving skills. Individuals with peripheral field defects (especially in combination with reduced visual acuity) need more driving ability training compared to normal-sighted people - especially to accomplish reversing. Individual assessment of visually impaired people is recommended, since participants in this study showed a wide variation in ability to learn driving a mobility scooter.

Vision-related fitness to drive mobility scooters: A practical driving test.

OBJECTIVE: To investigate practical fitness to drive mobility scooters, comparing visually impaired participants with healthy controls. DESIGN: Between-subjects design. SUBJECTS: Forty-six visually impaired (13 with very low visual acuity, 10 with low visual acuity, 11 with peripheral field defects, 12 with multiple visual impairment) and 35 normal-sighted controls. METHODS: Participants completed a practical mobility scooter test-drive, which was recorded on video. Two independent occupational therapists specialized in orientation and mobility evaluated the videos systematically. RESULTS: Approximately 90% of the visually impaired participants passed the driving test. On average, participants with visual impairments performed worse than normal-sighted controls, but were judged sufficiently safe. In particular, difficulties were observed in participants with peripheral visual field defects and those with a combination of low visual acuity and visual field defects. CONCLUSION: People with visual impairment are, in practice, fit to drive mobility scooters; thus visual impairment on its own should not be viewed as a determinant of safety to drive mobility scooters. However, special attention should be paid to individuals with visual field defects with or without a combined low visual acuity. The use of an individual practical fitness-to-drive test is advised.

Assessing fitness to drive-A validation study on patients with mild cognitive impairment.

OBJECTIVES: There is no consensus yet on how to determine which patients with cognitive impairment are able to drive a car safely and which are not. Recently, a strategy was composed for the assessment of fitness to drive, consisting of clinical interviews, a neuropsychological assessment, and driving simulator rides, which was compared with the outcome of an expert evaluation of an on-road driving assessment. A selection of tests and parameters of the new approach revealed a predictive accuracy of 97.4% for the prediction of practical fitness to drive on an initial sample of patients with Alzheimer's dementia. The aim of the present study was to explore whether the selected variables would be equally predictive (i.e., valid) for a closely related group of patients; that is, patients with mild cognitive impairment (MCI). METHODS: Eighteen patients with mild cognitive impairment completed the proposed approach to the measurement of fitness to drive, including clinical interviews, a neuropsychological assessment, and driving simulator rides. The criterion fitness to drive was again assessed by means of an on-road driving evaluation. The predictive validity of the fitness to drive assessment strategy was evaluated by receiver operating characteristic (ROC) analyses. RESULTS: Twelve patients with MCI (66.7%) passed and 6 patients (33.3%) failed the on-road driving assessment. The previously proposed approach to the measurement of fitness to drive achieved an overall predictive accuracy of 94.4% in these patients. The application of an optimal cutoff resulted in a diagnostic accuracy of 100% sensitivity toward unfit to drive and 83.3% specificity toward fit to drive. Further analyses revealed that the neuropsychological assessment and the driving simulator rides produced rather stable prediction rates, whereas clinical interviews were not significantly predictive for practical fitness to drive in the MCI patient sample. CONCLUSIONS: The selected measures of the previously proposed approach revealed adequate accuracy in identifying fitness to drive in patients with MCI. Furthermore, a combination of neuropsychological test performance and simulated driving behavior proved to be the most valid predictor of practical fitness to drive.

Walking trajectory in neglect patients.

A lateral deviation of the walking trajectory is often observed in stroke patients with unilateral spatial neglect. However, existing research appears to be contradictory regarding the direction of this deviation. The aim of the present study was to gain more insight into the walking trajectory of neglect patients. Twelve right hemisphere stroke patients (six neglect, six no neglect), eight left hemisphere stroke patients (none neglect) and 10 healthy control subjects were instructed to walk towards a target while a two-dimensional ultrasonic positioning system recorded their walking trajectory. Patients' recovery of walking ability was assessed and they were tested for the presence of neglect. Neglect patients showed a larger lateral deviation in their walking trajectory compared to stroke patients without neglect or controls. Neglect patients with good walking ability showed a deviation to the contralesional side. Neglect patients with limited walking ability showed a deviation to the ipsilesional side. Within the neglect group we found no relation between the severity of neglect and lateral deviation. Differences in walking ability may account for the contradictory results between studies regarding the lateral deviation in neglect patients' walking trajectory. We suggest that when a neglect patient's walking ability is limited, walking towards a target becomes a dual task: heading control and walking. A limited walking ability will cause a higher task priority of walking compared to heading control. This shift in task priority may be causing the change in walking trajectory deviation.

