Elena K. Festa

A longitudinal study of drivers with Alzheimer disease

Objective: The goal of this study was to define the natural progression of driving impairment in persons who initially have very mild to mild dementia. Methods: We studied 128 older drivers, including 84 with early Alzheimer disease (AD) and 44 age-matched control subjects without cognitive impairment. Subjects underwent repeated assessments of their cognitive, neurologic, visual, and physical function over 3 years. Self-reports of driving accidents and traffic violations were supplemented by reports from family informants and state records. Within 2 weeks of the office evaluation, subjects were examined by a professional driving instructor on a standardized road test. Results: At baseline, subjects with AD had experienced more accidents and performed more poorly on the road test, compared to controls. Over time, both groups declined in driving performance on the road test, with subjects with AD declining more than controls. Survival analysis indicated that while the majority of subjects with AD passed the examination at baseline, greater severity of dementia, increased age, and lower education were associated with higher rates of failure and marginal performance. Conclusions: This study confirms previous reports of potentially hazardous driving in persons with early Alzheimer disease, but also indicates that some individuals with very mild dementia can continue to drive safely for extended periods of time. Regular follow-up assessments, however, are warranted in those individuals.

Neuropsychological deficits associated with driving performance in Parkinson's and Alzheimer's disease

Neuropsychological and motor deficits in Parkinsons disease that may contribute to driving impairment were examined in a cohort study comparing patients with Parkinsons disease (PD) to patients with Alzheimers disease (AD) and to healthy elderly controls. Nondemented individuals with Parkinsons disease [Hoehn & Yahr (H&Y) stage I-III], patients with Alzheimers disease [Clinical Demetia Rating scale (CDR) range 0-1], and elderly controls, who were actively driving, completed a neuropsychological battery and a standardized road test administered by a professional driving instructor. On-road driving ability was rated on number of driving errors and a global rating of safe, marginal, or unsafe. Overall, Alzheimers patients were more impaired drivers than Parkinsons patients. Parkinsons patients distinguished themselves from other drivers by a head-turning deficiency. Drivers with neuropsychological impairment were more likely to be unsafe drivers in both disease groups compared to controls. Compared to controls, unsafe drivers with Alzheimers disease were impaired across all neuropsychological measures except finger tapping. Driving performance in Parkinsons patients was related to disease severity (H&Y), neuropsychological measures [Rey Osterreith Complex Figure (ROCF), Trails B, Hopkins Verbal List Learning Test (HVLT)-delay], and specific motor symptoms (axial rigidity, postural instability), but not to the Unified Parkinson Disease Rating Scale (UPDRS) motor score. Multifactorial measures (ROCF, Trails B) were useful in distinguishing safe from unsafe drivers in both patient groups.

Computerized Maze Navigation and On-Road Performance by Drivers With Dementia

This study examined the ability of computerized maze test performance to predict the road test performance of cognitively impaired and normal older drivers. The authors examined 133 older drivers, including 65 with probable Alzheimer disease, 23 with possible Alzheimer disease, and 45 control subjects without cognitive impairment. Subjects completed 5 computerized maze tasks employing a touch screen and pointer as well as a battery of standard neuropsychological tests. Parameters measured for mazes included errors, planning time, drawing time, and total time. Within 2 weeks, subjects were examined by a professional driving instructor on a standardized road test modeled after the Washington University Road Test. Road test total score was significantly correlated with total time across the 5 mazes. This maze score was significant for both Alzheimer disease subjects and control subjects. One maze in particular, requiring less than 2 minutes to complete, was highly correlated with driving performance. For the standard neuropsychological tests, highest correlations were seen with Trail Making A (TrailsA) and the Hopkins Verbal Learning Tests Trial 1 (HVLT1). Multiple regression models for road test score using stepwise subtraction of maze and neuropsychological test variables revealed significant independent contributions for total maze time, HVLT1, and TrailsA for the entire group; total maze time and HVLT1 for Alzheimer disease subjects; and TrailsA for normal subjects. As a visual analog of driving, a brief computerized test of maze navigation time compares well to standard neuropsychological tests of psychomotor speed, scanning, attention, and working memory as a predictor of driving performance by persons with early Alzheimer disease and normal elders. Measurement of maze task performance appears to be useful in the assessment of older drivers at risk for hazardous driving.

Neocortical disconnectivity disrupts sensory integration in Alzheimer's disease.

The cortical pathology in Alzheimers disease (AD) should lead to the loss of effective interaction between distinct neocortical areas. This study compared 2 conditions within a single sensory integration task that differed in the demands placed on effective cross-cortical interaction. AD patients were impaired in their ability to bind distinct visual features of a stimulus when this binding placed greater demands on cross-cortical interaction (i.e., motion and color) but were not impaired when this binding placed lesser demands on such interaction (i.e., motion and luminance). In contrast, neurologically intact individuals and patients with Huntingtons disease were able to effectively bind features under both conditions. These results provide psychophysical support for the presence of functional disconnectivity in AD and demonstrate the utility of AD for investigating the neurocognitive substrates of sensory integration.

