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Objectives: This study examined the extent to which multiple relationship-specific attachment schemas (general, parent-child, and romantic) are interrelated and relate to depressive symptoms among older adults living with early-stage dementia and their adult children, a context likely to activate the attachment system., Methods: The study consisted of 150 early-stage cognitively impaired parents and one child. Both self-reported general, parent-child, and romantic attachment anxiety as well as avoidance and depressive symptoms. Parents' cognitive and functional impairment were assessed., Results: Most attachment variables were interrelated for individuals, except that the child's parent-child-specific avoidance was not associated with their general or romantic avoidance. The parent's worse functional, but not cognitive, impairment was associated with the child's greater parent-child-specific attachment anxiety. Using Actor Partner Interdependence Models, general attachment anxiety was associated with greater depressive symptoms (actor effects). When both dyad members were high in general avoidance, depressive symptoms were greatest (actor × partner effect). A parent had the greatest depressive symptoms when they were avoidantly attached to their child (role × actor effect) and their child was high in anxiety and low in avoidance toward them (role × partner effects). A child had the greatest depressive symptoms when they were low in avoidance toward the parent (role × actor effect) and the parent was low in anxiety and high in avoidance toward the child (role × partner effects). Romantic anxiety was associated with greater depressive symptoms (actor effects)., Discussion: Psychosocial interventions that incorporate attachment theory as a framework may benefit parent-child dyads coping with dementia., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Objectives: As symptoms emerge and worsen in people living with dementia, their spouses can benefit from behavioral interventions to support their adjustment as a care partner. The Wish Outcome Obstacle Plan (WOOP) intervention improves the well-being of spouses of people living with dementia early in the disease course, but intervention mechanisms and opportunities for improvement are unclear. The present study gave voice to spouses who participated in a trial of WOOP, describing how WOOP was incorporated into their lives and how it could be improved for future implementation., Method: For this qualitative study, we conducted longitudinal semi-structured interviews among 21 spouses of people living with dementia (three interviews over three months; 63 interviews total). Codebook thematic analysis was performed., Results: Three meta-themes were derived: (1) assessing baseline strengths and limitations of WOOP, (2) learning from experience, and (3) fine-tuning and sustaining WOOP. Participants described how WOOP addressed their interpersonal and emotional stressors, their responses to behaviors of the person living with dementia, and their relationship quality. Considerations for future intervention delivery (e.g., solo vs. in group settings) and instructions (e.g., encouraging writing vs. thinking through the four steps of WOOP) were identified as areas of improvement., Conclusions: WOOP was described as a practical, feasible, and desirable intervention for spouses at the early stages of their partner's dementia. Participants made WOOP easier to incorporate in their everyday lives by adapting the design into a mental exercise that they used as needed. Suggestions from participants specified how to make the everyday use of WOOP more feasible, sustainable, and applicable in a variety of contexts., Trial Registration: ClinicalTrials.gov HIC 2000021852., (© 2024 John Wiley & Sons Ltd.)

Background: Early change in function in older adults has been termed preclinical disability (PCD). PCD has been understudied compared to other stages of disability because it is unlikely to receive comparative priority in clinical settings. It has major implications for prevention and population health as it may be the optimal time to intervene to prevent further decline. A standardized approach to research in PCD, including a common definition and measurement approaches, is needed to advance this work., Methods: The process to establish how PCD should be defined and measured was undertaken in 2 stages: (1) a scoping review of the literature, which was used to inform (2) a web-enabled consensus meeting with content experts., Results: The scoping review and the consensus meeting support the use of the term preclinical mobility limitation (PCML) and that it should be measured using both patient-reported and performance-based measures. It was agreed that the definition of PCML should include modification of frequency and/or method of task completion, without overt disability, and that requisite mobility tasks include walking (distance and speed), stairs, and transfers., Conclusions: Currently, there are few standardized assessments that can identify PCML. PCML is the term that most clearly describes the stage where people experience a change in routine mobility tasks, without a perception of disability. Further evaluation into the reliability, validity, and responsiveness of outcome measures is needed to advance research on PCML., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To design a modular, flipped-classroom curriculum using character animations to improve knowledge and attitudes regarding dementia care among pre-clinical nursing students., Background: Demographic trends suggest an urgent, unmet need for nurses with interest and adequate training in caring for people with dementia and other disorders of cognition. While flipped classrooms using video show promise, little is known about specific animation techniques to impact knowledge and attitudes in preclinical nursing education., Design: A curriculum was developed, implemented and assessed across three nursing schools in series, totaling 223 eligible students in the states of Connecticut and Hawaii, USA from 2019 to 2022. The evaluation included prospective pre-post assessment of knowledge, attitudes and module acceptability, as well as qualitative interpretations of needs assessment data., Methods: The six-step curriculum development process was based on that described by Kern et al., including: 1) general needs assessment in the form of literature review; 2) targeted needs assessment, in the form of faculty stakeholder meetings, a student focus group and baseline surveys; 3) optimization of learning objectives based on needs; 4) development of a pedagogical approach, namely animated, interactive modules informed by previously described best practices in animation development; 5) implementation across three different nursing schools; and 6) assessment of the learners and evaluation of the curriculum, primarily via surveys and engagement metadata., Results: Needs assessments confirmed the importance of prior experiences, sense of mission and other affective elements as key factors mitigating learners' baseline receptiveness to training and careers in cognition-related care. Students at all three institutions rated the modules' impact on their dementia-related attitudes highly, however these ratings were statistically significantly lower when both modules were delivered as a single assignment at one site. Knowledge quiz scores significantly increased from baseline at all three sites. Only 2.6% of respondents would have preferred a text-based reading assignment. Acceptability scores, including clarity, relevance, entertainment, attention and complexity, were generally rated highly, but attention and entertainment were rated significantly lower when both modules were administered as a single assignment., Conclusion: Cognition and Dementia with Raymond and Brain demonstrates the successful blending of animation industry workflows with best practices of curriculum development to create a novel, animated module series that is acceptable and effective in priming nursing students with the attitudes and knowledge to continue learning about cognition and its disorders., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