Correction: The Effects of Compensatory Scanning Training on Mobility in Patients with Homonymous Visual Field Defects: A Randomized Controlled Trial.

[This corrects the article DOI: 10.1371/journal.pone.0134459.].

The Effects of Compensatory Scanning Training on Mobility in Patients with Homonymous Visual Field Defects: Further Support, Predictive Variables and Follow-Up.

INTRODUCTION: People with homonymous visual field defects (HVFD) often report difficulty detecting obstacles in the periphery on their blind side in time when moving around. Recently, a randomized controlled trial showed that the InSight-Hemianopia Compensatory Scanning Training (IH-CST) specifically improved detection of peripheral stimuli and avoiding obstacles when moving around, especially in dual task situations. METHOD: The within-group training effects of the previously reported IH-CST are examined in an extended patient group. Performance of patients with HVFD on a pre-assessment, post-assessment and follow-up assessment and performance of a healthy control group are compared. Furthermore, it is examined whether training effects can be predicted by demographic characteristics, variables related to the visual disorder, and neuropsychological test results. RESULTS: Performance on both subjective and objective measures of mobility-related scanning was improved after training, while no evidence was found for improvement in visual functions (including visual fields), reading, visual search and dot counting. Self-reported improvement did not correlate with improvement in objective mobility performance. According to the participants, the positive effects were still present six to ten months after training. No demographic characteristics, variables related to the visual disorder, and neuropsychological test results were found to predict the size of training effect, although some inconclusive evidence was found for more improvement in patients with left-sided HVFD than in patients with right-sided HFVD. CONCLUSION: Further support was found for a positive effect of IH-CST on detection of visual stimuli during mobility-related activities specifically. Based on the reports given by patients, these effects appear to be long-term effects. However, no conclusions can be drawn on the objective long-term training effects.

Prediction of Fitness to Drive in Patients with Alzheimer's Dementia.

The number of patients with Alzheimer's disease (AD) is increasing and so is the number of patients driving a car. To enable patients to retain their mobility while at the same time not endangering public safety, each patient should be assessed for fitness to drive. The aim of this study is to develop a method to assess fitness to drive in a clinical setting, using three types of assessments, i.e. clinical interviews, neuropsychological assessment and driving simulator rides. The goals are (1) to determine for each type of assessment which combination of measures is most predictive for on-road driving performance, (2) to compare the predictive value of clinical interviews, neuropsychological assessment and driving simulator evaluation and (3) to determine which combination of these assessments provides the best prediction of fitness to drive. Eighty-one patients with AD and 45 healthy individuals participated. All participated in a clinical interview, and were administered a neuropsychological test battery and a driving simulator ride (predictors). The criterion fitness to drive was determined in an on-road driving assessment by experts of the CBR Dutch driving test organisation according to their official protocol. The validity of the predictors to determine fitness to drive was explored by means of logistic regression analyses, discriminant function analyses, as well as receiver operating curve analyses. We found that all three types of assessments are predictive of on-road driving performance. Neuropsychological assessment had the highest classification accuracy followed by driving simulator rides and clinical interviews. However, combining all three types of assessments yielded the best prediction for fitness to drive in patients with AD with an overall accuracy of 92.7%, which makes this method highly valid for assessing fitness to drive in AD. This method may be used to advise patients with AD and their family members about fitness to drive.

P300 component identification in auditory oddball and novel paradigms using source analysis techniques: reduced latency variability in the elderly.

