Matthew Croucher

Assessment of Older Drivers in New Zealand: The Current System, Research and Recommendations

The purpose of this article is to clarify the current New Zealand driving licensing requirements for older adults and to provide practical recommendations for those health professionals who make decisions regarding driving ability in older adults. Health professionals involved in the assessment of older drivers were asked to clarify areas where more efficient use could be made of assessment resources. A review of driving literature was performed to find specific factors associated with increased risk of negative driving outcomes in older adults. Particular attention was paid to the suitability of different types of on‐road assessment for certain patient groups, the effect of specific diseases and medications on driving safety, and the effect of cognitive impairment. A list of seven recommendations were compiled which include a focus on appropriate on‐road driving assessment referral, driver refresher courses, cognitive screening for those presenting for licence renewal and sensitive broaching of the topic of driving cessation.

Measuring Outcomes in Mental Health Services for Older People: An evaluation of the Health of the Nation Outcome Scales for elderly people (HoNOS65+)

The Health of the Nation Outcome Scales (HoNOS) family of measures is routinely used in mental health services in the New Zealand, Australia, and the United Kingdom. However, the psychometric properties of the HoNOS65+ for elderly people have not been extensively evaluated. The aim of the present study was to examine the validity, reliability, and sensitivity to change of the HoNOS65+. Routinely collected HoNOS65+ data from a psychiatric service for older people (n = 2065) were collated, and a subsample (n = 66) of older service users were assessed with an additional battery of established measures. The individual HoNOS65+ items generally showed adequate concurrent validity and sensitivity to change. Estimates of inter‐rater reliability across settings indicated areas of concern however, and confirmatory factory analysis did not support models based on existing subscales. These findings indicate some limitations of the HoNOS65+ as an outcome scale for older people.

Bipolar affective disorder, type II, apparently precipitated by donepezil.

There is considerable evidence that pro-cholinergic agents can cause depressed mood. However, there are also published case reports of a rare association between cholinesterase inhibitors and mood elevation in patients with pre-existing major functional psychiatric disorders, or organic disorders other than dementia. This report adds to the literature by describing a case of mood elevation in a patient without pre-existing psychiatric disorder.

Developing a dementia-friendly Christchurch: Perspectives of people with dementia.

Christchurch, New Zealand has a unique opportunity to potentially rebuild as a dementia‐friendly city in the wake of the 2010 and 2011 earthquakes. The present study gathered insights from people with dementia about what would make it possible for them to live better in Christchurch.

Clozapine-induced pneumonitis.

Australian & New Zealand Journal of Psychiatry, 47(12) achieved. After 12 weeks, steady state without oral supplementation was reached (serum level 25 μg/ml). Ms J’s BAD remained in remission with her extended hospitalisation on OLAI 405 mg every two weeks with lithium and valproate at previous doses. OLAI therapy was ceased after several months due to considerable weight gain in the context of morbid obesity, sleep apnoea and diabetes mellitus. Ascher-Svanum et al. (2011) found that supplemental oral olanzapine with OLAI was necessary for 8–12 weeks in 21% of 931 patients in clinical settings. Supplementation was required most frequently in the severely ill as a rescue therapy until steady state was attained. An alternate study suggested OLAI initiation without oral supplementation would suffice, however, patients selected for this study were stable on oral olanzapine without adherence problems (Kane et al., 2009). Ms J was a complex case, resembling patients in the study by Ascher-Svanum and colleagues (2011) necessitating prolonged oral supplementation. This case exemplified the potential challenges in clinical practice when starting OLAI depot. The required dosage, frequency of administration and the need for oral supplementation and for how long, must be weighed up in each individual case based on clinical complexity. Illness factors, age, sex, smoking status and genotypic variation in genetic polymorphisms have been documented as affecting antipsychotic metabolism, distribution and elimination (Frampton, 2010). The case we have described indicates that OLAI 405 mg every two weeks, although not generally recommended, can be safely administered and tolerated. It also highlights the importance of a conservative approach with oral supplementation until steady state is achieved, especially in patients with an unstable illness course. Serum olanzapine levels should be used to guide clinicians as to when to cease oral supplementation. This being a single case study with inherent limitations, we recommend that OLAI 405 mg administered every two weeks should only be given under close clinical supervision with serum level monitoring, as was possible in Ms J’s case. In light of two unexpected deaths of unidentified cause in patients on OLAI therapy to date, a cautious approach is presently recommended when initiating OLAI. Additional research in clinical settings with challenging cases like Ms J’s may shed further light on how best to proceed in the future with OLAI depot. Declaration of interest

Performance of three cognitive screening tools in a sample of older New Zealanders.