This study examined whether changes in middle-aged children's perceptions of their parents' activities of daily living needs (ADL needs) were associated with changes in the mutuality of support in their relationship. A group of 366 middle-aged children in Waves 1 (2008) and 2 (2013) of the Family Exchanges Study self-reported providing and receiving tangible, emotional, and informational support to and from their n = 468 parents. Increased perceived parental ADL needs were associated with increased provision of tangible and informational support to parents but not with changes in support received. Increases in perceived parental ADL needs were associated with higher incongruence for all three support types (the child providing more support than they receive)., Competing Interests: Conflict of Interest The authors declare no conflict of interest.

Objectives: Behavioral interventions can reduce distress for couples coping with early-stage dementia. However, most interventions are limited in accessibility and fail to address individualized goals. This pilot study examined the dyadic effects on multiple indicators of well-being of the Wish Outcome Obstacle Plan (WOOP) intervention, which guides participants to use Mental Contrasting with Implementation Intentions to achieve attainable goals in their daily lives., Methods: This randomized controlled trial included 45 older persons with early-stage dementia (PWD) and their spousal care partners (CPs: n = 90 individuals). CPs were assigned randomly to WOOP training immediately after baseline (WOOP) or after a 3-month follow-up interview (Control; CON). Both groups received a dementia care education booklet. WOOP CPs were instructed to practice WOOP at least once a day for 2 weeks. All CPs and PWDs completed home surveys (baseline, 2 weeks, and 3 months), measuring perceived stress, depressive symptoms, quality of life, and affect., Results: Mixed-effects models showed significant intervention × time interaction effects with large effect sizes for CPs on three of the five outcomes over 3 months. Compared with CON, WOOP CPs had decreased perceived stress (δ = 1.71) and increased quality of life (δ = 1.55) and positive affect (δ = 2.30). WOOP PWD showed decreased perceived stress (δ = 0.87) and increased quality of life (δ = 1.26), but these effects were not statistically significant., Discussion: WOOP is a promising, brief intervention to improve dementia CPs' well-being that may also positively affect their partners with dementia., (© The Author(s) 2021. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: To determine the age-related differences in the association between level of acculturation and perceptions about change in health status after migration in mid- to late-life immigrants., Design: Cross-sectional study., Setting: Nationally representative cohort of legal U.S. immigrants., Participants: Legal immigrants ≥50 years of age., Measurements: The outcome was perceived change in health status, determined by the survey question, "compared with your health right before you most recently came to the United States to live, would you say that your health is better now, about the same or worse?" The main predictor included age group (50-64, 65-74, and ≥75 years) and secondary variable of interest was level of acculturation. Analyses were adjusted for demographic characteristics, medical, and functional comorbidities., Results: Immigrants age ≥75 years were more likely to report worse health after migration [RRR 1.93, 95% CI (1.17, 3.17), p < 0.01] compared with immigrants of 50-64 years, but this difference was not statistically significant in the adjusted model. Acculturation level was associated with increased likelihood of reporting worse health status, [RRR 2.10, (1.02, 4.35), p < 0.05] for somewhat acculturated and [RRR 2.55, (1.10, 5.88), p < 0.05] for most acculturated, compared with participants who were not acculturated., Conclusion: The oldest immigrant group (≥75 years) was more likely to report worse health after migration, but this association was no longer significant after accounting for acculturation level and other covariates. Future work should be undertaken to identify specific health needs across older immigrant age groups and identify acculturative stressors that negatively impact health., (© 2021 The American Geriatrics Society.)