P300 latency variability in normal subjects limits its diagnostic applicability as a test for cognitive function. One of the causes of variation is the overlap in P300 (P3A and P3B) components resulting in inaccurate latency determination. Recently, we have shown that identification of P3A and P3B components using source analysis techniques significantly reduces P300 latency variability in healthy younger subjects. Here, we included a novel paradigm to enhance sensitivity and investigated the efficiency of the source analysis technique in reducing the P300 latency variability in healthy older subjects. Data were recorded with a 128-channel EEG system in 28 healthy subjects (aged 53-82 years, 12 males). We used a standard two-tone and a novel three-tone auditory oddball paradigm and an established source analysis technique, and compared the latencies to those obtained with conventional P300 analysis. The source analysis method identified both P3A and P3B components in a substantially larger percentage of subjects (93% versus 32%) than the conventional method. Both for the standard and novel paradigm, the source analysis method yielded a later mean P3B latency (361.4 versus 344.2 milliseconds, P = 0.017, and 374.4 milliseconds versus 354.3 milliseconds, P = 0.014, respectively) with a smaller standard deviation (15.8 versus 26.2 milliseconds, P = 0.013, and 18.9 versus 30.0 milliseconds, P = 0.052, borderline significant, respectively) than the conventional P300 method, for subjects aged 50 to 70 years. When applying the source analysis technique, as in young healthy subjects, a considerable reduction of P300 latency variability was thus found in healthy older subjects aged 50 to 70 years for both paradigms. This may have important consequences for applications of clinical event-related potential research in the early diagnosis of dementia, because the first signs of this disease are mostly observed in this age category.

Cognitive, physiological, and personality correlates of recurrence of depression.

BACKGROUND: The risk of recurrence in depressive disorder is high and increases with the number of episodes. We investigated whether individuals with a history of recurrent depression deviate from individuals with a single episode, as regards risk-related variables in 3 different domains of depression research. METHODS: Participants were 102 outpatients with major depressive disorder remitted from an episode (60 recurrent, 42 nonrecurrent). We assessed the perception of emotions from vocal stimuli, 24-h urinary free cortisol, and neuroticism. RESULTS: The recurrent group had higher cortisol levels than the nonrecurrent group, and recurrent women also had a more negative perception than nonrecurrent women. These results were independent of each other, and could also not be accounted for by neuroticism or residual symptoms. Gender differences were found in all 3 domains. LIMITATIONS: The cross-sectional design limits the possibility to draw conclusions on the causality of the observed effects. CONCLUSIONS: Remitted outpatients with recurrent depression deviate from remitted outpatients with single episode depression as regards physiology and social cognition, in a way that may increase their risk of the development of subsequent episodes. The results may have implications for prophylactic treatment strategies.

Effect of ageing on the ability to adapt to a visual distortion during walking.

Degradation of major sensory systems such as proprioception, the vestibular system and vision may be a factor that contributes to the decline in walking stability in older people. In the present study this was examined by introducing a visual distortion by means of prism glasses shifting subject's view 10 degrees to the right while subjects walked towards a target (exposure condition). Shifting the view while walking towards a target will cause subjects to alter their heading in such a way that their walking trajectory describes a curvilinear path. It was expected that older people, when compared to young people, would have greater difficulty adjusting their heading and would show a greater decrease in heading stability, quantified by means of the standard deviation of the lateral position (SDLP). This was indeed the case. When performance in a pre- and post-exposure condition, in which subjects walked without prism glasses, were compared to each other, older people (O group) showed a greater decrease in heading stability than young people (Y group) and middle aged people (M group). Furthermore, it appeared that during the exposure condition adaptation effects were present in the Y and M group, which were absent in the O group. It is discussed that this adaptation is a form of realignment of the proprioceptive and visual system. The absence of realignment in the O group is argued to be caused by degradation of the proprioceptive system, which results in a lowering of the proprioceptive bias of vision.

Longer-term effects of ADAS use on speed and headway control in drivers diagnosed with Parkinson's disease.

OBJECTIVE: An advanced driver assistance system (ADAS) provided information about speed limits, speed, speeding, and following distance. Information was presented to the participants by means of a head-up display. METHODS: Effects of the information on speed and headway control were studied in a longer-term driving simulator study including 12 repeated measures spread out over 4 weeks. Nine healthy older drivers between the ages of 65 and 82 years and 9 drivers between the ages of 68 and 82 years diagnosed with Parkinson's disease (PD) participated in the study. Within the 4 weeks, groups completed 12 consecutive sessions (10 with ADAS and 2 without ADAS) in a driving simulator. RESULTS: Results indicate an effect of ADAS use on performance. Removing ADAS after short-term exposure led to deterioration of performance in all speed measures in the group of drivers diagnosed with PD. CONCLUSIONS: These results suggest that provision of traffic information was utilized by drivers diagnosed with PD in order to control their speed.