The Addenbrooke's Cognitive Examination Revised as a potential screening test for elderly drivers

Strong evidence for age as the single most dominant predictor of medically supervised driving test-mini mental status test outcomes provide only weak but significant moderate additional predictive value

Background

With age, medical conditions impairing safe driving accumulate. Consequently, the risk of accidents increases. To mitigate this risk, Swiss law requires biannual assessments of the fitness to drive of elderly drivers. Drivers may prove their cognitive and physical capacity for safe driving in a medically supervised driving test (MSDT) when borderline cases, as indicated by low performance in a set of four cognitive tests, including e.g. the mini mental status test (MMST). Any prognostic, rather than indicative, relations for MSDT outcomes have neither been confirmed nor falsified so far. In order to avoid use of unsubstantiated rules of thumb, we here evaluate the predictive value for MSDT outcomes of the outcomes of the standard set of four cognitive tests, used in Swiss traffic medicine examinations.

Methods

We present descriptive information on age, gender and cognitive pretesting results of all MSDTs recorded in our case database from 2017 to 2019. Based on these retrospective cohort data, we used logistic regression to predict the binary outcome MSDT. An exploratory analysis used all available data (model 1). Based on the Akaike Information Criterion (AIC), we then established a model including variables age and MMST (model 2). To evaluate the predictive value of the four cognitive assessments, model 3 included cognitive test outcomes only. Receiver operating characteristics (ROC) and area under the curve (AUC) allowed evaluating discriminative performance of the three different models using independent validation data.

Results

Using N = 188 complete data sets of a total of 225 included cases, AIC identified age (p < 0.0008) and MMST (p = 0.024) as dominating predictors for MSDT outcomes with a median AUC of 0.71 (95%-CI 0.57–0.85) across different training and validation splits, while using the four cognitive test results exclusively yielded a median AUC of 0.55 (95%-CI 0.40–0.71).

Conclusions

Our analysis provided strong evidence for age as the single most dominant predictor of MSDT outcomes. Adding MMST provides only weak additional predictive value for MSDT outcomes. Combining the results of four cognitive test used as standard screen in Swiss traffic medicine alone, proved to be of poor predictive value. This highlights the importance of MSDTs for balancing between the mitigation of risks by and the right to drive for the elderly.

The incremental value of neuropsychological assessment: A critical review

Objective: The purpose of this critical review was to evaluate the current state of research regarding the incremental value of neuropsychological assessment in clinical practice, above and beyond what can be accounted for on the basis of demographic, medical, and other diagnostic variables. The focus was on neurological and other medical conditions across the lifespan where there is known risk for presence or future development of cognitive impairment.Method: Eligible investigations were group studies that had been published after 01/01/2000 in English in peer-reviewed journals and that had used standardized neuropsychological measures and reported on objective outcome criterion variables. They were identified through PubMed and PsychInfo electronic databases on the basis of predefined specific selection criteria. Reference lists of identified articles were also reviewed to identify potential additional sources. The Grades of Recommendation, Assessment, Development and Evaluation Working Group's (GRADE) criteria were used to evaluate quality of studies.Results: Fifty-six studies met the final selection criteria, including 2 randomized-controlled trials, 9 prospective cohort studies, 12 retrospective cohort studies, 21 inception cohort studies, 2 case control studies, and 10 case series studies. The preponderance of the evidence was strongly supportive with regard to the incremental value of neuropsychological assessment in the care of persons with mild cognitive impairment/dementia and traumatic brain injury. Evidence was moderately supportive with regard to stroke, epilepsy, multiple sclerosis, and attention-deficit/hyperactivity disorder. Participation in neuropsychological evaluations was also associated with cost savings.Conclusions: Neuropsychological assessment can improve both diagnostic classification and prediction of long-term daily-life outcomes in patients across the lifespan. Future high-quality prospective cohort studies and randomized-controlled trials are necessary to demonstrate more definitively the incremental value of neuropsychological assessment in the management of patients with various neurological and other medical conditions.

General cognitive impairment as a risk factor for motor vehicle collision involvement: a prospective population-based study

This study examined whether cognitive impairment and decline as assessed by a brief mental status screening test is associated with future crash risk in a cohort of older drivers. A three-year prospective study was conducted in a population-based sample of 2000 licensed drivers, aged 70 years and older. At the baseline visit, cognitive impairment was defined as <24 on the Mini Mental State Exam (MMSE). Decline was defined as those with a one-year change in MMSE scores in the lowest quartile (largest decrease). Motor vehicle collision involvement was obtained from the Alabama Department of Public Safety. Poisson regression was used to calculate crude and adjusted rate ratios (RR). There were 278 crashes during the follow-up period. Rates of crash involvement were higher for those with cognitive impairment (crude RR = 2.33) compared to those without impairment at baseline; adjustment for potential confounders namely age and visual processing speed attenuated this relationship (adjusted RR = 1.26, 95% confidence interval (CI) 0.65–2.44). Drivers who experienced a pronounced decline in estimated MMSE scores in one year were 1.64 (95% CI 1.04–2.57) times more likely to have a future at-fault crash, as compared to those whose scores did not decline. Evaluation of MMSE over time may provide important insight in an older driver’s future risk of at-fault crash involvement.