Objective: Family visits with residents at long-term care (LTC) facilities have been restricted during the COVID-19 pandemic. The objective was to examine what communication methods, other than in-person visits, during the pandemic were associated with greater positive and lower negative emotional experiences for LTC residents and their family members and friends., Design: Cross-sectional., Setting: Nationally targeted online survey., Participants: One hundred sixty-one community-dwelling adults who had a family member or friend in a LTC facility., Measurements: The Positive and Negative Affect Scale was used to assess participant's own emotions and perceived resident emotions during the pandemic. Questions were asked about nine communication methods other than physical visits (e.g., phone, video-conference, e-mail, and letters) in terms of frequency of use during the pandemic. Sociodemographics, resident health, and facility factors were assessed and used as covariates where indicated., Results: During the pandemic, greater phone frequency was associated with less participant negative emotions (β = -0.17). Greater e-mail frequency was associated with more perceived resident positive emotions (β = 0.28). Greater frequency of letters delivered by staff was associated with more participant negative emotions (β = 0.23). Greater frequency of letters delivered by staff and the postal service were associated with more perceived resident negative emotions (β = 0.28; β = 0.34, respectively)., Conclusion: These findings highlight the importance of synchronous, familiar methods of communication like the phone and email between families and LTC residents to maintain their emotional well-being when in-person visits are restricted., (Copyright © 2020 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Aim: The σ 1 receptor is a druggable target involved in many physiological processes and diseases. To clarify its physiology and derive therapeutic benefit, nine analogs based on the σ 1 antagonist PB212 were synthesized replacing the 4-methylpiperidine with basic moieties of varying size and degree of conformational freedom. Results & methodology: 3-Phenylpyrrolidine, 4-phenylpiperidine or granatane derivatives displayed the highest affinity ( K i .#x00A0;= 0.12, 0.31 or 1.03 nM). Calcium flux assays in MCF7σ 1 cells indicated that the highest σ 1 receptor affinity are σ 1 antagonists. Molecular models provided a structural basis for understanding the σ 1 affinity and functional activity of the analogs and incorporated Glennon's σ 1 pharmacophore model. Conclusion: Herein, we identify new compounds exploitable as therapeutic drug leads or as tools to study σ 1 receptor physiology.

Purpose of Review: The purpose of this study was to update a national guideline on assessing drivers with dementia, addressing limitations of previous versions which included a lack of developmental rigor and stakeholder involvement., Methods: An international multidisciplinary team reviewed 104 different recommendations from 12 previous guidelines on assessing drivers with dementia in light of a recent review of the literature. Revised guideline recommendations were drafted by consensus. A preliminary draft was sent to specialist physician and occupational therapy groups for feedback, using an a priori definition of 90% agreement as consensus., Recent Findings: The research team drafted 23 guideline recommendations, and responses were received from 145 stakeholders. No recommendation was endorsed by less than 80% of respondents, and 14 (61%) of the recommendations were endorsed by more than 90%.The recommendations are presented in the manuscript. The revised guideline incorporates the perspectives of consensus of an expert group as well as front-line clinicians who regularly assess drivers with dementia. The majority of the recommendations were based on evidence at the level of expert opinion, revealing gaps in the evidence and future directions for research.

