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‘Fit2Drive’ transforms assessing older drivers with cognitive decline

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‘Fit2Drive’ transforms assessing older drivers with cognitive decline

As the world’s population ages, so does the proportion of older drivers on the road. Safe driving requires adequate memory, perceptual and motor skills, and executive function abilities.

Although individuals with severe Alzheimer’s disease and related dementias (ADRD) are no longer able to drive safely, changes in driving performance may start at the preclinical stage of AD.

The decision to stop driving due to cognitive decline is difficult and contentious for older adults, their families and clinicians alike. While there are numerous cognitive tests and on-road evaluations available, clinical practitioners have reported that they have limited training as well as time constraints to administer these tests to determine whether a patient should stop driving. Moreover, objective evidence is difficult to obtain.

With the help of an evidence-based calculator called “Fit2Drive,” researchers from Florida Atlantic University have made it easy to administer and evaluate an in-office test to predict an older individual’s probability of passing an on-road driving test. Based upon brief, easily administered cognitive tests, Fit2Drive provides an objective estimation of the ability to drive for those with cognitive concerns.

For the study, FAU Christine E. Lynn College of Nursing and Charles E. Schmidt College of Science researchers created an algorithm to rapidly generate the prediction for an individual patient. They combined 12 cognitive tests and on-road evaluation data from two samples: patients from FAU’s Louis and Anne Green Memory and Wellness Center data repository and older drivers from the community.

The cognitive tests included the Mini-Mental State Exam (MMSE), a well-known 30-point dementia screening tool; and Trail Making Tests A, a test of visual tracking; and B, to evaluate cognitive flexibility and measure executive functioning. In total, 412 study participants, ages 59 to 89, completed the cognitive assessments and an on-road driving test.

Results of the study, published in the Journal of the American Medical Directors Association, showed that the Fit2Drive algorithm demonstrated a strong 91.5% predictive accuracy. A step-by-step examination of the predictive power of the results and a number of combinations, showed that the MMSE highest score and Trails B time in seconds accounted for the highest proportion of unique variance in the predictive model with minimal additional increase in predictive strength contributed by additional test scores.

Findings also showed statistically significant differences in the on-road evaluation results across the two samples, with most of those who failed the on-road driving test coming from the repository data set (53.7%) compared with those from the community sample (7.9%).

“The anger, tears and frustration on the part of the individual patient and the lack of objective data to guide clinician recommendations are the driving forces behind our efforts to develop a highly accurate, evidence-based predictor of the ability to pass an on-road driving test,” said Ruth Tappen, Ed.D., senior author and the Christine E. Lynn Eminent Scholar and Professor, FAU Christine E. Lynn College of Nursing. “Fit2Drive results are intended to provide the clinician with useful objective evidence that may be shared with the patient and family concerned about the advisability of continuing to drive, a situation that is a major life event for them and a challenge for primary care providers.”

To identify the smallest number of cognitive test results that could predict a person’s likelihood of passing an on-road driving test, researchers entered the in-office test results into a logistic regression (statistical model) using pass or fail on the on-road test results as the outcome on which the possible predictor variables were regressed.

The binary pass-fail outcome allowed the predictive model to assess the sensitivity (a true positive) and specificity (a true negative) of the predictive outcomes compared with the on-road evaluation. From this data, researchers created a contingency table from the four possible outcomes (true positive, false positive, true negative, false negative). The overall combination of the sensitivity and specificity is then graphed (called an ROC curve), and the AUC provides an estimate of the overall accuracy of their predictors.

“Printing a table with every possible combination of the MMSE score and Trails B time would yield 176 pages, which would be awkward for any clinician to use during a patient consultation,” said Tappen. “Therefore, we developed a calculator based on an equation derived from our data to provide easy access to the requisite data. When the results of a patient’s MMSE and Trails B time scores are entered, the calculator provides the clinician with the probability of a patient’s ability to pass an on-road driving test.”

The Fit2Drive calculator can be accessed at fit2drive.org. Researchers recommend the MMSE be administered first, followed by administration of Trails A and Trails B, which is how the tests were administered in this study. Providers can download the application from the Fit2Drive website to an Android or iOS mobile device and use a smartphone to enter the data.

“As our ability to administer cognitive tests online increases, we may be able to create an entirely online version of Fit2Drive to further streamline its use,” said Tappen.

Study co-authors are David Newman, Ph.D., professor and statistician, FAU Christine E. Lynn College of Nursing; Monica Roselli, Ph.D., professor and associate chair of psychology, FAU Charles E. Schmidt College of Science; Joshua Conniff, a Ph.D. student working in Roselli’s neuropsychology lab; Consolacion Paulette Sepe, a Ph.D. student, FAU Christine E. Lynn College of Nursing; and Matthew Newman, a systems architect, SolveIT.

