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Using an online survey, we examined the knowledge, attitudes, and practices with respect to older driver safety concerns of clinical psychologists from across Canada who self-identified as working with at least some drivers over 60 years of age. Eighty-four psychologists completed the survey, and many were aware of the issues relevant to older driver safety, although only about half reported that assessing fitness to drive was an important issue in their practice. The majority (75%) reported that they would benefit from education concerning evaluation of fitness to drive. The primary recommendation emerging from this investigation is to increase efforts to inform and educate psychologists about driving-related assessment and regulatory issues in general, and specifically with respect to older adults. As the population ages, it is of growing importance for all health care providers to understand the influence of mental health conditions-including cognitive impairment and dementia-on driving skills.

Background: Many scoring systems exist for clock drawing task variants, which are common dementia screening measures, but all have been derived from clinical samples. This study evaluates and combines errors from two published scoring systems for the Clock Drawing Test (CDT), the Lessig and Tuokko methods, in order to create a simple yet optimal scoring procedure to screen for dementia using a Canadian population-based sample., Methods: Clock-drawings from 356 participants (80 with dementia, 276 healthy controls) from the Canadian Study on Health and Aging were analyzed using logistic regression and Receiver Operating Characteristic curves to determine a new, simplified, population-based CDT scoring system. The new Jouk scoring method was then compared to other commonly used systems (e.g. Shulman, Tuokko, Watson, Wolf-Klein)., Results: The Jouk scoring system reduced the Lessig system even further to include five critical errors: missing numbers, repeated numbers, number orientation, extra marks, and number distance, and produced a sensitivity of 81% and a specificity of 68% with a cut-off score of one error. With regard to other traditionally used scoring methods, the Jouk procedure had one of the most balanced sensitivities/specificities when using a population-based sample., Conclusions: The results from this study improve our current state of knowledge concerning the CDT by validating the simplified scoring system proposed by Lessig and her colleagues in a more representative sample to mimic conditions a general clinician or researcher will encounter when working among a wide-ranging population and not a dementia/memory clinic. The Jouk CDT scoring system provides further evidence in support of a simple and reliable dementia-screening tool that can be used by clinicians and researchers alike.

Demographic corrections for cognitive tests should improve classification accuracy by reducing age or education biases, but empirical support has been equivocal. Using a simulation procedure, we show that creating moderate or extreme skewness in cognitive tests compromises the classification accuracy of demographic corrections, findings that appear replicated within clinical data for the few neuropsychological test scores with an extreme degree of skew. For most neuropsychological tests, the dementia classification accuracy of raw and demographically corrected scores was equivalent. These findings suggest that the dementia classification accuracy of demographic corrections is robust to slight degrees of skew (i.e., skewness <1.5).

The lack of gold standard diagnostic criteria for cognitive impairment in the absence of dementia has resulted in variable nomenclature, case definitions, outcomes, risk factors, and prognostic utilities. Our objective was to elucidate the clinical correlates of conversion to dementia in a longitudinal population-based sample. Using data from the Canadian Study of Health and Aging, a machine learning algorithm was used to identify symptoms that best differentiated converting from nonconverting cognitively impaired not demented participants. Poor retrieval was the sole predictor of conversion to dementia over 5 years. This finding suggests that patients with impaired retrieval are at greater risk for progression to dementia at follow-up. Employing significant predictors as markers for ongoing monitoring and assessment, rather than as clinical markers of conversion, is recommended given the less than optimal specificity of the predictive algorithms.

Our objective was to compare the predictive ability of different models of mild cognitive impairment (MCI) as a marker of incipient dementia in a longitudinal population-based Canadian sample. We examined the use of existing, well-documented MCI criteria using data from persons who underwent a clinical examination in the second wave of the Canadian Study of Health and Aging (CSHA). Demographic characteristics, average neuropsychological test performance, and sample frequencies and conversion rates were calculated for each classification. Receiver operating characteristic (ROC) analyses were employed to assess the predictive power of each cognitive classification. The highest sample frequencies and conversion rates were associated with case definitions of multiple-domain MCI. The only diagnostic criteria to significantly predict dementia 5 years later was the cognitive impairment no dementia (CIND)-2 case definition. More restrictive MCI case definitions fail to address the varying temporal increases in decline across different cognitive domains in the progression from normal cognitive functioning and dementia.