Guidelines that physicians use to assess fitness to drive for dementia are limited in their currency, applicability, and rigor of development. Therefore, we performed a systematic review to determine the risk of motor vehicle collisions (MVCs) or driving impairment caused by dementia, in order to update international guidelines on driving with dementia. Seven literature databases (MEDLINE, CINAHL, Embase, etc.) were searched for all research studies published after 2004 containing participants with mild, moderate, or severe dementia. From the retrieved 12,860 search results, we included nine studies in this analysis, involving 378 participants with dementia and 416 healthy controls. Two studies reported on self-/informant-reported MVC risk, one revealing a four-fold increase in MVCs per 1,000 miles driven per week in 3 years prior, and the other showing no statistically significant increase over the same time span. We found medium to large effects of dementia on driving abilities in six of the seven recent studies that examined driving impairment. We also found that persons with dementia were much more likely to fail a road test than healthy controls (RR: 10.77, 95% CI: 3.00-38.62, z = 3.65, p < 0.001), with no significant heterogeneity (χ 2  = 1.50, p = 0.68, I 2  = 0%) in a pooled analysis of four studies. Although the limited data regarding MVCs are equivocal, even mild stages of dementia place patients at a substantially higher risk of failing a performance-based road test and of demonstrating impaired driving abilities on the road., (Copyright © 2017 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Despite the promising potentials of σ2 receptors in cancer therapy and diagnosis, there are still ambiguities related to the nature and physiological role of the σ2 protein. With the aim of providing potent and reliable tools to be used in σ2 receptor research, we developed a novel series of fluorescent σ2 ligands on the basis of our previous work, where high-affinity σ2 ligand 1-cyclohexyl-4-[3-(5-methoxy-1,2,3,4-tetrahydronaphthalen-1-yl)-n-propyl]piperazine (1, PB28) was used as the pharmacophore. Compared to the previous compounds, these novel ligands displayed improved fluorescence and σ2 binding properties, were σ2-specifically taken up by breast tumor cells, and were successfully employed in confocal microscopy. Compound 14, which was the best compromise between pharmacological and fluorescent properties, was successfully employed in flow cytometry, demonstrating its potential to be used as a tool in nonradioactive binding assays for studying the affinity of putative σ2 receptor ligands.

σ₂ Receptors are promising biomarkers for cancer diagnosis given the relationship between the proliferative status of tumors and their density. With the aim of contributing to the research of σ₂ receptor Positron Emission Tomography (PET) probes, we developed 2-[3-[6,7-dimethoxy-3,4-dihydroisoquinolin-2(1H)-yl]propyl]-3,4-dihydroisoquinolin-1(2H)-one (3), with optimal σ₂ pharmacological properties and appropriate lipophilicity. Hence, 3 served as the lead compound for the development of a series of dihydroisoquinolinones amenable to radiolabeling. Radiosynthesis for compound 26, which displayed the most appropriate σ₂ profile, was developed and σ₂ specific binding for the corresponding [(18)F]-26 was confirmed by in vitro autoradiography on rat brain slices. Despite the excellent in vitro properties, [(18)F]-26 could not successfully image σ₂ receptors in the rat brain in vivo, maybe because of its interaction with P-gp. Nevertheless, [(18)F]-26 may still be worthy of further investigation for the imaging of σ₂ receptors in peripheral tumors devoid of P-gp overexpression., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance; extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 years of age screened, but at the price of stopping the driving of 121 people who would not have had a crash., Primary Objectives: 1. to assess whether driving assessment facilitates continued driving in people with dementia;2. to assess whether driving assessment reduces accidents in people with dementia., Secondary Objective: 1. to assess the quality of research on assessment of drivers with dementia., Search Methods: ALOIS, the Cochrane Dementia Group's Specialized Register was searched on 13 September 2012 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly., Selection Criteria: We sought randomised controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment., Data Collection and Analysis: Each review author retrieved studies and assessed for primary and secondary outcomes, study design and study quality., Main Results: No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented., Authors' Conclusions: In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.

Background: Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance; extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 years of age screened, but at the price of stopping the driving of 121 people who would not have had a crash., Primary Objectives: 1. to assess whether driving assessment facilitates continued driving in people with dementia; 2. to assess whether driving assessment reduces accidents in people with dementia., Secondary Objective: 1. to assess the quality of research on assessment of drivers with dementia., Search Methods: ALOIS, the Cochrane Dementia Group's Specialized Register was searched on 13 September 2012 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly., Selection Criteria: We sought randomised controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment., Data Collection and Analysis: Each review author retrieved studies and assessed for primary and secondary outcomes, study design and study quality., Main Results: No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented., Authors' Conclusions: In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.

1-Cyclohexyl-4-[3-(5-methoxy-1,2,3,4-tetrahydronaphthalen-1-yl)propyl]piperazine 1 (PB28) and 2-Methoxy-5-methyl-N-[4-(6,7-dimethoxy-3,4-dihydro-1H-isoquinolin-2-yl)butyl]benzamide 2 (RHM-1) represent leads for tumor diagnosis, given their high affinity at σ(2) receptors. With the purpose of obtaining good candidates for σ(2) PET tracers development, hybrid structures between 1 and 2 were designed. Excellent σ(1)/σ(2) selectivities were reached when 6,7-dimethoxytetrahydroisoquinoline was linked to an o-methoxy substituted arylamide (11a, 12a, 15a), and for these benzamides an intramolecular H-bond in the active conformation at the σ sites, was hypothesized. However these excellent σ(2) ligands were accompanied by interaction with P-gp, which may limit their use as σ(2) receptor PET agents when tumors overexpress P-gp. Compound 15a whose P-gp interaction was just moderate represents an interesting tool for the development of σ(2) PET tracers useful in tumors overexpressing P-gp., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Background: Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Although cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance, extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 screened, but at the price of stopping the driving of 121 people who would not have had a crash., Primary Objectives: 1. To assess whether driving assessment facilitates continued driving in people with dementia 2. To assess whether driving assessment reduces accidents in people with dementia., Secondary Objective: To assess the quality of research on assessment of drivers with dementia., Search Strategy: The Cochrane Dementia Group's Specialized Register was searched on 30 October 2007 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly., Selection Criteria: We sought randomized controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment., Data Collection and Analysis: Each author retrieved studies and assessed for primary and secondary outcomes, study design and study quality., Main Results: No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented., Authors' Conclusions: In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.