BACKGROUND With the ubiquitous Mini-Mental State Exam now under copyright, attention is turning to alternative cognitive screening tests. The aim of the present study was to investigate three common cognitive screening tools: the Montreal Cognitive Assessment (MoCA), the Rowland Universal Dementia Assessment Scale (RUDAS), and the recently revised Addenbrookes Cognitive Assessment Version III (ACE-III). METHODS The ACE-III, MoCA and RUDAS were administered in random order to a sample of 37 participants with diagnosed mild dementia and 47 comparison participants without dementia. The diagnostic accuracy of the three tests was assessed. RESULTS All the tests showed good overall accuracy as assessed by area under the ROC Curve, 0.89 (95% CI = 0.80-0.95) for the ACE-III, 0.84 (0.75-0.91) for the MoCA, and 0.86 (0.77-0.93) for RUDAS. The three tests were strongly correlated: r(84) = 0.85 (0.78-0.90) between the ACE-III and MoCA, 0.70 (0.57-0.80) between the ACE-III and RUDAS; and 0.65 (0.50-0.76) between the MoCA and RUDAS. The data derived optimal cut-off points for were lower than the published recommendations for the ACE-III (optimal cut-point ≤76, sensitivity = 81.1%, specificity = 85.1%) and the MoCA (≤20, sensitivity = 78.4%, specificity = 83.0%), but similar for the RUDAS (≤22, sensitivity = 78.4%, specificity = 85.1%). CONCLUSIONS All three tools discriminated well overall between cases of mild dementia and controls. To inform interpretation of these tests in clinical settings, it would be useful for future research to address more inclusive and potentially age-stratified local norms.

Perceptions of a cognitive rehabilitation group by older people living with cognitive impairment and their caregivers: A qualitative interview study

Cognitive rehabilitation has been developed to improve quality of life, activities of daily living and mood for people with cognitive impairment, but the voice of people with cognitive impairment has been underrepresented. This study aimed to understand the experience of people living with cognitive impairment, as well as their caregivers who took part in a cognitive rehabilitation intervention programme. Twelve individuals with cognitive impairment and 15 caregivers participated in individual qualitative interviews. The interview data were analysed in three steps: 1) familiarisation of the transcripts; 2) identification of themes; 3) re-interpretation, refinement and integration of themes with methodological auditors. Both participants living with cognitive impairment and caregivers valued the comfortable environment with friendly, caring and supportive group leaders who taught practical tips and strategies. The participants living with cognitive impairment enjoyed socialising with like others. Caregivers benefited from learning about memory problems and sharing their challenges with other caregivers. The participants living with cognitive impairment emphasised the benefits of relational and practical aspects, whereas the caregivers valued the informational and emotional support. In conclusion, both participants living with cognitive impairment and caregivers found the cognitive rehabilitation group useful.

Geographic variation in psychotropic drug utilisation among older people in New Zealand

To examine psychotropic drug utilisation in older people in New Zealand by age, sex, health board domicile and deprivation status.

Convergent Validity, Concurrent Validity, and Diagnostic Accuracy of the interRAI Depression Rating Scale:

Aims: Depression Rating Scale (DRS) is one of the clinical outcome measures of the International Resident Assessment Instrument (interRAI) assessment. The primary aim of this study is to investigate the diagnostic accuracy and concurrent validity of the 3-day assessment window version of the DRS. Methods: The performance of DRS was compared with a gold standard clinical diagnosis of depression in 92 patients (age ≥65) who had interRAI version 9.1 Home Care assessment completed within 30 days of discharge from psychogeriatric inpatient care or memory clinic assessment. Results: The DRS had poor diagnostic accuracy for depression diagnosis with an area under the curve of 0.68 (95% confidence interval [CI] = 0.57-0.77). The DRS score had a poor to moderate correlation with the Health of the Nation Outcome Scale 65+ depression item score (rs = 0.30, 95% CI = 0.09-0.48, P = .006). Conclusion: This study and the existing literature raise concerns that the DRS is not an adequate measure of depression.

The prevalence of late-life mental disorders in New Zealand and Australia is still unknown.

Australian & New Zealand Journal of Psychiatry, 50(3) among older people. Snowdon et al. (1998) also raised the possibility of ageism in the design of surveys. Community residents with dementia were excluded from the MHWB studies. The 5.7% scoring <24 on the Mini-Mental State Examination were labelled as cognitively impaired, even if some fulfilled criteria for depression. Those living outside domestic environments (but not in hospital) were excluded, as were those who could not speak English. Sunderland et al. (2015) drew attention to various limitations of the 2007 MHWB study, including that the survey did not attempt to detect dementia. They referred to the response rate (60%) as sub-optimal. In 1997, the response rate was 78%. In neither study did investigators report response rate differences between age groups. Because the MHWB study was of a non-representative community sample of older Australians (having excluded at least 10% because they were nonEnglish-speaking, in residential care, dementing or too physically disabled to take part), because the response rate was low and because of methodological limitations, there is good reason to question its findings concerning the community prevalence of depression in Australia. We believe that 0.9% is a considerable underestimate of the point prevalence of late-life affective disorder, even if Australians in nursing homes are excluded. Sadly, bad and unfair policies may arise if the MHWB results are taken at face value.