Bonnie Dobbs

Aging Baby Boomers-A Blessing or Challenge for Driver Licensing Authorities

Introduction. In less than 5 years, the first wave of baby boomers will begin turning 65, with the last wave of boomers entering their senior years in January 2029. Currently, boomers make up a significant percentage of the population in Canada, the United States, and other developed countries. The baby boom generation has had a profound impact on our society over the last six decades, and this large cohort will continue to exert its influence for several decades to come. Central to this article is the rapid growth in the number of persons 65 years of age and older, beginning in 2011, with a corresponding increase in the number of older drivers. The demographic shift has important implications for licensing authorities, the regulatory bodies charged with licensing and ‘fitness to drive’ decisions. Objectives. The objectives of this paper are to summarize the published scientific literature on licensing policies and procedures currently in use for older drivers, discuss their limitations, and provide recommendations for meeting the upcoming challenges of an aging baby boomer population of drivers. Method. Online searches were conducted using the following databases: PsycINFO, MEDLINE, Scopus, and TRIS. Google and Google Scholar also were searched for scientific articles. References identified from database and online searches were examined for relevant articles. Results. A number of studies have investigated the utility of different licensing policies and procedures for identifying older drivers who may be at risk for impaired driving performance. Overall, results suggest that current policies and procedures are ineffective in identifying high-risk older drivers. The results also emphasize the need for a different approach for the identification of high risk older drivers by licensing agencies. Recommendations to assist with that goal are provided. Conclusions. The aging of the baby boomer population, combined with the projected high crash rates for this cohort of drivers as it moves through the senior years, underscores the need for cost-effective, accurate, and efficient methods for identifying and assessing the subgroup of older drivers whose driving has declined to an unsafe level. That subgroup consists of individuals with medical conditions (and treatments) affecting driving performance. The demographic shift has been a blessing for licensing authorities in that it has created awareness of the need for a reexamination of licensing policies and procedures designed to identify those older drivers who may no longer be safe to drive. If that awareness becomes translated into effective policies and procedures that appropriately target the medically at-risk/impaired older driver rather than the older driver per se, the result will be an increase in the safety and mobility of the older driving population and increased public safety overall. However, a continued focus on older drivers rather than medically at-risk drivers will result in a costly, ineffective, and overburdened system.

Working memory deficits associated with chronic fatigue syndrome.

Cognitive impairments are among the most frequently reported and least investigated components of the chronic fatigue syndrome (CFS). As part of a multifaceted study of the CFS, the present study investigated the cognitive functioning of chronic fatigue patients. The performance of 20 CFS patients was compared to that of controls (N = 20) on 4 tests of working memory (WM). Digit Span Forward was used to assess the storage capacity of WM. Multiple aspects of central executive functioning were assessed using several standard measures: Digit Span Backward, and Trails A and Trails B. More recently developed measures of WM were used to assess control of processing under temporal demands (working memory task) and resistance to interference (a sustained attention task). Deficits were restricted to more demanding tasks, requiring resistance to interference and efficient switching between processing routines. The overall results clearly implicate deficits in the control aspects of central executive function in CFS.

Qualitative Research on Older Drivers

Abstract With an aging population, concerns for road safety point to a growing need for research into the driving attitudes and habits of older adults. In this review of the qualitative literature, we have identified 25 studies that used focus groups or interviews to learn about the experiences and concerns of older drivers. The review addresses four themes: (1) The importance of driving; (2) negative aspects of driving; (3) the process of driving cessation, and; (4) views of transportation alternatives. An understanding of these topics can help to improve program and research planning for the transportation needs of older adults.

Geriatric Core Competencies for Family Medicine Curriculum and Enhanced Skills: Care of Elderly

Background There is a growing mandate for Family Medicine residency programs to directly assess residents’ clinical competence in Care of the Elderly (COE). The objectives of this paper are to describe the development and implementation of incremental core competencies for Postgraduate Year (PGY)-I Integrated Geriatrics Family Medicine, PGY-II Geriatrics Rotation Family Medicine, and PGY-III Enhanced Skills COE for COE Diploma residents at a Canadian University. Methods Iterative expert panel process for the development of the core competencies, with a pre-defined process for implementation of the core competencies. Results Eighty-five core competencies were selected overall by the Working Group, with 57 core competencies selected for the PGY-I/II Family Medicine residents and an additional 28 selected for the PGY-III COE residents. The core competencies follow the CanMEDS Family Medicine roles. Both sets of core competencies are based on consensus. Conclusions Due to demographic changes, it is essential that Family Physicians have the required skills and knowledge to care for the frail elderly. The core competencies described were developed for PGY-I/II Family Medicine residents and PGY-III Enhanced Skills COE, with a focus on the development of geriatric expertise for those patients that would most benefit.

Video programming for individuals with dementia: assessing cognitive congruence.

The effect of cognitively congruent video programming on attentional engagement, as measured by the average look duration and the proportion of the video viewed, was examined among long-term care facility residents with Alzheimers disease. Over a 2-week period, 24 residents viewed 4 cognitively congruent videos and 1 control video (ie, a recorded episode of a local news program) at least once. Level of attentional engagement was significantly higher for cognitively congruent video programs compared to the News. Neither history of television viewing nor cognitive status was related to engagement. The results suggest that video programs with less cognitive complexity may be more engaging for individuals with Alzheimers disease.