Objectives: Increasing age, socioeconomic factors, and declining function and health have been linked to driving cessation, but little is known about the consequences of stopping driving. This study was designed to test the hypothesis that driving cessation leads to a decline in out-of-home activity levels., Methods: In 1989 a survey of driving practices was administered to surviving noninstitutionalized members of the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort. Of 1,316 respondents, 502 were active drivers as of 1988, 92 had stopped driving between 1982 and 1987, and 722 never drove or stopped before 1982. Information on sociodemographic and health-related variables came from in-home EPESE interviews in 1982, 1985, and 1988, and from yearly phone interviews. Activity was measured at all three in-home interviews, and an activity measure was created based on self-reported participation in nine out-of-home activities. A repeated measures random-effects model was used to test the effect of driving cessation on activity while controlling for potential confounders., Results: Driving cessation was strongly associated with decreased out-of-home activity levels (coefficient-1.081, standard error 0.264, p < .001) after adjustment for sociodemographic and health-related factors., Discussion: The potential consequences of driving limitations or cessation should be taken into account when advising older drivers and developing alternative transportation strategies to help maintain their mobility.

Objectives: To examine any association between social, productive, and physical activity and 13 year survival in older people., Design: Prospective cohort study with annual mortality follow up. Activity and other measures were assessed by structured interviews at baseline in the participants' homes. Proportional hazards models were used to model survival from time of initial interview., Setting: City of New Haven, Connecticut, United States., Participants: 2761 men and women from a random population sample of 2812 people aged 65 and older., Main Outcome Measure: Mortality from all causes during 13 years of follow up., Results: All three types of activity were independently associated with survival after age, sex, race/ethnicity, marital status, income, body mass index, smoking, functional disability, and history of cancer, diabetes, stroke, and myocardial infarction were controlled for., Conclusions: Social and productive activities that involve little or no enhancement of fitness lower the risk of all cause mortality as much as fitness activities do. This suggests that in addition to increased cardiopulmonary fitness, activity may confer survival benefits through psychosocial pathways. Social and productive activities that require less physical exertion may complement exercise programmes and may constitute alternative interventions for frail elderly people.

Objective: To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care., Design: A randomized controlled trial with 12 months of follow-up., Setting: General community; 27 home care agencies., Participants: Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days., Intervention: Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care., Main Outcome Measures: A battery of self-report and performance-based measures of physical and social function., Results: There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08)., Conclusions: The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture.

Active drivers (n = 125) in a representative cohort of older individuals age 77 years and older in New Haven, Connecticut were interviewed. Confidence in different driving situations, self-rating of driving ability, and driving patterns were assessed during these in-person interviews. A history of crashes, moving violations and being stopped by police was available for approximately the past 6 years. Concurrent driving performance was assessed in a subsample (n = 35). Analyses focused on determining the relationship of confidence and self-rating of driving ability to: (1) each other; (2) driving patterns; (3) adverse driving events; and (4) driving performance. All participants rated themselves as being average or above average drivers compared to others their age, with the majority rating themselves as above average. Individuals who drove more miles and more frequently were more likely to rate themselves better drivers than same-age peers. Individuals who rated themselves as "much better" drivers than their peers tended to have higher confidence levels than those who rated themselves a "little bit better" or the "same" as other drivers. On-road driving performance and history of adverse events were not associated with self-ratings of driving ability. Confidence was associated with driving frequency and mileage, but not age or education. Although men were more likely to drive under risky conditions, for those conditions in which each drove, men and women were equally confident. No relationship was found between confidence and adverse driving events or driving performance. Understanding the relationship of confidence and self-rating of driving ability to driving patterns, adverse events and driving performance may provide additional insights into identifying older drivers at increased risk for problems and formulating intervention strategies to help lower risk.

