Sylviane Lafont

A Randomized Controlled Trial of Cognitive Therapy versus Intensive Behavior Therapy in Obsessive Compulsive Disorder

Background: The study was designed to compare cognitive therapy (CT) with intensive behavior therapy (BT) in obsessive-compulsive disorder (OCD) and to study their change process. Methods: Sixty-five outpatients with DSM-4 OCD were randomized into 2 groups for 16 weeks of individual treatment in 3 centers. Group 1 received 20 sessions of CT. Group 2 received a BT program of 20 h in two phases: 4 weeks of intensive treatment (16 h), and 12 weeks of maintenance sessions (4 h). No medication was prescribed. Results: Sixty-two patients were evaluated at week 4, 60 at week 16 (post-test), 53 at week 26 and 48 at week 52 (follow-up). The response rate was similar in the 2 groups. The Beck Depression Inventory (BDI) was significantly more improved by CT (p = 0.001) at week 16. The baseline BDI and Obsessive Thoughts Checklist scores predicted a therapeutic response in CT, while the baseline BDI score predicted a response in BT. At week 16, only the changes in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and a scale measuring the interpretation of intrusive thoughts correlated in CT, while the changes in Y-BOCS, BDI, and interpretation of intrusive thoughts correlated in BT. Improvement was retained at follow-up without a between-group difference. The intent-to-treat analysis (last observation carried forward) found no between-group differences on obsessions, rituals and depression. Conclusions: CT and BT were equally effective on OCD, but at post-test CT had specific effects on depression which were stronger than those of BT. Pathways to improvement may be different in CT and BT. The outcomes are discussed in the light of an effect size analysis.

Prospective measurements of dehydroepiandrosterone sulfate in a cohort of elderly subjects: relationship to gender, subjective health, smoking habits, and 10-year mortality.

The decrease with age of the adrenal-secreted dehydroepiandrosterone sulfate (DHEAS) in serum has suggested that it may be causally related to longevity. For the PAQUID [People (Personnes) Aged (Agées) About What (Quid, in Latin)] cohort of elderly subjects, we have previously reported higher DHEAS in men than in women, a decrease with age and, among men, a negative correlation between the DHEAS level and mortality at 2 and 4 years. Here, with an 8-year followup in 290 subjects, we show a global decrease of 2.3% per year for men and 3.9% per year for women. However, in approximately 30% of cases, there was an increase of DHEAS. We observed no relationship between the evolution of DHEAS level and functional, psychological, and mental status, possibly because of selection by death. In women, no association was found between mortality and DHEAS level. In men, the relative risk (RR) of death was higher for the lowest levels of DHEAS (RR = 1.9, P = 0.007), with RR = 6.5, P = 0.003 for those under 70 years old, a result indicating heterogeneity of the population. There was an effect of subjective health on mortality that disappeared after adjustment of DHEAS levels, suggesting its relation with these DHEAS levels. Death RR was much higher in smokers with a low DHEAS level than in nonsmokers with high DHEAS (RR = 6.7, P = 0.001). We submit that the involvement of DHEAS is possibly different according to gender, that association between low DHEAS level and mortality only for men under 70 years old possibly reflects heterogeneity of the population, and that DHEAS level is a reliable predictor of death in male smokers.

The effect of education on cognitive performances and its implication for the constitution of the cognitive reserve.

Some studies have suggested that people with a high educational level have a lower risk of developing dementia compared to people with a low educational level. This protective effect of education has been explained by the constitution of a cognitive reserve which might delay the cognitive and functional expression of neurodegenerative illnesses. The aim of this study is, on the one hand, to evaluate the impact of education on cognitive functioning, which is thought to support the cognitive reserve capacity, and on the other, to determine the extent to which cognitive functioning is affected by other explanatory variables. The analysis was conducted on 1,022 individuals without physical or neurological disorders in the Personnes Agées Quid study. These participants were aged 66 and over and had completed a neuropsychological battery. The effect of some demographic and socioeconomic variables on cognitive performance was also analyzed. Multivariate analysis showed a significant effect of education on most neuropsychological performances, independently of the other variables, and more particularly, in the high-attention-demanding tests. A principal component analysis demonstrated that education specifically increases 2 cognitive components: controlled processes and conceptualization ability. Moreover, mental stimulation occurring after the education years, such as high-complex activity occupations, seems to increase the controlled component. All these results suggest that the effect of education on cognitive reserve may be explained by an increase in controlled processes and conceptualization abilities. These 2 cognitive components might delay the clinical expression of neurodegenerative illnesses by maintaining global cognitive efficiency. Of these 2 components, controlled processes were also influenced by high attention-demanding occupations.