In contrast to expectations, demographic corrections to reduce biases against those of advanced age or few years of education does not universally improve diagnostic classification accuracy. Age corrections may be particularly problematic because age is also a risk factor for a dementia diagnosis. We found that simulating increased risk for dementia based on demographic variables, such as age, reduced the overall classification accuracy for demographically corrected simulated scores relative to the raw, uncorrected test scores. In clinical data with a small magnitude of association between age and dementia diagnosis, we found equivalent overall classification accuracy for demographically corrected and raw test scores. Regardless of the overall classification accuracy results, cutoff comparisons (16th and 9th percentiles) in clinical and simulated data demonstrated that for the most part, the sensitivity of raw scores was higher than the sensitivity of demographically corrected scores, but the specificity of scores corrected with normative data was superior.

In this study, the relations between cognitive status and neuropsychiatric impairments in nondemented older adults in cross section and over time is examined. Using data from the Canadian Study of Health and Aging (CSHA), a longitudinal, nation-wide study in which data were collected 3 times (ie, CSHA-1, CSHA-2, CSHA-3) at 5-year intervals, individuals were classified with (n = 240) and without (n = 386) cognitive impairment at CSHA-2. Loss of interest, changes in personality and mood, and depression were reported by a knowledgeable informant (ie, family or friends) more frequently for those with cognitive impairment than for those without cognitive impairment. After controlling for initial cognitive status, loss of interest and depression contributed significantly to the prediction of mild cognitive impairment, dementia, and Alzheimer's disease over time. These findings suggest that these neuropsychiatric impairments play significant roles throughout the course of cognitive decline and should be taken into consideration even before cognitive impairment is evident.

We investigated the effects of correcting for demographic biases on the sensitivity and specificity of the Modified Mini Mental Status Exam (3MS) using a sample of English-speaking older adults (N=8901) from the Canadian Studies of Health and Aging. The sensitivity and specificity of the original 3MS were compared to the 3MS regression-adjusted for the influence of demographic variables and then to 3MS percentiles based on published normative data with age and education corrected cutoff scores. According to receiver operating characteristic curve analyses, the regression-adjusted 3MS was no more accurate than the original 3MS when screening for dementia, and it was less accurate when screening for cognitive impairment. The use of 3MS percentiles based on normative data with age and education corrected cut-off points were less accurate than the original 3MS when screening for both cognitive impairment and when screening for dementia.

The present study examined the relations among levels of cognitive functioning, executive dysfunction, and awareness of financial management capabilities among a sample of 42 community-dwelling persons with dementia. Financial tasks on the Measure of Awareness of Financial Skills (MAFS) were dichotomized as simple or complex based on Piaget's operational levels of childhood cognitive development. Severity of global cognitive impairment and executive dysfunction were significantly related to awareness of financial abilities as measured by informant-participant discrepancy scores on the MAFS. For persons with mild and moderate/severe dementia, and persons with and without executive dysfunction, proportions of awareness within simple and complex financial task categories were tabulated. Significantly less awareness of financial abilities occurred on complex compared with simple tasks. Individuals with mild dementia were significantly less aware of abilities on complex items, whereas persons with moderate/severe dementia were less aware of abilities, regardless of task complexity. Similar patterns of awareness were observed for individuals with and without executive dysfunction. These findings support literature suggesting that deficits associated with dementia first occur for complex cognitive tasks involving inductive reasoning or decision-making in novel situations, and identify where loss of function in the financial domain may first be expected., (Copyright Taylor & Francis Ltd)

This article reviews the concept of mild cognitive impairment in groups of people whose cognitive impairment does not warrant a diagnosis of dementia (cognitive impairment, no dementia; CIND). Problems with the application of existing sets of criteria to the Canadian Study of Health and Aging (CSHA) data sets are addressed and a procedure for identifying a subgroup presumed "at risk" for developing dementia is presented. Application of an informant's report of changes in cognitive functioning and neuropsychologists' ratings of mild to severe deficits in any of eight cognitive domains results in approximately half of the CIND cases being identified as "at risk." The rationale for the collection of specific information related to CIND in CSHA-2 is provided. A minority of people identified with CIND at CSHA-2 showed only memory impairment, and most demonstrated cognitive loss over the preceding five-year interval. This article provides a conceptual basis for procedures to identify people with cognitive impairment most likely to decline to dementia.