Retroperitoneal haematoma associated with enoxaparin use in an elderly woman with chronic kidney disease

An 81-year-old woman with chronic kidney disease was on enoxaparin (1 mg/kg subcutaneously two times a day) for 4 months to manage pulmonary embolism. While admitted for diagnostic evaluation of frequent falls, transient ischaemic attacks and pain management, she developed vomiting, diarrhoea, melena and hypotension. Her estimated glomerular filtration rate decreased from an admission value of 34 mL/min/1.73 m2 to 13 mL/min/1.73 m2. CT scan showed retroperitoneal haematoma. She was placed in intensive care and stabilised with aggressive fluid replacement, blood transfusion, and discontinuation of enoxaparin and concomitant aspirin. We attribute this major bleeding to enoxaparin use in an elderly woman with chronic kidney disease and concomitant aspirin intake. We will review reported cases of enoxaparin-associated retroperitoneal haematoma. We suggest that enoxaparin be used with caution in elderly patients with chronic kidney disease, and stress that treatment monitoring and reversal may not be readily available.

Training of Specialized Geriatric Physicians to Meet the Needs of an Aging Population—A Unique Care of the Elderly Physician Program in Canada

accepted at the North American Primary Care Research Group 2013 for a poster presentation. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Funded by the Northern Alberta Academic Family Physician Endowment Fund. Author Contributions: LC: conception and design, acquisition of data, interpretation of data, drafting the article, critical revision of the article for important intellectual content, final approval of the version to be published. BD: conception and design, analysis and interpretation of data, critical revision of the article for important intellectual content, final approval of the version to be published. RM: conception and design, analysis and interpretation of data, drafting the article, critical revision of the article for important intellectual content, final approval of the version to be published. OB: analysis and interpretation of data, critical revision of the article for important intellectual content; final approval of the version to be published. JT: conception, drafting the article, critical revision of the article for important intellectual content, final approval of the version to be published. Sponsor’s Role: None.

Predicting Hepatic Encephalopathy-Related Hospitalizations Using a Composite Assessment of Cognitive Impairment and Frailty in 355 Patients With Cirrhosis

INTRODUCTION: Hepatic encephalopathy (HE) is the most common potentially modifiable reason for admission in patients with cirrhosis. Cognitive and physical components of frailty have pathophysiologic rationale as risk factors for HE. We aimed to assess the utility of a composite score (MoCA‐CFS) developed using the Montreal Cognitive Assessment (MoCA) and the Clinical Frailty Scale (CFS) for predicting HE admissions within 6 months. METHODS: Consecutive adult patients with cirrhosis were followed for 6 months or until death/transplant. Patients with overt HE and dementia were excluded. Primary outcome was the prediction of HE‐related admissions at 6 months. RESULTS: A total of 355 patients were included; mean age 55.9 ± 9.6; 62.5% male; Hepatitis C and alcohol etiology in 64%. Thirty‐six percent of patients had cognitive impairment according to the MoCA (≤24) and 14% were frail on the CFS (>4). The MoCA‐CFS independently predicted HE hospitalization within 6 months, a MoCA‐CFS score of 1 and 2 respectively increasing the odds of hospitalization by 3.3 (95% CI:1.5‐7.7) and 5.7 (95% CI:1.9‐17.3). HRQoL decreased with increasing MoCA‐CFS. Depression and older age were independent predictors of a low MoCA. CONCLUSIONS: Cognitive and physical frailty are common in patients with cirrhosis. In addition to being an independent predictor of HE admissions within 6 months, the MoCA‐CFS composite score predicts impaired HRQoL and all‐cause admissions within 6 months. These data support the predictive value of a “multidimensional” frailty tool for the prediction of adverse clinical outcomes and highlight the potential for a multi‐faceted approach to therapy targeting cognitive impairment, physical frailty and depression.

Effectiveness of a Core-Competency-based Program on Residents' Learning and Experience.

Background The Care of the Elderly (COE) Diploma Program is a six-to-twelve-month enhanced skills program taken after two years of core residency training in Family Medicine. In 2010, we developed and implemented a core-competency–based COE Diploma program (CC), in lieu of one based on learning objectives (LO). This study assessed the effectiveness of the core-competency–based program on residents’ learning and their training experience as compared to residents trained using learning objectives. Methods The data from the 2007–2013 COE residents were used in the study, with nine and eight residents trained in the LO and CC programs, respectively. Residents’ learning was measured using preceptors’ evaluations of residents’ skills/abilities throughout the program (118 evaluations in total). Residents’ rating of training experience was measured using the Graduate’s Questionnaire which residents completed after graduation. Results For residents’ learning, overall, there was no significant difference between the two programs. However, when examined as a function of the four CanMEDS roles, there were significant increases in the CC residents’ scores for two of the CanMEDS roles: Communicator/Collaborator/Manager and Scholar compared to residents in the LO program. With respect to residents’ training experience, seven out of ten program components were rated by the CC residents higher than by the LO residents. Conclusion The implementation of a COE CC program appears to facilitate resident learning and training experience.