Objectives: The purposes of this study were (1) to develop a battery of tests that assessed a wide range of functional abilities relevant to driving yet could be performed in a clinician's office and (2) to determine which of these tests were most closely associated with self-reported adverse driving events., Design: A cohort study., Setting: An urban community., Participants: Participants were drawn from the Project Safety cohort, a probability sample of noninstitutionalized older persons in New Haven, Connecticut, initiated in 1989. The current study included surviving, active drivers in the cohort (N=125)., Measures: The test battery assessed visual, cognitive, and physical abilities potentially relevant to driving, and was administered in participants' homes by trained interviewers between October 1994 and July 1995. Outcome measures included the self-report of a crash, moving violation, or being stopped by police in any Project Safety interview since the inception of the cohort. Analyses compared performance on the elements of the test battery with participants' histories of adverse driving events., Results: Of the 125 drivers, 50 (40%) had reported an adverse event in a mean period of 5.76 (+/-.25) years before the current interview. The elements of the test battery independently associated with a history of events, adjusting for driving frequency, included near visual acuity worse than 20/40 (adjusted odds ratio 11.90), limited neck rotation (OR 6.10), and poor performance on a test of visual attention, the number cancellation task (OR 3.00). The resulting regression equation yielded a sensitivity of 80%, a specificity of 55%, and an area under the curve of .75 by receiver operating characteristic analysis., Conclusion: These findings suggest it may be possible to identify individuals potentially at risk for self-reported adverse driving events using simple tests of functional ability. If validated, such an approach could be used to identify individuals who need a more detailed assessment of functional abilities to determine the severity and etiology of impairments, and their effect on driving performance, as well as possible interventions to correct or compensate for the impairments.

Background: There is growing concern about the potential safety implications of the increasing number of older drivers. A primary consideration in determining risk is the method of outcome ascertainment. In the case of motor vehicle crashes, the two most common methods are self-report and state records of events., Methods: The self-report of motor vehicle crashes was compared to state records among all active drivers (n = 358) in a representative cohort of community-living individuals age 72 years and older in New Haven, Connecticut, in 1989. In the baseline interview, participants who reported driving were asked if they had had any crashes in the previous year. This was compared to state-recorded crashes over the same period., Results: Of the 358 drivers, 33 either reported or had a state record of a crash in the previous year. Of the 33, 20 were identified by self-report only, 9 by both self-report and state records, and 4 by state records only. In the two cases where license reexamination was requested by the officer at the scene, both drivers reported the event in the interview., Conclusions: Self-report and state records provide complementary information for the ascertainment of crashes among older drivers, although in this sample self-report yielded more events.

Objectives: This study examined the sociodemographic and health characteristics and problems of older pedestrians., Methods: Interviews and assessments were conducted with 1249 enrollees aged 72 or older from the New Haven, Conn, community of the Established Populations for Epidemiologic Studies of the Elderly who agreed to participate in a seventh follow-up., Results: Approximately 11% of the New Haven residents reported difficulty crossing the street. Older pedestrians needing help in one or more activities of daily living were more than 10 times as likely as others, and those with the slowest walking speeds were nearly 3 times as likely as others, to report difficulty crossing the street. Fewer than 1% of these pedestrians aged 72 or older had a normal walking speed sufficient to cross the street in the time typically allotted at signalized intersections (1.22 m/sec)., Conclusions: Crossing times at signalized intersectíons in areas with large populations of elders should be extended, and the recommended walking speed for timing signalized crossings should be modified to reflect the range of abilities among older pedestrians.

Objectives: The purpose of this study was to determine the association between driving cessation and depressive symptoms among older drivers. Previous efforts in this area have focused on the factors associated with cessation, not the consequences of having stopped., Design: Cohort study., Setting: Urban community., Participants: A driving survey was administered in 1989 to surviving noninstitutionalized members of the New Haven Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort. Of 1316 respondents, 502 were active drivers as of 1988, 92 had stopped driving between 1982 and 1987, and the remainder had either never driven or had stopped before 1982., Measurements: Information about independent and dependent variables other than driving status came from the in person EPESE interviews in 1982, 1985, and 1988, except for medical conditions, which were updated yearly. Depressive symptoms were assessed by the Centers for Epidemiologic Studies-Depression (CES-D) scale. Analyses focused on the changes in depressive symptoms before and after driving cessation. Repeated measures multivariable analysis accounted for the effect of cessation on the outcome adjusting for the potential confounding due to sociodemographic and health-related factors., Results: Individuals who stopped driving exhibited substantial increases in depressive symptoms during the 6-year interval. Driving cessation was among the strongest predictors of increased depressive symptoms (Coefficient 2.464, SE 0.758, P = .001) even when adjusting for sociodemographic and health-related factors., Conclusions: Driving cessation was associated with an increase in depressive symptoms even when accounting for sociodemographic and health-related factors. These consequences need to be taken into account when advising older drivers and when developing alternative transportation strategies.

