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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.”

Independence

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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Independence

NHS health records help predict risk of falling

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Patients’ risk of falling in the next 12 months could be predicted from their NHS data using a newly developed calculator.

eFalls is a falls prediction model which uses routinely available primary care electronic health record data, the first of its kind in the world.

Developed and tested by researchers from the University of Leeds, the University of Birmingham, and a team of collaborators*, with funding from the National Institute for Health and Care Research (NIHR), it can be used to help identify people at risk of hospitalisation or emergency department attendance after a fall over the next 12 months. This means these people can be provided with interventions to prevent falls taking place.

A research paper outlining the findings is published in Age and Ageing

Falls are common among people aged over 65 and can be devastating for people’s personal independence. The risks are multifactorial and include conditions that affect mobility or balance; medications, and home hazards. A history of falls is the strongest risk factor. The incidence of falls is also projected to rise in line with the global ageing demographic.

The findings help proactive identification of people who are at risk of experiencing a fall in the next 12 months. eFalls uses existing primary care data, reducing the need for intensive clinical falls assessment, saving doctors and nurses valuable time. Once identified as at risk of falling, people can be referred on to a specialist falls prevention service for assessment and treatment to prevent future falls.

The National Institute for Health and Care Excellence (NICE) estimates that 40% to 60% of falls result in major lacerations, traumatic brain injuries, or fractures. Other complications of falls include distress, pain, loss of self-confidence, reduced quality of life, loss of independence, and mortality.

Principal Investigator Andrew Clegg, Professor of Geriatric Medicine in the University of Leeds School of Medicine, said: “Falls are a global health problem of major importance to health and social care systems. Currently, people’s fall risk is usually only assessed when they have already experienced a fall, which means that they might have already experienced a major injury such as a hip fracture.

“Our eFalls calculator means that, for the first time, it is possible to proactively identify a person’s risk of future falls which means that they can be referred to specialist falls prevention services, reducing the risk of a fall from happening. The ability to put plans in place to protect those at risk is invaluable to the patient and their loved ones.

“The benefit to the health service is that it reduces the need for treatment and care in hospital and in the community, and the associated costs to the NHS of that treatment. We hope that eFalls will be widely adopted across the NHS to prevent falls from taking place.”

Lead author Lucinda Archer, Assistant Professor in Biostatistics at the University of Birmingham, said: “The eFalls calculator can be used to predict a person’s risk of a fall, based on information that is already included in their GP records. The accuracy of the tool has been thoroughly tested in two large datasets, containing routinely recorded information on patients from Wales and England, which has shown promising results.

“If this accuracy is consistent across the wider population, the use of eFalls to target those who would benefit from specialist assessment could vastly improve the way that falls prevention services are provided in the UK.”

Health Minister Andrew Stephenson said: “Suffering from a fall can be traumatic for both the individual and their family but innovations such as eFalls could provide a fantastic solution to prevent such incidents, saving people from a lot of pain, as well as time and resource for the NHS.

“Our ongoing work to ensure people get the right care at the right time includes giving people access to local falls services and rehabilitations services, but I’m proud that the UK is at the forefront of developing further solutions to such a widespread issue, through co-funding the development of this technology.”

The team set out to produce and assess a robust and reliable method to proactively identify people for falls prevention interventions, due to the currently limited availability of such systems.

The team developed the eFalls tool using data from more than 750,000 healthcare records. Of these almost 35,000 people experienced a fall or a fracture resulting in A&E attendance or hospitalisation within 12 months.

The researchers now hope the eFalls prediction model to be successfully integrated into UK primary care electronic patient record systems and are keen to work with UK policymakers to explore how eFalls could be used to inform health policy.

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Technology

UK body calls for more ageing research backing

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The British Society for Research on Ageing (BSRA) is calling for more public backing in the UK for research to help people stay healthier for longer, as an alternative to charities that support research on diseases.

The greatest risk factor for disease is ageing, but we have very little charitable support for research into how to slow ageing, the organisation warns.

Many diseases such as cancers and heart disease tragically shorten lives far too early, or like Alzheimer’s and arthritis, destroy quality of life for patients and carers. There is understandably huge public charitable support for more research. However, the greatest risk factor for those diseases, and even infectious diseases like COVID, is ageing.

Yet in comparison there is currently very little support for research to understand how we can slow ageing to prevent disease. This approach may be more productive in the long term to fight disease. Furthermore, keeping people healthier for longer, or avoiding chronic diseases all together, would be the most favourable outcome.

The UK population is ageing fast, putting pressure on the NHS and the economy. Despite this pressing problem all around us, there is no accessible way for people to support research into ageing in the UK. The BSRA aims to change that.

With a very small budget and almost completely run by volunteers, the BSRA has successfully funded several small research projects but progress needs to be accelerated. More funding is needed because it takes years to see the effects of ageing, so studies are long. Also ageing affects individuals in different ways, meaning that large numbers of people must be studied to make firm conclusions.

Therefore, there is an urgency to get studies funded and the BSRA has decided to launch an ambitious fundraising campaign to boost research into ageing. Initially, the Society aims to fund a series of one year research projects at the Masters degree level at universities across the UK and with plans to raise much more in the future to support longer and more ambitious projects that will impact the lives of the general public.

Chair of the BSRA, Prof David Weinkove from Durham University, says “The time is now to really get behind research into the biology of ageing. We have fantastic researchers across the country, but they are held back by a lack of funding. Evidence-based research is needed to understand how we people can stay healthier for longer, and to then we must make that knowledge available to as many people as possible”.

Dr Jed Lye says “This is a great opportunity for the public to help, for corporations to contribute, or philanthropists wanting a large impact with a relatively small donation; every £20,000 we raise can fund an entire year of research into ageing and longevity, and gets a budding scientist their research qualification.”

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