Barbara Freund

Drawing clocks and driving cars.

AbstractOBJECTIVE: The purpose of the study was to determine whether a new method of scoring the Clock Drawing Test (CDT) is a reliable and valid method for identifying older adults with declining driving competence. DESIGN: Prospective cohort study. SETTING: An outpatient driving evaluation clinic. PARTICIPANTS: One hundred nineteen community-dwelling, active drivers with a valid driver’s license, aged 60 and older referred for driving evaluation. MAIN OUTCOME MEASURES: The CDT and a driving test using a STISIM Drive simulator. RESULTS: The CDT showed a high level of accuracy in predicting driving simulation outcome (area under the receiver-operator curve, 0.90; 95% confidence interval, 0.82 to 0.95). CDT scoring scales were comparable and all correlations between CDT scores and driving performance were negative, implying that as the CDT score decreases, the number of errors increases. Interrater reliability of CDT scores was 0.95. Subjects scoring less than 5 out of 7 points on the CDT made significantly more driving errors, hazardous and in total (P<.001). CONCLUSIONS: The CDT can help establish problems with executive function and indicate the need for a formal driving evaluation. Our CDT scoring scale is a reliable, valid, and time-effective screening tool for identifying elderly drivers in need of further evaluation.

Zanamivir: a review of clinical safety.

Preclinical and clinical studies have clearly demonstrated that zanamivir, a potent and highly selective inhibitor of the influenza A and B virus neuraminidase, has an impressive safety profile. This report describes the safety and tolerability findings from the clinical studies completed up to the 17 July 1998 involving over 6000 adult and adolescent patients from North America, Europe and the Southern Hemisphere. Serious adverse events from an ongoing Japanese clinical programme are also reported. Zanamivir was administered in various dose forms and frequencies and was found to have a comparable safety profile with placebo when given for both the treatment and prophylaxis of influenza-like illness. These findings were independent of age and underlying medical condition. 4152 patients received zanamivir and the most commonly reported adverse events were consistent with the signs and symptoms of influenza-like illness. Most of the adverse events were mild and did not result in patient withdrawal from the studies. Less than 1% of zanamivir and placebo recipients reported a serious adverse event. In addition, 490 healthy volunteers received zanamivir in clinical pharmacology studies. It was well tolerated and the incidence of adverse events was similar in zanamivir and placebo recipients. In addition, no clinically significant laboratory abnormalities were detected. Results from in vitro and in vivo animal studies suggest that zanamivir has low acute toxicity and no significant systemic toxicity or respiratory tract irritancy at plasma exposures more than 100-fold higher than those anticipated following clinical use. Neither genotoxic nor reproductive types of toxicity have been observed in toxicology studies at doses equal to 17 to 197 times the current therapeutic dose (20 mg/day). The characteristics of the molecule and the low systemic exposure indicate a very low potential for drug interactions with the inhaled route. Furthermore, repeated 600mg intravenous doses were well tolerated in healthy volunteers. The observed safety profile of zanamivir compares favourably with currently available agents with anti-influenza virus activity, such as rimantadine and amantadine, as well as GS4104, a neuraminidase inhibitor currently in phase III development. This may be attributed to the low systemic bioavailability of zanamivir, which is given by oral inhalation, direct to the primary site of viral replication. The potential advantages of this include a reduced risk of drug-drug interactions, other nontarget organ toxicities (e.g. brain) and drug clearance issues from both kidney and liver. Therefore, the safety profile of zanamivir supports its use in the management of influenza.

Evaluating driving performance of cognitively impaired and healthy older adults: a pilot study comparing on-road testing and driving simulation.

Adults aged 67 to 78 were compared in driving performance on the road and in driving simulators. The driving simulator operated in an urban environment and required the subjects to execute maneuvers that would allow evaluation of their driving ability in a multitask situation. The two tests proved to be strongly and negatively correlated - the higher the score on the road test, the lower the score on the driving simulator.

In my car the brake is on the right: pedal errors among older drivers.

PURPOSE To assess to what extent specific cognitive functions contribute to pedal errors among older drivers. METHODS 180 subjects aged 65 and older completed a 30 min driving evaluation on a simulator as well as three cognitive tests, the Mini-Mental State Exam (MMSE), the Clock Drawing Test, and Trailmaking Part A and B. Analyses based on logistic regressions were performed using age, gender, MMSE, Trailmaking Part A and B, and Clock Drawing Test as independent variables. RESULTS Results indicate that Clock Drawing is the best predictor of pedal errors (odds ratio=10.04, p<.0001, 95% CI: 3.80, 26.63) followed by age > or =84 (odds ratio 6.10, p<.05, 95% CI: 1.77, 21.03). In contrast, Trailmaking Part A and B, gender, and the MMSE were not significantly related to pedal errors. CONCLUSION Executive dysfunction may be an important contributor to pedal errors and thus unsafe driving. Practitioners may wish to consider measures of executive function when evaluating patients for driving safety.

