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To assess the clinical utility of the Trail-Making Tests (TMTs) as screens for impaired road-test performance.Secondary analyses of three data sets from previously published studies of impaired driving in older adults using comparable road test designs and outcome measures.Two academic driving specialty clinics.Older drivers (N = 392; 303 with cognitive impairment, 89 controls) from Rhode Island and Missouri.Standard operating characteristics were evaluated for the TMT Part A (TMT-A) and Part B (TMT-B), as well as optimal upper and lower test cut-points that could be useful in defining groups of drivers with indeterminate likelihood of impaired driving who would most benefit from further screening or on-road testing.Discrimination remained high (70%) when cut-points for the TMTs derived from Rhode Island data were applied to Missouri data, but calibration was poor (all P.01). TMT-A provided the best utility for determining a range of scores (68-90 seconds) for which additional road testing would be indicated in general practice settings. A high frequency of cognitively impaired participants unable to perform the TMT-B test within the allotted time limited the utility of the test (25%). Mere inability to complete the test in a reasonable time frame (e.g., TMT-A48 seconds or TMT-B108 seconds) may still be a useful tool in separating unsafe from safe or marginal drivers in such samples.The TMTs (particularly TMT-A) may be useful as screens for driving impairment in older drivers in general practice settings, where most people are still safe drivers, but more-precise screening measures need to be analyzed critically in a variety of clinical settings for testing cognitively impaired older drivers.

Background Identifying effective and accessible interventions for dementia caregivers is critical as dementia prevalence increases. Objective Examine the effects of a telephone-based intervention on caregiver well-being. Design Randomized, controlled trial. Setting Academic medical center. Participants Two hundred and fifty distressed, family, dementia caregivers. Intervention Caregivers randomized to receive 16 telephone contacts over 6 months of either the Family Intervention: Telephone Tracking—Caregiver (FITT-C) or Telephone Support (TS). Outcome Primary outcome variables were family caregivers' depressive symptoms, burden, and reactions to care recipients' behavior problems at 6 months. Results The FITT-C intervention resulted in significantly improved caregiver depressive symptoms ( P = .003; 27% net improvement) and less severe reactions to care-recipient depressive behaviors ( P = .009; 29% net improvement) compared with the control condition (TS). Conclusion An entirely telephone-based intervention improves caregivers' depressive symptoms and reactions to behavior problems in the care recipient and is comparable with reported results of face-to-face interventions.

Aims To update our prior meta-analysis that showed past major depression (MD+) to be unrelated to smoking cessation outcome. Methods Eligible trials included 14 from our original review and 28 identified through an updated systematic review (2000–2009). We coded for assessment of past MD, exclusion for recent MD episode (MDE; ≤6 months versus no exclusion), duration/modality of cognitive behavioral treatment (CBT; face-to-face versus self-help) and other factors. To minimize influence of experimental treatments that may selectively benefit MD+ smokers we analyzed placebo/lowest intensity control arms only. Study-specific ORs for the effect of past MD on short-term (≤3 months) and long-term (≥6 months) abstinence were estimated and combined using random effects. Two-way interaction models of past MD with study methodology and treatment factors were used to evaluate hypothesized moderators of the past MD-abstinence association. Results MD+ smokers had 17% lower odds of short-term abstinence (n = 35, OR = 0.83, 95% CI = 0.72–0.95, P = 0.009) and 19% lower odds of long-term abstinence (n = 38, OR = 0.81, 95% CI = 0.67–0.97, P = 0.023) than MD- smokers after excluding the sole study of varenicline because of its antidepressant properties. The association between past MD and abstinence was affected by methodological (recent MDE exclusion, type of MD assessment) and treatment (CBT modality) factors. Conclusions Past major depression has a modest adverse effect on abstinence during and after smoking cessation treatment. An increased focus on the identification of effective treatments or treatment adaptations that eliminate this disparity in smoking cessation for MD+ smokers is needed.