Saccular Impairment in Alzheimer's Disease Is Associated with Driving Difficulty

BACKGROUND/AIMS

Patients with Alzheimer's disease (AD) experience increased rates of vestibular loss. Recent studies suggest that saccular impairment in mild cognitive impairment (MCI) and AD patients is associated with impaired spatial cognitive function. However, the impact of saccular impairment on everyday behaviors that rely on spatial cognitive function is unknown.

METHODS

We recruited 60 patients (21 MCI and 39 AD) from an interdisciplinary Memory Clinic. Saccular function was measured, and a visuospatial questionnaire was administered to assess whether participants experienced impairments in terms of driving difficulty, losing objects, falls, and fear of falling.

RESULTS

In multiple logistic regression analyses, MCI and AD patients with bilateral saccular impairment had a significant, greater than 12-fold odds of driving difficulty (OR 12.1, 95% CI 1.2, 117.7) compared to MCI and AD patients with normal saccular function, and the association appears to be mediated by spatial cognition as measured by the Money Road Map Test.

CONCLUSION

This study suggests a novel link between saccular impairment and driving difficulty in MCI and AD patients and demonstrates that driving difficulty may be a real-world manifestation of impaired spatial cognition associated with saccular impairment.

Vestibular Dysfunction and Difficulty with Driving: Data from the 2001-2004 National Health and Nutrition Examination Surveys

BACKGROUND AND OBJECTIVE

There is growing understanding of the role of vestibular function in spatial navigation and orientation. Individuals with vestibular dysfunction demonstrate impaired performance on static and dynamic tests of spatial cognition, but there is sparse literature characterizing how these impairments might affect individuals in the real-world. Given the important role of visuospatial ability in driving a motor vehicle, we sought to evaluate whether individuals with vestibular dysfunction might have increased driving difficulty.

MATERIALS AND METHODS

We used data from the 2001-2004 National Health and Nutrition Examination Surveys to evaluate the influence of vestibular dysfunction in driving difficulty in a nationally representative sample of U.S. adults aged ≥50 years (n = 3,071). Vestibular function was measured with the modified Romberg test. Furthermore, since vestibular dysfunction is a known contributor to falls risk, we assessed whether individuals with vestibular dysfunction and concomitant driving difficulty were at an increased risk of falls.

RESULTS

In multivariate analyses, vestibular dysfunction was associated with a twofold increased odd of driving difficulty (odds ratio 2.16, 95% CI 1.57, 2.98). Among participants with vestibular dysfunction, concomitant driving difficulty predicted an increased risk of falls that was significantly higher than in participants with vestibular dysfunction only (odds ratio 13.01 vs. 2.91, p < 0.0001).

CONCLUSION

This study suggests that difficulty driving may be a real-world manifestation of impaired spatial cognition associated with vestibular loss. Moreover, driving difficulty may be a marker of more severe vestibular dysfunction.

Reporting of the translation and cultural adaptation procedures of the Addenbrooke's Cognitive Examination version III (ACE-III) and its predecessors: a systematic review

BACKGROUND

The ACE-III, a gold standard for screening cognitive impairment, is restricted by language and culture, with no uniform set of guidelines for its adaptation. To develop guidelines a compilation of all the adaptation procedures undertaken by adapters of the ACE-III and its predecessors is needed.

METHODS

We searched EMBASE, Medline and PsychINFO and screened publications from a previous review. We included publications on adapted versions of the ACE-III and its predecessors, extracting translation and cultural adaptation procedures and assessing their quality.

RESULTS

We deemed 32 papers suitable for analysis. 7 translation steps were identified and we determined which items of the ACE-III are culturally dependent.

CONCLUSIONS

This review lists all adaptations of the ACE, ACE-R and ACE-III, rates the reporting of their adaptation procedures and summarises adaptation procedures into steps that can be undertaken by adapters.

Cognitive basis about risk level classifications for the self-assessment of older drivers

[Purpose] This study analyzed the cognitive functions according to risk level for the Driver 65 Plus measure, and examined the cognitive basis of self-assessment for screening the driving risk of elderly drivers. [Subjects and Methods] A total of 46 older drivers with a driver’s license participated in this study. All participants were evaluated with Driver 65 Plus. They were classified into three groups of “safe,” “caution” and “stop,” and examined for cognitive functions with Trail Making Test and Montreal Cognitive Assessment-K. The cognitive test results of the three groups were compared. [Results] Trail Making Test-A, Trail Making Test-B, and Montreal Cognitive Assessment-K showed a significant difference between the three groups. The safe group showed significantly higher ability than the caution and stop groups in the three cognitive tests. In addition, cognitive functions of naming, attention, language, and delayed recall were significantly different between the three groups. [Conclusion] Self-assessment of older drivers is a useful tool for screening the cognitive aspects of driving risk. The cognitive functions, such as attention and recall, are the critical factors for screening the driving risk of elderly drivers.