Background: Serious fall injury represents a little studied, yet common and potentially preventable, cause of morbidity and mortality among older persons. We determined the frequency of, and risk factors for, experiencing serious fall injury events among older persons in the community., Subjects: A representative sample of 1103 community-living persons aged 72 years and older underwent comprehensive baseline and 1-year evaluations., Main Outcome Measures: During a median 31 months of follow-up, fall data were obtained using fall calendars. Injury data were obtained from telephone interviews and from surveillance of emergency room and hospital records., Results: At least one fall was experienced by 546 (49%) participants. A total of 123 participants, representing 23% of fallers and 12% of the cohort, experienced 183 serious fall injury events. The factors independently associated with experiencing a serious injury during a fall included cognitive impairment (adjusted odds ratios 2.2; 95% confidence interval 1.5, 3.2); presence of at least two chronic conditions (2.0; 1.4, 2.9); balance and gait impairment (1.8; 1.3, 2.7); and low body mass index (1.8; 1.2, 2.5). In a separate analysis, including only subjects who fell, female gender (1.8; 1.1, 2.9) as well as most of the above factors were associated with experiencing a fall injury., Conclusions: Several readily identifiable factors appeared to distinguish the subgroup of older fallers at risk for suffering a serious fall injury. These factors should help guide who and what to target in prevention efforts.

Objective: To identify the factors associated with automobile crashes, moving violations, and being stopped by police in a cohort of elderly drivers., Design: Prospective cohort study., Setting: Urban community., Participants: All 283 persons who drove between 1990 and 1991, selected from a representative cohort of community-living persons aged 72 years and older in New Haven, Connecticut., Measurements: Data on independent variables in five domains (demographic, health, psychosocial, activity, and physical performance) were collected in structured interviews before events occurred. The outcome measure was the self-report of involvement in automobile crashes, moving violations, or being stopped by police in a 1-year period., Results: Of the 283 drivers, 13% reported a crash, a moving violation, or being stopped by police in 1 year. The baseline factors associated with the occurrence of adverse events in multivariable analysis (with adjustment for driving frequency and housing type) were the following: poor design copying on the Mini-Mental State Examination (relative risk, 2.7; 95% CI, 1.5 to 5.0), fewer blocks walked (relative risk, 2.3; CI, 1.3 to 4.0), and more foot abnormalities (relative risk, 1.9; CI, 1.1 to 3.3). These risk factors were combined for assessment of their ability to predict the occurrence of adverse driving events. If no factors were present, 6% of drivers had events; if 1 factor was present, 12% had events; if 2 factors were present, 26% had events; and if 3 factors were present, 47% had events., Conclusions: In this urban population, several simple clinical measures correlated with the risk for adverse driving events.

Objectives: Hip fractures can have devastating effects on the lives of older individuals. We determined the frequency of occurrence of hip fracture and the baseline factors predicting death and institutionalization at 6 months after hip fracture., Methods: A representative cohort of 2812 individuals aged 65 years and older was followed prospectively for 6 years. Hip fractures were identified, and the occurrence of death and institutionalization within 6 months of the fracture was determined. Prefracture information on physical and mental function, social support, and demographic features and in-hospital data on comorbid diagnoses, fracture site, and complications were analyzed to determine predictors of death and institutionalization after hip fracture., Results: Of 120 individuals suffering a hip fracture, 22 (18%) died within 6 months and 35 (29%) were institutionalized at 6 months. The predictors of death in multiple logistic regression included fracture site, a high number of comorbid conditions, a high number of complications, and poor baseline mental status. The primary predictor of institutionalization was poor baseline mental status., Conclusions: The frequency of death, institutionalization, and loss of function after hip fracture should prompt a reevaluation of the current approach to this problem.

This study describes the present physician practice of counseling patients about driving and reporting potentially unsafe drivers. A survey was sent to all licensed general practitioners, internists, ophthalmologists, neurologists, and neurosurgeons in Connecticut. Fifty-nine percent (2,049/3,450) of eligible physicians responded to the questionnaire. Seventy-seven percent of responding physicians stated that they discussed driving with their patients and 14% reported patients to the Department of Motor Vehicles. Specialists were more likely to discuss driving. Seventy-four percent of physicians thought that after a certain age individuals should be screened for their ability to drive. Overall, 59% of physicians thought it was their responsibility to report unsafe drivers to the Department of Motor Vehicles and the primary reasons for reporting were that driver safety was a public health issue and that potentially unsafe drivers posed a risk to themselves or to others. It was concluded that physicians recognize that driving safety is an important public health issue that needs better-defined legal and medical guidelines.