Recruitment mechanisms in speed and fine-direction discrimination tasks

The minimum information necessary to specify motion requires a change in position across time. Previous studies have shown that human motion measurements improve with more than two frames of motion. This study clarifies how motion information is integrated to produce the best speed and direction discrimination. Using random-dot kinematograms, fine-direction discrimination thresholds and speed discrimination thresholds are assessed as a function of dot lifetime. Specifically, we ask if performance on both tasks depends on dot lifetime in the same manner. If both speed and direction discrimination performance improve the same way with increasing dot lifetime, this would indicate that both tasks have the same integration limit and both tasks may depend on the same underlying mechanisms. Experiment 1 shows that for both tasks a four-frame dot lifetime is necessary for observers to reach asymptotic threshold levels. The absolute level of performance improves with increasing stimulus duration or signal-to-noise ratio, but the integration limit itself does not vary. Experiment 2 examines whether this integration limit is constrained by the number of frames or by the temporal duration of the dot lifetime. The data in Experiment 2 suggest that both a minimum number of samples and a minimal temporal integration period determine the integration limit for recruitment mechanisms. The results suggest that speed and fine-direction discrimination depend upon the same underlying motion mechanisms. These results are discussed in relation to possible underlying physiological substrates and computational models of motion measurement.

Road Test and Naturalistic Driving Performance in Healthy and Cognitively Impaired Older Adults: Does Environment Matter?

To relate the standardized road test to video recordings of naturalistic driving in older adults with a range of cognitive impairment.

Assessment of driving-related skills prediction of unsafe driving in older adults in the office setting

To examine the sensitivity and specificity of the Assessment of Driving‐Related Skills (ADReS), a clinical tool recommended by the American Medical Association for identifying potentially unsafe older drivers that includes tests of vision, motor function, and cognition.

Effect of Cognitive Status on Self-Regulatory Driving Behavior in Older Adults: An Assessment of Naturalistic Driving Using In-Car Video Recordings

Previous findings that older drivers engage in strategic self-regulatory behaviors to minimize perceived safety risks are primarily based on survey reports rather than actual behavior. This study analyzed in-car video recording of naturalistic driving of 18 patients with Alzheimer disease (AD) and 20 age-matched controls in order to (1) characterize self-regulatory behaviors engaged by older drivers and (2) assess how behaviors change with cognitive impairment. Only participants who were rated “safe” on a prior standardized road test were selected for this study. Both groups drove primarily in environments that minimized the demands on driving skill and that incurred the least risk for involvement in major crashes. Patients with AD displayed further restrictions of driving behavior beyond those of healthy elderly individuals, suggesting additional regulation on the basis of cognitive status. These data provide critical empirical support for findings from previous survey studies indicating an overall reduction in driving mobility among older drivers with cognitive impairment.

Dual-task conditions modulate the efficiency of selective attention mechanisms in Alzheimer’s disease

Given previous demonstrations of both selective and divided attention deficits in Alzheimers disease (AD) patients, understanding how declines in the integrity of component processes of selective attention in these patients interact with impairments to executive processes mediating dual-task performance has both theoretical and practical relevance. To address this issue, healthy elderly and AD patients performed computerized tasks of spatial orienting, Simon response interference, and visual search both in isolation and while simultaneously engaged in a visuomotor tracking task (i.e., maintaining car position within a simulated driving environment). Results from the single-task conditions confirmed previous demonstrations of selective attention deficits in AD. Dual-task conditions produced in AD patients (but not healthy elderly) a change in the efficiency of the selective attention mechanisms themselves, as reflected in differential effects on cue or display conditions within each task. Rather than exacerbating the selective attention deficits observed under single-task conditions, however, dual-task conditions produced an apparent diminution of these deficits. We suggest this diminution is due to the combination of deficient top-down inhibitory processes along with a decrease in the attention-capturing properties of cue information under dual-task conditions in AD patients. These findings not only increase our understanding of the nature of the attentional deficits in AD patients, but also have implications for understanding the processes mediating attention in neurologically intact individuals.

Effects of cholinesterase inhibitors on visual attention in drivers with Alzheimer disease

Objective: We conducted a combined observational cohort and case-control study in patients with Alzheimer disease (AD) to assess the effects of acetylcholinesterase inhibitor (ChEI) treatment on cognitive functions important for driving. Methods: Performance of 24 outpatients with newly diagnosed (untreated) early-stage AD was compared before beginning ChEI (pre-ChEI) and after 3 months of therapy (post-ChEI) on a set of computerized tests of visual attention and executive function administered under both single-task and dual-task conditions. To address the limitation of a lack of an untreated control group in this observational cohort study, performance of 35 outpatients with newly diagnosed (untreated) early-stage AD (ChEI nonusers) were also compared with a demographically matched group of AD patients treated with stable doses of a ChEI (ChEI users) on these tasks. Results: Performance was consistently worse under dual-task than single-task conditions regardless of ChEI treatment status. However, ChEI treatment consistently affected specific components of attention within each test across both sets of comparisons: ChEI treatment enhanced simulated driving accuracy and was associated with significantly better visual search target detection accuracy and response time in both pre-ChEI-post-ChEI and users-nonusers treatment comparisons. Cholinesterase inhibitor treatment also improved overall time to complete a set of mazes while not affecting accuracy of completion. Conclusions: Cholinesterase inhibitor treatment was associated with improvements in tests of executive function and visual attention. These findings could have important implications for patients who continue to drive in the early stages of AD.