Effects of Age and Task Load on Drivers' Response Accuracy and Reaction Time When Responding to Traffic Lights

Due to population aging, elderly drivers represent an increasing proportion of car drivers. Yet, how aging alters sensorimotor functions and impacts driving safety remains poorly understood. This paper aimed at assessing to which extent elderly drivers are sensitive to various task loads and how this affects the reaction time (RT) in a driving context. Old and middle-aged people completed RT tasks which reproduced cognitive demands encountered while driving. Participants had to detect and respond to traffic lights or traffic light arrows as quickly as possible, under three experimental conditions of incremental difficulty. In both groups, we hypothesized that decision-making would be impacted by the number of cues to be processed. The first test was a simple measure of RT. The second and third tests were choice RT tasks requiring the processing of 3 and 5 cues, respectively. Responses were collected within a 2 s time-window. Otherwise, the trial was considered a no-response. In both groups, the data revealed that RT, error rate (incorrect answers), and no-response rate increased along with task difficulty. However, the middle-aged group outperformed the elderly group. The RT difference between the two groups increased drastically along with task difficulty. In the third test, the rate of no-response suggested that elderly drivers needed more than 2 s to process complex information and respond accurately. Both prolonged RT and increased no-response rate, especially for difficult tasks, might attest an impairment of cognitive abilities in relation to aging. Accordingly, casual driving conditions for young drivers may be particularly complex and stressful for elderly people who should thus be informed about the effects of normal aging upon driving.

Supporting Safety in the Older Adult Driver: A Public Health Nursing Opportunity

The effective operation of a motor vehicle encompasses a wide range of cognitive processes that can decline due to age-related changes in neuroanatomical structures and cognitive functionality. The increasing number of older adult drivers in our rapidly aging population heightens the public safety concern of unsafe driving associated with these changes. Nurses caring for older adults in public health settings are well positioned to make a difference in the management of older patients who may be at risk of endangering themselves or others on the roadways. In this article, information is provided for increasing nurses' awareness of the cognitive factors inhibiting effective driving, recognizing older adults who may be at risk for unsafe driving, and facilitating a patient/family to seek a driving evaluation.

Validity of the mini-mental state examination and the montreal cognitive assessment in the prediction of driving test outcome

OBJECTIVES

To evaluate the effectiveness of two cognitive screening measures, the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA), in predicting driving test outcome for individuals with and without cognitive impairment.

DESIGN

Retrospective cohort study.

SETTING

A clinical driving evaluation program at a teaching hospital in the United States.

PARTICIPANTS

Adult drivers who underwent assessment with the MMSE and MoCA as part of a comprehensive driving evaluation between 2010 and 2014 (N=92).

MEASUREMENTS

MMSE and MoCA total scores were independent variables. The outcome measure was performance on a standardized road test.

RESULTS

A preestablished diagnosis of cognitive impairment enhanced the validity of cognitive screening measures in the identification of at-risk drivers. In individuals with cognitive impairment there was a significant relationship between MoCA score and on-road outcome. Specifically, an individual was 1.36 times as likely to fail the road test with each 1-point decrease in MoCA score. No such relationship was detected in those without a diagnosis of cognitive impairment.

CONCLUSION

For individuals who have not been diagnosed with cognitive impairment, neither the MMSE nor the MoCA can be reliably used as an indicator of driving risk, but for individuals with a preestablished diagnosis of cognitive impairment, the MoCA is a useful tool in this regard. A score on the MoCA of 18 or less should raise concerns about driving safety.

Validation of the Chinese version of Addenbrooke's cognitive examination-revised for screening mild Alzheimer's disease and mild cognitive impairment

BACKGROUND/AIMS

As a suitable test to screen for Alzheimer's disease (AD) or mild cognitive impairment (MCI), studies to validate the Chinese version of Addenbrooke's Cognitive Examination-Revised (ACE-R) are rare.

METHODS

A total of 151 subjects were recruited and the neuropsychological assessments were employed. One-way analysis of variance and Bonferroni correction were used to compare scores of different psychometric scales. Intraclass correlation coefficient (ICC) and Cronbach's coefficient α were used to evaluate the reliability of psychometric scales. The validity of ACE-R to screen for mild AD and amnestic subtype of MCI (a-MCI) was assessed by receiver operating characteristic (ROC) curves.

RESULTS

The Chinese ACE-R had good reliability (inter-rater ICC = 0.994; test-retest ICC = 0.967) as well as reliable internal consistency (Cronbach's coefficient α = 0.859). With its cutoff of 67/68, the sensitivity (0.920) and specificity (0.857) were lower than for the Mini-Mental State Examination (MMSE) cutoff (sensitivity 1.000 and specificity 0.937) to screen for mild AD. However, the sensitivity of ACE-R to screen for a-MCI was superior to the MMSE with a cutoff of 85/86. The specificity of ACE-R was lower than that of the MMSE to screen for a-MCI. The area under the ROC curve of ACE-R was much larger than that of the MMSE (0.836 and 0.751) for detecting a-MCI rather than mild AD.

CONCLUSION

The Chinese ACE-R is a reliable assessment tool for cognitive impairment. It is more sensitive and accurate in screening for a-MCI rather than for AD compared to the MMSE.