OBJECTIVES: To relate the standardized road test to video recordings of naturalistic driving in older adults with a range of cognitive impairment. DESIGN: Cross-sectional observational study. SETTING: Academic medical center memory disorders clinic. PARTICIPANTS: One hundred three older drivers (44 healthy, 59 with cognitive impairment) who passed a road test. MEASUREMENTS: Error rate and global ratings of safety (pass with and without recommendations, marginal with restrictions or training, or fail) made by a professional driving instructor. RESULTS: There was fair agreement between global ratings on the road test and naturalistic driving. More errors were detected in the naturalistic environment, but this did not affect global ratings. Error scores between settings were significantly correlated, and the types of errors made were similar. History of crashes corrected for miles driven per week was related to road test error scores but not naturalistic driving error scores. Global cognition (Mini-Mental State Examination) was correlated with road test and naturalistic driving errors. In healthy older adults, younger age was correlated with fewer errors on the road test and more errors in naturalistic driving. CONCLUSION: Road test performance is a reasonable proxy for estimating fitness to drive in older individuals' typical driving environments, but differences between performance assessed using these two methods remain poorly understood and deserve further study. Language: en

This study examined self-reported physical activity (PA) barriers, and their effects on PA behavior change at 3 and 12 months among 280 previously inactive women enrolled in a PA promotion trial. Effect modification of baseline barriers by baseline weight status on PA behavior change was also examined. At baseline and month 12, obese women reported significantly greater PA barriers compared with normal and overweight women (P < 0.05). Individual barriers that were more likely to be elevated for obese vs. normal and overweight participants at baseline were feeling too overweight, feeling self-conscious, reporting minor aches and pains, and lack of self-discipline. Also, weight status moderated the effect of PA barriers on PA behavior change from baseline to month 3 (P < 0.05), but not to month 12 (P = 0.637), with obese participants reporting high barriers achieving 70 min/week fewer than those with low barriers (P < 0.05). Finally, the interaction between barriers (high vs. low) and weight status (obese vs. normal), shows PA barriers had a detrimental PA effect among obese participants that was 122.5 min/week (95% confidence interval (CI) = 15.7, 229.4; P < 0.05) lower than their effect on normal-weight participants. These results suggest that for obese women, PA barriers have quantifiable effects on PA behavior change. This study has implications for the design of future weight loss and PA interventions, suggesting that a comprehensive assessment of PA barriers is a prerequisite for appropriate tailoring of behavioral PA interventions.

Background The efficacy of a home-based physical activity (PA) intervention for colorectal cancer patients versus contact control was evaluated in a randomized controlled trial. Methods Forty-six patients (mean age = 57.3 years [SD = 9.7], 57% female, mean = 2.99 years post-diagnosis [SD = 1.64]) who had completed treatment for stages 1–3 colorectal cancer were randomized to telephone counseling to support PA (PA group, n = 20) or contact control (control group, n = 26). PA group participants received 3 months of PA counseling (based on the transtheoretical model and the social cognitive theory) delivered via telephone, as well as weekly PA tip sheets. Assessments of PA (Seven-day Physical Activity Recall [7-day PAR] and Community Healthy Activities Model Program for Seniors [CHAMPS]), submaximal aerobic fitness (Treadwalk test), motivational readiness for PA, and psychosocial outcomes were conducted at baseline, 3, 6, and 12 months post-baseline. Objective accelerometer data were collected at the same time points. Results The PA group reported significant increases in minutes of PA at 3 months (7-day PAR) and caloric expenditure (CHAMPS) compared with the control group, but the group differences were attenuated over time. The PA group showed significant improvements in fitness at 3, 6, and 12 months versus the control group. Improvements in motivational readiness for PA were reported in the PA group only at 3 months. No significant group differences were found for fatigue, self-reported physical functioning, and quality of life at 3, 6, and 12 months. Conclusion A home-based intervention improved survivors' PA and motivational readiness at 3 months and increased submaximal aerobic fitness at 3, 6, and 12 months. Copyright © 2011 John Wiley & Sons, Ltd.