Identification of persons at risk for developing dementia is of increasing importance as the proportion of persons over the age of 65 years grows globally. This review examines the neuropsychological literature specifically addressing the concept of impaired cognitive functioning of insufficient magnitude to warrant a diagnosis of dementia and its meaning with respect to the development of dementia. Although the most obvious finding in the literature is that persons with impaired cognitive functioning have varied outcomes, it is clear that a significant proportion of persons with mild cognitive impairment progress to dementia over a 1- to 2-year interval and approximately 50% progress to dementia by 5 years. The best and most commonly identified predictors of decline to dementia include age and lower baseline performance on neuropsychological measures (e.g., measures of memory). In discussing these findings, issues related to sample definition, sample selection, and methodology are identified and recommendations for future research are provided.

Background: Not all cognitively impaired people have dementia, but those who do not meet current criteria for dementia have received little study. We report a comprehensive estimate of the prevalence of "cognitive impairment, no dementia" (CIND) in an elderly population., Methods: The Canadian Study of Health and Aging gathered population representation information about elderly Canadians aged 65 and over from 36 cities and surrounding areas in five regions. In each region, the sample size was 1800 people in the community and 250 people in institutions. Patients in the community were screened for cognitive impairment by means of the modified mini-mental state examination. Those who scored below the cut-off point (n = 1106) and a randomly selected sample of those who scored above the cut-off point (n = 494) were referred for clinical examination. 59 individuals unable to take the screening test were also assessed clinically. We selected 17 long-term care institutions in each region, and then randomly selected consenting residents of these institutions for clinical assessment (n = 1255)., Results: The prevalence of CIND was 16.8%, which was more than all types of dementia combined (8.0%). The prevalence of all types of cognitive impairment, including dementias, increased with age. Patients with CIND were three times more likely to be living in institutions than were cognitively unimpaired patients (odds ratio 3-1 [95% CI 2.4-3.9]). Circumscribed memory loss has a prevalence of 5.3% in the elderly Canadian population, and was the most common category. CIND was related to some degree of functional impairment in elderly patients., Interpretation: CIND is commonly associated with functional disability and a need for institutional care. This diagnostic category includes a costly group of disorders that merit further study.

The driving records of 249 persons referred to an outpatient dementia clinic were examined retrospectively to assess the specificity of the association between diagnosed dementia and increased traffic accidents. The clinic patients were divided into two groups: those who met criteria for dementia and those who did not. For each group, control subjects matched on age, gender, and location of residence were randomly selected from the records of all drivers in the province. The dementia sample had approximately 2.5 times the traffic crash rate of their matched control sample. The not-demented sample had approximately 2.2 times the traffic crash rate of their matched control sample. These individuals exhibited a variety of psychiatric, neurological, and medical conditions which could have affected their driving, and multiple medical problems were often present. Further clarification of the characteristics of "high risk" drivers is required if effective strategies for maximizing independence while minimizing the risk of traffic crashes are to be realized.

As part of the Canadian Study of Health and Aging (CSHA), a battery of neuropsychological measures was administered to 1879 participants. Participants who received neuropsychological evaluations were selected from an age-stratified random sample on the basis of scores on a cognitive screening tool, the Modified Mini-Mental State Examination (3MS). Seventy-five percent of the sample seen for neuropsychological evaluation scored between 50 and 77 on the 3MS and 25% of the sample scored 78 or over. This paper provides a descriptive summary of the methodological basis of the neuropsychological component of the CSHA. The findings indicated that differences existed between participants administered the battery in English or French in terms of refusal rates and diagnoses of dementia. Cursory examination of the utility of the battery indicated that the battery was tolerated well by both the participants and the psychologists involved with the study and that measures of memory functioning were central to diagnostic decision-making. The relations between neuropsychological, preliminary medical and consensus diagnoses were examined and indicated that neuropsychological information influenced diagnostic decision-making. The neuropsychology component of the CSHA is a rich source of information on persons aged 65 years and older in Canada.

Objective: We tested three hypotheses about the effects of perceived and actual patient deficits on caregiver burden: (1) objective patient deficits directly influence caregiver burden; (2) caregiver burden is the result of caregiver perceptions of patient deficits; (3) objective patient deficits influence caregiver burden indirectly by determining perceived deficits., Design: Causal modeling., Setting: A hospital-based out-patient diagnostic clinic., Participants: An elderly sample (n = 136) referred to a diagnostic dementia clinic and their caregivers., Measurements: Neuropsychological tests of patient functioning, a measure of patient mood (the Geriatric Depression Scale), caregiver perceptions of patient functioning, and a measure of caregiver burden (the Burden Interview)., Results: The Geriatric Depression Scale and neuropsychological battery-based indices of functioning were not predictive of caregiver burden. Caregiver perceptions of patient dysphoria, and of everyday functioning skills were related to burden. Caregiver perceptions of patient memory, self-care, and language skills were unrelated to caregiver burden., Conclusions: The results are consistent with the Lazarus and Folkman model of stress and coping; the caregiver's perceptions of the patient's functioning were the most important determinants of caregiver burden. Objective patient deficits influenced caregiver burden indirectly by influencing caregiver perceptions of patient deficits. These findings suggest that practitioners attempting to assess and manage caregiver burden should attend to the caregivers' perceptions of patient mood and everyday functioning. The relationship of caregiver appraisals with actual patient deficits also sheds light on the nature of caregiver stress.