The factors associated with driving cessation, number of miles driven, and changes in mileage were assessed in a community-living elderly population. A driving survey was administered in 1989 to surviving members of the New Haven EPESE cohort. Of 1,331 respondents, 456 had driven and 139 had stopped driving between 1983 and 1989. Independent predictors of driving cessation from a multiple logistic regression model included higher age, lower income, not working, neurologic disease, cataracts, lower physical activity level, and functional disability. These risk factors were combined to assess their ability to predict driving cessation. If no factors were present, no subjects stopped driving; if one or two factors were present, 17 percent stopped; if three or more factors were present, 49 percent stopped. Along with the expected medical factors, physical activity level and social and economic factors contributed to driving cessation. High mileage drivers tended to be younger, active males who still worked. Increasing age and disability were associated with mileage reduction compared to five years earlier.

Driving safety in elderly individuals is becoming an increasingly important issue in geriatrics and in medical practice. The number of elderly drivers is increasing as the population ages, and especially as current generations of female drivers age. Concern is raised about their safe operation of motor vehicles because of the increasing likelihood with advancing age of developing conditions that may adversely affect the visual, cognitive, and motor abilities integral to driving. But this issue is not only a medical one, since there are social and political components as well. This discussion will describe the background of this issue, focus on the changes that may occur with aging and their potential relationship to driving ability, and, finally, will outline an approach that physicians may employ in their practice.

In summary, declines in motor ability and reaction time are noted with aging, although the effect of these changes on actual driving performance needs further elucidation. It may be possible to compensate partially for some of these declines through physical and behavioral training. Attention to the physical, cognitive, and sensory capacities of older individuals in the design of vehicles and roadways also may be beneficial. Considerable work still needs to be done to adequately assess the changes that occur with aging in driving ability, what factors influence these changes and their potential modification, as well as the costs of any interventions planned.

Objective: The main objective of the study was to determine the change in physical function following hip fractures in a community-living elderly population. A secondary objective was the determination of baseline factors predictive of altered function following hip fracture., Design: Prospective, cohort study., Setting: Urban, community-living elders., Participants: 120 members of a cohort of 2806 individuals age 65 and older in New Haven, CT who sustained a hip fracture from 1982 to 1988 and were treated in the two New Haven hospitals., Outcome Measure: Self-reported performance of dressing, transferring, walking across a room, climbing stairs, and walking one-half mile before the fracture occurred and 6 weeks and 6 months post-fracture. Baseline factors were assessed before the hip fracture occurred., Results: Of the 120 cohort members who sustained a hip fracture in the 6-year study period, 22 died within 6 months of the fracture. Among survivors there was a sustained decline in function at 6 weeks after the fracture with little improvement by 6 months. At baseline, 86% could dress independently versus 49% at 6 months; 90% could transfer independently versus 32% at 6 months; 75% could walk across a room independently versus 15% at 6 months; 63% could climb a flight of stairs versus 8% at 6 months; and 41% could walk one-half mile versus 6% at 6 months. Physical function and mental status were the only baseline factors significantly associated with physical function at 6 months after the fracture in bivariate analysis, while physical function and depression were associated in multivariate analysis., Conclusion: We found a substantial decline in physical function following hip fracture in a prospectively followed community-living elderly population. Only pre-morbid physical and mental function predicted this decline.

The patterns of and risk factors for mechanical restraint use were determined in 12 skilled nursing facilities. Restraints were being used for 59% of residents at the beginning of the study; 31% of remaining residents were restrained during the follow-up year. No facility characteristic was associated with restraint use. The resident characteristics independently associated with initiation of restraints were older age, disorientation, dependence in dressing, greater participation in social activities, and nonuse of antidepressants. Unsteadiness (72%), disruptive behavior such as agitation (41%), and wandering (20%) were the most frequently cited reasons for initiation of restraints.

We propose a short, simple approach that can be used by general internists to routinely screen the functional status of elderly patients in office practice. The approach relies on checking a limited number of targets that are commonly dysfunctional but often unappreciated when conventional histories and physical examinations are done for elderly patients. The new focus is on carefully selected tests of vision, hearing, arm and leg function, urinary incontinence, mental status, instrumental and basic activities of daily living, environmental hazards, and social support systems. Brief questions and easily observed tasks are used to obtain the information needed for a suitable, effective screening while minimizing the time for administration. The approach can be incorporated into routine practice if certain relatively unproductive procedures are eliminated from the routine clinical examination, and particularly if internists are suitably compensated for the additional time.