Aims To examine the reliability of self-report cigarette smoking questions by describing recanting (denial of previous smoking reports) in a nationally representative sample of US adolescents followed throughout young adulthood. Predictors of recanting across stages of smoking uptake/progression are examined. Design A total of 12 985 respondents to cigarette smoking questions during in-home interviews at waves I and III (6 years apart) of the National Longitudinal Study of Adolescent Health (Add Health). The sample survey procedures of Stata 9.0 were used to produce nationally representative estimates, with standard errors adjusted for both clustering at the school level and stratification by geographical region. Measurements Recanting probabilities determined by reports of stages of smoking uptake/progression at each time-point were predicted by race/ethnicity, parental education, household income, poverty level, depression and peer daily smoking. Findings Stage-specific results indicated that recanting is higher when the earlier smoking was less frequent/intense. Recanters were older, from lower-income households and had higher baseline depression levels. Non-Hispanic black youth were significantly more likely to recant previous smoking compared to non-Hispanic white youth, even in multivariate models controlling for socio-demographic variables. Predictors of recanting differed by level of tobacco involvement. The greater likelihood of non-Hispanic black respondents to deny previous smoking may be a reflection of less intense or more intermittent use of tobacco that leads to recall differences over time. Conclusions Racial/ethnic subgroups and/or respondents endorsing depressive symptoms may be more vulnerable to misclassification during interpretation of national survey data and subsequently not identified properly for prevention/intervention programs.

There is growing evidence that physical activity (PA) can improve quality of life (QOL) and reduce fatigue in cancer survivors. Research staff or healthcare providers have delivered PA interventions to cancer populations. As a first step to dissemination of a previously tested PA intervention, seven American Cancer Society Reach to Recovery volunteers (mean age = 57.4 years) were trained to deliver the telephone-based intervention to 25 breast cancer survivors (mean age = 52.9 years, 56% Stage 2 cancer, mean of 3.3 years since diagnosis). A single group design was used. The theory-based intervention consisted of 12 weekly calls to encourage participants to adopt moderate-intensity PA. Participants' PA, QOL, mood, and fatigue were assessed at baseline, 12, and 24 weeks. Data on intervention feasibility and preliminary effects were collected. The intervention was feasible (mean of 10.7 out of 12 calls were delivered) and acceptable to the volunteers. At 12 weeks, there were significant increases in participants' PA and improvements in fatigue, QOL, and vigor. Effects were maintained at 24 weeks. This pilot study demonstrated that it was feasible for trained volunteers to deliver a telephone-based PA intervention to breast cancer survivors, and there were positive effects on survivors' PA behavior and psychological outcomes.

This article reports on a study undertaken to determine the validity and reliability of clinician ratings of the driving competence of patients with mild dementia. The observational study included a cross-section of 50 drivers with mild dementia, based on chart review by clinicians with varying types of expertise and experience. The clinicians rated each driver as safe, marginal, or unsafe. A professional driving instructor compared these ratings with total driving scores on a standardized road test and categorical ratings of driving competence. Results showed that accuracy of clinician ratings ranged from 62% to 78% for the instructor’s global rating of safe versus marginal or unsafe. In general, there was moderate accuracy and interrater reliability. The authors note that accuracy could have been improved in the least-accurate raters by greater attention to dementia duration and severity ratings, as well as less reliance on the history and physical examination. The authors conclude that although a clinician may be able to identify many potentially hazardous drivers, the accuracy achieved in insufficient to state that a clinician’s assessment alone is adequate to determine driving competence in those with mild dementia.

OBJECTIVES: Physicians and family members frequently are asked to provide information about driving ability in patients with Alzheimer's disease (AD), yet there has been little research on the validity of their assessments of driving performance. DESIGN: Cross-sectional. SETTING: Participants were recruited from the neurology department of a community hospital affiliated with Brown Medical School. PARTICIPANTS: Participants included 75 older adults (17 with mild AD, 33 with very mild AD, and 25 elderly controls). MEASUREMENTS: The participant him/herself, an informant, and an experienced neurologist rated each participant's driving ability on a 3-point rating scale (safe, marginal, unsafe). A professional driving instructor also completed a standardized 108-point on-road driving assessment of each participant and then rated driving ability on the 3-point scale. Ratings were compared with the on-road driving score and with each other. RESULTS: Only the neurologist's rating of the participants' driving abilities was significantly related to on-road driving score. When related to the instructor's safety rating, the neurologist's ratings were the most sensitive and specific. Mini-Mental State Examination score was a borderline covariate for the neurologist's rating. Overall, the instructor was the most stringent rater of participant driving ability, followed by the neurologist, the informant, and the participant. CONCLUSION: An experienced neurologist's assessment of driving competence may be a valid predictor of driving performance of patients with early AD.