The early detection of dementia carries implications for clinical management for patients and their families and is of utmost concern if an effective pharmacological treatment is to be found. The utility of an enhanced cued recall paradigm for predicting dementia in a group of elderly subjects was examined. Forty-five subjects referred for clinical evaluation who did not meet the criteria for dementia at initial assessment were reassessed 12-18 months later. Eighteen of these subjects were diagnosed as having possible or probable Alzheimer Disease at reassessment and the diagnostic status of 27 remained unchanged. At initial assessment the 'change' group performed more poorly than the 'no change' group on measures of retrieval, acquisition and retention derived from the cued recall procedure. As would be expected, the performance of the 'no change' group remained stable over time whereas the performance of the 'change' group deteriorated, resembling the performance of a group of subjects with mild possible or probable Alzheimer disease. When the sensitivity and specificity of the memory variables were examined, the retrieval measure (i.e., free recall) appeared most useful as an early predictor of dementia. Continued longitudinal evaluations of subjects with questionable dementia are needed to address more fully the natural history of early memory changes associated with dementia.

Memory functioning of normal elderly subjects and patients with suspected malignant memory disorders were examined using a cued recall memory assessment procedure. Levels of psychosocial functioning were rated by a multidisciplinary team. Ability to engage in free and cued recall was studied to determine the relationship between problems of acquisition and retrieval. Normal and impaired elderly showed strong differences on free recall and total recall resulting in 90.58% and 79.06% rates of accuracy of prediction of group membership. There were significant multivariate and univariate differences among the memory-impaired groups defined in terms of their psychosocial functioning. These findings indicate that differences in acquisition and retrieval are associated with increasing impairment of psychosocial functioning. Patients whose psychosocial functioning was rated as falling within the questionable range exhibited only deficits in retrieval. Patients whose psychosocial functioning was rated as more severely impaired, exhibited problems of retrieval and acquisition.

Head trauma has been found with greater frequency in the histories of Alzheimer patients than age-matched controls in some studies, but not in others. We hypothesized that events that accelerate neuron loss, such as significant head trauma, hasten the onset of symptoms of Alzheimer's disease in persons vulnerable to the disorder. Retrospective data on 148 probable Alzheimer patients and 33 demented controls were examined. Alzheimer patients with severe head injury before the age of 65 showed onset of symptoms at an earlier age than Alzheimer patients without head trauma.

The inclusion of individuals with incipient dementia in normative data contaminates the distinction between normal and pathological aging. Conventional and Robust (excluding persons with incipient dementia) norms were created using data from the Canadian Study of Health and Aging (CSHA). Robust norms were not significantly better at distinguishing between normal and pathological aging. Norms reflecting the relationship between age and the prevalence of dementia revealed a probability of dementia of less than 35%. The results of the norming procedure serve to illustrate the validity of our current measures and methods for identifying cognitive impairment. CSHA Conventional norms are adequate for the identification of cognitive impairment. [ABSTRACT FROM AUTHOR]

This paper examines the psychometric properties of a three-part (participant, informant, and performance) Measure for assessing Awareness of Financial Skills (MAFS). The MAFS was administered to 10 seniors with dementia and 25 well-functioning seniors, and their informants. Measures of cognitive functioning, social desirability, neuroticism, and perceived control were administered to each participant to allow for an assessment of validity. Internal consistency estimates for the participant and informant questionnaires were found to be 0.92 and 0.97, respectively. Convergent validity analysis indicated that performance on this measure was related to level of cognitive functioning, with higher level of unawareness associated with decreased cognitive ability. Discriminant validity analysis showed that performance on this measure was not related to social desirability or neuroticism. This study provides evidence that the MAFS is a reliable and valid tool for assessing awareness of financial skills in older adults. [ABSTRACT FROM AUTHOR]