Marital status and risk of Alzheimer’s disease A French population-based cohort study

Objective: To analyze the relationship between marital status and risk of AD or dementia. Methods: This study was carried out from the Personnes Agées QUID (PAQUID) cohort, an epidemiologic study on normal and pathologic aging after age 65 years. The PAQUID cohort began in 1988. Individuals were followed up at 1, 3, and 5 years, with an active detection of dementia. Marital status was divided into four categories: widowed, never married, divorced or separated, and the reference category, married or cohabitant. The longitudinal relationship between marital status and risk of incident AD or dementia was analyzed by a Cox model with delayed entry. Results: Among the 3,675 individuals initially not demented, 2,106 were married or cohabitants, 1,287 were widowers, 179 were never married, and 103 were divorced or separated. Among the 2,881 individuals reevaluated at least once for the risk of dementia during the 5-year follow-up, 190 incident cases of dementia were identified, including 140 with AD. The relative risks (RRs) of dementia (RR = 1.91, p = 0.018) and of AD (RR = 2.68, p < 0.001) were increased for the never-married individuals compared with those who were married or cohabitants. This excess of risk was specifically associated with AD. Adjustment for other risk factors of dementia (education, wine consumption), or for factors reflecting social environment, leisure activities, and depression, did not modify the risk of AD for never-married individuals (RR = 2.31, p = 0.02). Conclusions: We confirmed an association between marital status and AD, with an excess risk observed among never-married individuals. This association may provide clues about the pathogenesis of AD.

Inhibitory breakdown and dementia of the Alzheimer type: a general phenomenon?

Several recent studies have provided substantial support for the proposal that a decrease in inhibitory processing may play an important role in cognitive changes occurring in the early stages of Dementia of the Alzheimer Type (DAT). The question addressed by the present study was whether these deficits are the result of the failure of a general inhibitory mechanism, or whether DAT is associated with selective decreases in a subset of inhibitory processes. For this, a computerized battery of tasks assessing several inhibitory mechanisms was administered to 28 mild DAT patients and 28 matched elderly adults. The results showed that DAT patients failed to produce Negative Priming effects and were severely impaired in the Stroop task. However, no evidence was found for an impairment on the Go–No go task and only limited impairment on the Stop Signal task, suggesting that in the early stages of the disease, not all inhibitory mechanisms are uniformly impaired.

Driving Cessation and Self-Reported Car Crashes in Older Drivers: The Impact of Cognitive Impairment and Dementia in a Population-Based Study

The complexity of driving activity has incited numerous developed countries to initiate evaluative procedures in elderly people, varying according to first evaluation age, frequency, and screening tools. The objective of this paper is to improve the knowledge of the driving cessation process regarding factors associated with crash involvement. Driving cessation and self-reported crashes during the past 5 years were analyzed with multivariate models, in a cross-sectional study including a population-based sample of 1051 drivers aged 65 years and more. Visual trouble, Parkinson disease, dementia, and stroke history were associated with driving cessation. Future dementia was associated with self-reported crashes only. Attentional and executive deficits were associated with both outcomes. The detection of attentional and executive deficits should be included in driving evaluation procedures to improve awareness of these deficits by older drivers.

Actual Incidences of Road Casualties, and Their Injury Severity, Modelled from Police and Hospital Data, France

BACKGROUND Nation-wide road casualty figures usually come from police data. In France, as in many developed countries, the reporting of fatalities is almost complete but the reporting of non-fatal casualties is rather low. It is moreover strongly biased. Valid estimates are needed. METHODS Using the capture-recapture method on police data and on a road trauma registry covering a large county of 1.6 million inhabitants, we estimate police under-reporting correction factors that account for unregistered casualties. These correction factors are then applied to the nation-wide police data, with standardization on under-reporting bias factors. RESULTS In 2004, whereas the police report 108,727 non-fatally injured, the estimation yields 400,200. Over the 1996-2004 study period, the average annual estimated incidence is 871/100,000 for all injured (3.4 times the police incidence), 232/100,000 for hospitalized, 103/100,000 for seriously injured (2.2 times the police incidence) and 12.6/100,000 for casualties with long-term major impairment. The incidence of seriously injured (NISS 9+) is 11.3/100,000 for pedestrians, 9.5/100,000 for cyclists, 36.3/100,000 for motorized two-wheel users and 42.5/100,000 for car users. CONCLUSIONS The estimated incidences are much higher than the police-based ones. This changes the scale of the road injuries issue. The risk of suffering a major impairment from a road crash is equal to the risk of being killed. Motorized two-wheel users experience a large burden of traffic casualties, much larger than that indicated by police data. The approach used can be reproduced in other countries, if an additional medical registration exists.