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On a mission to show that hearing loss is not inevitable

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The world’s largest investigation into the effectiveness of hearing training kicks off this week – as part of a movement to prove that hearing loss is not an inevitable part of ageing.

The research project aims to attract a minimum of 10,000 participants to better understand how hearing training impacts auditory processing skills like speech comprehension and the ability to locate where sounds are coming from.

Researchers are interested in the impact of hearing training on users who start training with different hearing ability levels, as well as training adherence in groups with different attitudes to smartphone technology.

Their aim is to find new ways to deliver and improve auditory training at scale and for a wider range of hearing skills; and to measure factors which influence training engagement.

The research is led by health tech firm Eargym. Co-founder Andy Shanks says:  Contrary to popular belief, hearing loss is not an inevitable consequence of ageing. We can take steps to improve and protect our hearing throughout our lives, yet preventative measures like hearing training have traditionally been under-researched.

“Our data shows the transformative impact hearing training can have on our ability to process sounds. Now, we want to deepen and widen our research and use our platform to make hearing training even more effective and accessible. Imagine improving and maintaining your hearing by up to 20% or more: it could make a big difference to the lives of so many people.”

The games on the Eargym app include a “busy barista” exercise, where users must discern speech over a cafe’s bustling background noise; and a “sound seeking” exercise, where users make their way through forests, jungles and oceans to locate the sources of different sounds. Each game is designed to be immersive and to help users practise specific auditory processing skills regularly.

Eargym was set up by former NHS CEO Amanda Philpott and DJ Andy Shanks in 2020, after they were both diagnosed with hearing loss. Amanda has moderate age related hearing loss, whilst Andy has “notch” or noise-induced hearing loss due to DJ-ing. Both found hearing loss isolating and it impacted their ability to socialise and communicate. They created eargym to empower others to better understand their hearing health and take proactive steps to protect it.

Hearing loss currently affects 18 million adults in the UK, with around one billion young people at risk of developing hearing loss due to increased use of headphones. Hearing loss is closely associated with increased dementia risk. Despite this, people wait an average ten years before seeking help for hearing loss.

Eargym plans to publish the findings of its research in early 2025.

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Who cares for the carer? Supervised physical exercise improves the wellbeing of carers

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Members of the Ageing On research group of the University of the Basque Country (UPV/EHU) have investigated how to better look after carers of the elderly.

The general profile of carers of the elderly is mainly older and middle-aged women, working class, with a very high prevalence of lower back pain and consequently possible psycho-affective problems and a poorer quality of life.

The Ageing On group develops, among other things, physical exercise programmes to maintain the functional capacity of older people. However, the group realised that carers could also benefit from physical exercise.

“…we realised that there was another group, the carers of the elderly who could benefit from the advantages of individualised physical exercise, as the prevalence of lower back pain among carers is very high and directly and negatively affects their wellbeing,” said  researcher Ana Rodriguez-Larrad.

“We studied more than 200 carers to see what problems they had, where we could make a difference, what could be effective and what could not.”

The organisation has now piloted a programme to relieve lower back pain among staff from six organisations, explained the researcher Ander Espin-Elorza: “For twelve weeks work was done as a team and at work involving simple strength exercises using body weight and resistance bands, and training in a progressive and personalised way with moderate intensity.”

At the end of the programme, the researchers observed that the lower back pain of the staff had decreased. “What is more, people who attended half of the planned sessions also experienced improvements in psycho-affective terms; the risk of depression declined, the use of hypnotic and anti-anxiety drugs decreased and the quality of life improved,” added Espín.

However, in the tests conducted 48 weeks after the end of the programme, it appears that the benefits regarding lower back pain had declined somewhat, which would indicate “the importance of ongoing physical exercise”.

In-company video call sessions

The research also validated a tool to assess, online, the physical fitness of the staff, and exercise programmes were run via videoconference, as the research was conducted in the context of the COVID-19 pandemic.

“Conducting virtual and remote sessions may be beneficial, for example, in terms of the economic advantage or being able to conduct them during a pandemic, etc.,” explained Espin.

In addition, “these types of programmes can also be extended to other types of carers, such as informal carers, and can also tackle other painful areas such as the shoulder, wrists, etc.”, said Rodriguez.

Supervised physical exercise programmes have a positive effect on the reduction of sick days per year, although this still needs to be investigated further.

“In addition to the benefits it can bring to workers’ well-being, the implementation of physical exercise enables better care to be given,” Rodriguez explained.

So some companies have already contacted the Ageing On research group to implement the programme: “It provides a lot of freedom and the results are good,” the team said.