teristics (i.e. demographics), primary stressors (i.e. participants’ cognitive, functional and behavioural decline over time), subjective stressors (i.e. distress due to participant’s behavioural symptoms and burden related to helping with everyday tasks), secondary role strains (i.e. caring for others), protective factors (i.e. coping) and personal stressors (i.e. self-rated health and quality of life). Over four years 37 participants developed dementia (7%), while 133 (24%) met Winblad criteria for mild cognitive impairment (35% incident cases). Our model fitted the data well (c 2/df1⁄42.517; CFI1⁄4.934; PCFI1⁄4.799; SRMR1⁄4.069; RMSEA1⁄4.052; PCLOSE1⁄4.172). Although change on all variables was subtle and informants overall did not experience significant increases in distress longitudinally (slope mean1⁄4-.03, p1⁄4.410), there was significant interindividual variability with respect to distress trajectories (slope variance1⁄4.10, p

We consider approximate Bayesian inference about scalar parameters of linear regression models with possible censoring. A second-order expansion of their Laplace posterior is seen to have a simple and intuitive form for logconcave error densities with nondecreasing hazard functions. The accuracy of the approximations is assessed for normal and Gumbel errors when the number of regressors increases with sample size. Perturbations of the prior and the likelihood are seen to be easily accommodated within our framework. Links with the work of DiCiccio et al. (1990) and Viveros and Sprott (1987) extend the applicability of our results to conditional frequentist inference based on likelihood-ratio statistics. Nous considerons l'inference Bayesienne approximative au sujet de parametres scalaires de modeles de regression lineaire avec censure possible. Nous demontrons qu'une expansion de second-ordre de leur approximation de Laplace a posteriori a une forme simple et intuitive pour les densites d'erreur logconcave avec fonctions de danger non-decroissantes. La precision des approximations est evaluee pour les erreurs Normal et Gumbel, lorsque le nombre de variables explicatives croit avec la taille de l'echantillon. Des perturbations de la loi a priori et de la vraisemblance sont facilement prise en compte au sein de notre structure. Des liens aux travaux de DiCiccio et al. (1990) et Viveros et Sprott (1987) etendent l'applicabilite de nos resultats a 1'inference conditionnelle frequentiste fondee sur les statistiques du rapport des vraisemblances.

We consider approximate Bayesian inference about the quantity R = P[Y2> Y1] when both the random variables Y1, Y2 have expectations that depend on certain explanatory variables. Our interest centers on certain characteristics of the posterior of R under Jeffreys's prior, such as its mean, variance and percentiles. Since the posterior of R is not available in closed form, several approximation procedures are introduced, and their relative performance is assessed using two real datasets. Nous considerons l'inference Bayesienne approximative pour la quantite R = P[Y2 > Y1], lorsque les deux variables aleatoires Y1, Y2 ont des esperances qui dependent de certaines variables explicatives. Notre interět se centre sur certaines caracteristiques de la loi a posteriori de R correspondant a une loi a priori de Jeffrey, telle que sa moyenne, sa variance et ses percentiles. Etant donne que la loi a posteriori de R n'est pas disponible sous forme explicite, nous proposons plusieurs procedures d'approximation et nous evaluons leur performance relative en utilisant deux ensembles de donnees reelles.

Clock drawing is recommended by medical and transportation authorities as a screening test for unsafe drivers. The objective of the present study was to assess the usefulness of different clock drawing systems as screening measures of driving performance in 122 healthy and cognitively impaired older drivers. Clock drawing was measured using four different scoring systems. Driving outcomes included global ratings of safety and the error rate on a standardized on-road test. Findings revealed that clock drawing was significantly correlated with the driving score on the road test for each of the scoring systems. However, receiver operator curve analyses showed limited clinical utility for clock drawing as a screening instrument for impaired on-road driving performance with the area under the curve ranging from 0.53 to 0.61. Results from this study indicate that clock drawing has limited utility as a solitary screening measure of on-road driving, even when considering a variety of scoring approaches.