EMOTIONAL STRESS AND TRAFFIC ACCIDENTS. THE IMPACT OF SEPARATION AND DIVORCE

Background: Personal responses to stressful life events are suspected of increasing the risk of serious traffic accidents. Methods: We analyzed data from a French cohort study (the GAZEL cohort), including a retrospective driving behavior questionnaire, from 13,915 participants (10,542 men age 52–62 years and 3373 women age 47–62 years in 2001). Follow-up data covered 1993–2000. Hazard ratios for serious accidents (n = 713) were computed by Coxs proportional hazard regression with time-dependent covariates. Separate analyses were also performed to consider only at-fault accidents. Results: Marital separation or divorce was associated with an increased risk of a serious accident (all serious accidents: hazard ratio 2.9, 95% confidence interval = 1.7–5.0; at-fault accidents: 4.4, 2.3–8.3). The impact of separation and divorce did not differ according to alcohol consumption levels. Other life events associated with increased risk of serious accident were a child leaving home (all accidents: 1.2, 0.97–1.6; at-fault accidents: 1.5, 1.1–2.1), an important purchase (all accidents: 1.4, 1.1–1.7; at-fault accidents: 1.6, 1.2–2.1), and hospitalization of the partner (all accidents: 1.4, 1.1–2.0). Conclusion: This study suggests that recent separation and divorce are associated with an increase in serious traffic accidents.

Attitudes associated with behavioral predictors of serious road traffic crashes: results from the GAZEL cohort

Objectives: To test the hypothesis that behavioral predictors of serious road traffic crashes (RTC) are correlated with unfavorable attitudes towards traffic safety. Design: Prospective and cross-sectional cohort study. Setting: France Participants: 13 447 of the 19 894 living members of the GAZEL cohort, workers and recent retirees of a French national utility company followed up since 1989. Main outcomes measures: Driving behavior and attitudes towards traffic safety in 2001 by questionnaire. Serious RTCs were recorded over the subsequent 3 years using the cohort annual questionnaire. Behavioral predictors of serious RTCs were assessed using generalized linear Poisson regression models with time-dependent covariates. Factor scores extracted from the first four attitudinal factors of principal component analysis were saved and then regressed on behavioral predictors as independent variables. Results: After controlling for potential confounders, the best predictors of serious RTCs were: “exceeding speed limits on rural roads”, “risky use of cellular phone”, and “sleepy driving”. The adjusted rate ratio ranged from 1.47 to 2.16. Predictors of contravention of the highway code (the first two predictors) were found to be strongly associated with negative attitudes towards “enforcement” and “speed limitations” with an adjusted odds ratio ranging from 1.31 to 2.02. Conclusion: Our study supports the view that individuals with a high propensity for driving behaviors associated with an increased risk of RTCs were more likely to have negative attitudes towards traffic safety. Changing drivers’ negative or distorted opinions of traffic “enforcement” as well as “speed limitations” and “alcohol prohibition on roads” could improve their compliance with road traffic rules.

The Wechsler Digit Symbol Substitution Test as the Best Indicator of the Risk of Impaired Driving in Alzheimer Disease and Normal Aging

Aims: Our purpose was to identify cognitive tools associated with unsafe driving among elderly drivers of varying cognitive levels. Methods: Twenty drivers with early-stage dementia of the Alzheimer type and 56 nondemented drivers aged 65–85 were recruited. Various cognitive processes were measured and unsafe driving was evaluated during an in-traffic road test with 3 different indicators and a composite indicator. Results: The Wechsler Digit Symbol Substitution Test score was the best cognitive measure to detect unsafe drivers using the composite driving indicator. Conclusion: The Digit Symbol Substitution Test may be used by physicians for the evaluation and follow-up of older patients, with or without Alzheimer-type dementia, as a screening tool of unsafe driving.