Error specific restrictions for older drivers: Promoting continued independence and public safety

OBJECTIVES To describe a population of older drivers with driving restrictions, their most common restrictions, and to compare restricted drivers to their safe and unsafe counterparts. Safe drivers are those who do not commit hazardous errors or traffic violations. Unsafe drivers are those who commit hazardous errors and/or traffic violations that place them in hazardous situations. Restricted drivers are those who have committed traffic or rule violations only under certain driving conditions. DESIGN A retrospective, cross-sectional study with mixed methodology. SETTING A clinical driving evaluation program within an academic geriatrics department. PARTICIPANTS Drivers age 60+ (N=108) referred for clinical driving evaluation and who consented to allow their data to be used for research purposes. INTERVENTION Drivers performing at an intermediate level driving fitness were issued error specific driving restrictions. MEASUREMENT Driving evaluation included clock drawing test (CDT), mini-mental status exam (MMSE), Trailmaking, geriatric depression scale (GDS), and simulated driving. RESULTS The three most common restrictions were limited driving distance (N=8), limited driving time (N=8), and daytime only driving (N=8). Safe, restricted, and unsafe drivers significantly differed on MMSE (F[2,104]=10.75, p<0.001), Trailmaking Part B (F[2,76]=9.96, p<0.001), CDT (F[2,98]=29.88, p<0.001), and total number of hazardous errors (F[2,97]=39.06, p<0.001). Tukeys test indicated safe and restricted drivers scored significantly better than unsafe drivers on MMSE (safe: p<0.001; restricted: p=0.008), CDT (p<0.001), and hazardous errors (p<0.001). Restricted and unsafe drivers required significantly more time to complete Trailmaking B than safe drivers (p=0.004). CONCLUSION Preliminary data indicate restricted drivers perform more like safe than unsafe drivers. Driving simulation is instrumental in discerning error specific limitations and categorizing patients as conditionally safe. This clinical evaluation pilots an effective alternative to premature driving cessation.

Office‐Based Evaluation of the Older Driver

This article comments on a companion piece in the same journal (Molnar, et al) that examines the usefulness of office-based cognition screening tests to determine fitness to drive in patients with dementia. This author notes that automobile driving places demands on attention, memory, problem solving, and information processing of cognitive skills that often decline with aging. However, screening tests for fitness to drive are just that, screening tests. They could be used to assist in the process of determining the need for further evaluation, and referral of patients for formal driver evaluation. The author stresses that decline in driving skills and the rate of decline is highly variable. The author concludes that what Molnar and colleagues have brought to attention is that, for those front-line clinicians who are looking for specific cutpoints, scoring algorithms, and decision rules, the driving and dementia literature falls short.

Silicone block interposition for traumatic bone loss.

In situations where bone is lost secondary to trauma, the use of a hand-carved silicone block provides good results. When bone grafting is undertaken, a well-defined membrane will have enveloped the implant. Incising the membrane allows easy block removal, and after freshening the bone ends, a cavity awaits the bone graft. This technique offers simplicity and adequate stability for therapy, and secondary bone grafting is facilitated by the created space.

Continued driving and time to transition to nondriver status through error-specific driving restrictions.

ABSTRACT We developed driving restrictions that are linked to specific driving errors, allowing cognitively impaired individuals to continue to independently meet mobility needs while minimizing risk to themselves and others. The purpose of this project was to evaluate the efficacy and duration expectancy of these restrictions in promoting safe continued driving. We followed 47 drivers age 60 years and older for 18 months, evaluating driving performance at 6-month intervals. Results demonstrated restricted drivers had safety profiles similar to safe drivers and gained additional driving time to transition to nondrivers.

Driving Habits of Older Drivers 3 Months Before Driving Evaluation

A retrospective chart review was conducted to describe the driving habit characteristics of older drivers referred for formal driving evaluation and compare habits of drivers found to be unsafe to drive with those of safe and restricted drivers. The subject population composed of community-dwelling older drivers (65 years or older) referred to a clinical driving evaluation program. At the time of the driving evaluation the Driving Habits Questionnaire (DHQ), Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), Trail Making Tests (Parts A and B), and a driving simulation were conducted. Logistic regression was used to examine the relationship between driving outcomes (dependent variable) and the selected variables from the DHQ. Driving habits did not predict driving evaluation outcomes. The CDT, the MMSE, and age were predictors of driving outcomes. In this sample of drivers, more than one-third were cognitively impaired when evaluated by the CDT and the MMSE and another one-third were borderline, whereas more than two-thirds were found unsafe to drive. Impaired cognition, along the continuum of mild to severe, negatively affects driving competency. Future research should continue to identify driving habits and restrictions that allow drivers to safely continue driving, particularly focusing on mild cognitive impairment and driving performance.