Researchers from the Ageing On group are continuing their research.

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Routine cognitive testing could help older adults make safer decisions around driving, finds study

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The findings of a new study say routine cognitive testing may help older drivers and their physicians make better decisions about driving to maximise safety while preserving independence as long as possible.

One of the thorniest decisions facing older adults is when to give up their keys and stop driving, but a new study by researchers at Washington University School of Medicine in St. Louis could provide guidance in helping seniors plan ahead.

The researchers found that impaired cognitive function foreshadows the decision for many seniors to stop driving — more so than age or molecular signs of Alzheimer’s disease. Even very slight cognitive changes are a sign that retirement from driving is imminent. Further, women are more likely to stop driving than men, the study showed.

The findings suggest that routine cognitive testing — in particular, the kind of screening designed to pick up the earliest, most subtle decline — could help older adults and their physicians make decisions about driving to maximise safety while preserving independence as long as possible.

“Many older drivers are aware of changes occurring as they age, including subjective cognitive decline,” said corresponding author Ganesh M. Babulal, PhD, OTD, an associate professor of neurology.

“Doctors should discuss such changes with their older patients. If risk is identified early, there is more time to support the remaining capacity and skills, extending the time they can drive safely, and to plan for a transition to alternative transportation options to maintain their independence when the time comes to stop driving.”

Adults over age 65 are the most careful drivers on the road. They are less likely than drivers in any other age group to speed or to drive in bad weather, at night or under the influence of substances.

Despite these precautions, age-related changes such as slower reaction time, impaired vision and cognitive decline still put older drivers at risk of crashes, and when such crashes happen, older drivers are more likely to be killed or seriously injured than younger drivers are. At the same time, giving up driving is not without its own risks. People who stop driving are more likely to develop depression and become isolated.

The American Academy of Neurology concluded in 2010 that cognitive impairment, as measured by a score greater than zero on the Clinical Dementia Rating (CDR) scale, was the best predictor of stopping driving.

The CDR scale goes from zero, indicating normal cognitive function, to three, indicating severe dementia. But the CDR, which was developed at Washington University in 1982, is designed to detect impairments significant enough to affect daily life. Studies have shown that a person’s cognitive skills can deteriorate for years before a CDR score indicates trouble.

Babulal and colleagues set out to determine the role of other factors, including subtle cognitive changes, in the decision to step away from the wheel. They studied 283 people with an average age of 72 who drove at least once a week and who had no cognitive impairments at the start of the study. The researchers were primarily interested in determining when and why each participant stopped driving.

The participants underwent cognitive tests at the start and then every year for an average of 5.6 years. The cognitive testing included the CDR and a preclinical Alzheimer’s cognitive composite (PACC) score, which is designed to detect subtle cognitive changes in people who score as unimpaired on the CDR. The participants also underwent brain scans and donated cerebrospinal fluid at the start of the study and then every two to three years, so the researchers could look for molecular signs of Alzheimer’s disease. At baseline, about one-third of the people met the criteria for preclinical Alzheimer’s disease based on levels of biomarkers for the disease — amyloid plaques and tau tangles — in the brain and cerebrospinal fluid.

During the study, 24 people stopped driving, 15 people died, and 46 people developed cognitive impairment as measured by a CDR score greater than zero.

Analysis showed that three factors predicted who would stop driving during the study: cognitive impairment, worsening PACC scores, and being a woman. People who met the criteria for cognitive impairment by scoring 0.5 or greater on the CDR were 3.5 times more likely to stop driving than were those who remained at zero, and people with lower scores on the PACC were 30 per cent more likely to stop driving than were those with higher scores. Age and the presence of biomarkers of Alzheimer’s disease were not tied to the decision to stop driving.

The biggest effect was seen regarding gender, with women four times more likely to stop driving during the course of the study than men were.

“We know from past studies that there isn’t a difference in driving ability between men and women,” Babulal said.

“What we have shown in prior work is that women are often more aware of their abilities, are more willing to admit that they are no longer able to safely drive, and plan more in advance to transition out of driving compared to their male counterparts. It is highly recommended that older male drivers talk with their providers about driving and consider stopping driving earlier.”

Doctors do not routinely counsel older patients on driving cessation, a fact that Babulal sees as a missed opportunity to promote healthy ageing.

“There are things we can do to help people adapt to age-related changes,” Babulal said. “Driver rehabilitation programs, often led by occupational therapists, can provide specialised training and strategies for older drivers to adjust to physical and cognitive changes to maintain driving capacity.

“Community support programs provide a forum for older adults to share experiences and learn from each other about safe driving practices and alternative transportation options. Ultimately, most people will need to stop driving, but by starting the conversation early, we can better support older adults’ independence and quality of life.”

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