Driving tests with older patients: effect of unfamiliar versus familiar vehicle

The aim of the study was to study the effect, for older license holders, of taking a driving test with an unfamiliar vehicle, as compared to their own cars. The study population consisted of licensed patients 65–85 years referred to the Traffic Medicine Centre (TrMC), Huddinge University Hospital, for an evaluation of their medical and cognitive fitness to drive. In the clinical practice of TrMC, driving tests have been used since 1997, with inspectors from the Swedish National Road Administration (SNRA) acting as evaluators. Initially, patients were allowed to use their own cars. From the beginning of the year 2000, however, dual brakes were made mandatory and most evaluations were then made with SNRA cars. When comparing the outcomes of driving tests from the period prior to 2000 (n=96) and after 2000 (n=69), it was found that the number of drivers who failed the test increased by 16%. Also, those who passed the test after more than one trial decreased by 20%. The potential of the neuropsychological assessment to correctly classify drivers in outcome groups was considerably reduced in the period after 2000. These results support the view that, for older drivers with cognitive deterioration, the need to adapt to an unfamiliar vehicle represents a supplementary cognitive load that may compromise their driving ability and the validity of the assessment. A measure aimed only at increasing the safety of examiners and examinees thus had an unintended side-effect that is detrimental to older clinical populations.     

Neuropsychological aspects of driving after a stroke—in the simulator and on the road

Thirty patients with stroke and 30 matched controls participated in the study (mean age 68 years, mean interval since stroke onset 8.6 months). The patients performed significantly worse on cognitive and attentional processing measured by a neuropsychological test battery. The patients had significantly greater difficulty in allocating processing resources to a secondary information processing task during driving in an advanced simulator. The patients performed worse driving in real traffic, and had less driving skill; fifty per cent did not pass the driving test. The neuropsychological test battery showed a pattern with three factors: (1) attentional processing (2) executive capacity, and (3) cognitive processing. Regression models based on simulator driving variables and neuropsychological test variables respectively, overall classified correctly in 85% and 83% of the cases with respect to driving skill. Decreased cognitive and attentional processing were suggested to be associated with an overall speed impairment. Copyright © 2000 John Wiley & Sons, Ltd.     

Comprehensive driving assessment: neuropsychological testing and on-road evaluation of brain injured patients

The study investigates the correspondence between neuropsychological test results and on-road driving performance among 55 patients with a CT-verified brain damage or documented neurological disorder (cerebrovascular accident: 43, traumatic brain injury: 5, multiple sclerosis: 4, other: 3). 5 patients showed unimpaired test profiles and passed the on-road evaluation. 18 patients showed severe neuropsychological deficits contrary to driving and were not recommended for on-road evaluation. Of the remaining 32 patients with some neuropsychological deficits, all 100% in the minor impaired group (n = 8) passed the driving evaluation, compared to 69% in the mildly impaired (n = 16) and 38% in the moderately impaired group (n = 8). Measures of reduced visuoconstructive ability, reaction time, visual attention, and awareness of cognitive impairments, were found to discriminate between groups. It is concluded that neuropsychological assessment of targeted functions provide an ecological valid prediction of driving skill after brain damage, but that on-road evaluation is needed as supplement in cases with ambiguous test findings.     

To drive or not to drive: Neuropsychological assessment for driver's license among stroke patients

Seventy-two stroke patients, 43 with right hemisphere (RHD) and 29 with left hemisphere damage (LHD), and 7 coronary infarct controls with no evidence of cerebral damage, were neuropsychologically tested as part of an assessment program for driver's license. Mean age in the group was 53 years. Stroke patients were tested on average 4 months post injury. The groups did not differ on major demographic variables except that RHD patients were more often hemiplegic than LHD patients. The test battery was factor analyzed into 4 valid principal components: (I) visual perception , (II) spatial attention , (III) visuospatial processing , and (IV) language/praxis. The presence of hemianopia (factor I) excludes driving. In addition, measures of neglect and reduced speed of mental processing from factor II, III and IV, were found to be the most discriminating variables when classifying patients for driving. Even though neglect was more frequently observed among RHD than LHD patients, the two hemisphere groups did not differ significantly in number of patients denied driving, 58% RHD compared to 41% LHD patients. The need for comprehensive neuropsychological assessment is underlined.     

Refreshing Older Adults’ Driving Skills (ROADSkills): A randomized controlled trial examining the effect of video feedback

ObjectivesThis study evaluated the effectiveness of a personalized video-based driver training program on the behind-the-wheel skills of community-dwelling older adults.MethodIn this randomized controlled trial (RCT), 80 older drivers [mean age (SD) = 71.0 (3.9)] were randomly assigned to view one of two educational videos: 1) personalized video feedback on their driving (n = 40) or 2) a generic video on aging-in-place (n = 40). The primary outcome, the total number of errors accrued in a 30-minute standardized on-road evaluation, was analyzed at baseline and 4 weeks after watching the assigned video. On-road evaluations were video-recorded and scored by a blinded rater. Self-report measures of driving abilities, behaviors, and comfort were also compared.ResultsAt the 4-week follow-up, the mean difference in the number of on-road performance errors [mean (95% CI) = -12.0 (-16.6, −7.4), p < 0.001] favored the intervention group compared to controls, with significant improvements across multiple domains: vehicle control [mean (95% CI) = -4.8 (-8.1, −1.5), p < 0.01], observing the roadway [mean (95% CI) = -5.5 (-8.4, −2.6), p < 0.001], and compliance with traffic rules [mean (95% CI) = -1.3 (-2.3, −0.2), p < 0.05]. Within-group change on behind-the-wheel errors was significant for the intervention group [mean (95% CI) = -10.3 (-13.5, −7.1), p < 0.001], but not for the control group [mean (95% CI) = 1.7 (-1.6, 4.9), p > 0.05]. No significant differences were found on the self-report measures.DiscussionA novel, video-based approach that provided personalized feedback to older drivers significantly reduced behind-the-wheel errors 4-weeks post-intervention. Changes in self-reported driving behaviors and abilities were not significant. Future research will examine the long-term effects of this approach on older adults’ actual and perceived driving abilities.     

Effects of contextual interference on feeding training in patients with stroke

The contextual interference (CI) effect of motor skill has been demonstrated through numerous studies. However, few studies have reported on daily living tasks in patients with stroke. This study investigated the CI effect on spooning training in such patients. Fourteen right hemiparetic patients with stroke were assigned to one of two groups: a group with a random practice schedule or a group with a blocked practice schedule. The spooning task involved scooping go stones from a bowl 30 cm away in 3 different directions to a bowl in front of the patient. We evaluated the acquisition, retention, and transfer of motor learning for spooning. The transfer was evaluated while participants ate cereal in a bowl with a spoon. Upper extremity function, defined as far-transfer, was also evaluated using the box-and-block test. In the retention test, no significant difference between random and blocked practice groups was shown, although both groups showed differences between pre-test and post-test movement times. However, in the transfer test, the random practice group had a significantly shorter movement time than the blocked practice group and also revealed improvement between the pre- and follow-up tests. Additionally, in the far-transfer test, there were significant differences between the pre- and post-, and pre- and follow-up tests only in the random practice group. These findings show that the benefits of CI for transfer can be applied to the learning of feeding skills in patients with stroke and that although the blocked practice is also partially beneficial to long-lasting skill learning in a treatment setting, it may not be efficient under changed conditions. We also suggest the possibility that feeding training with the CI effect could apply to not only transfer but also to far-transfer.     

Visual neglect in the first weeks after a stroke in the right hemisphere

The aim of the study was to characterize symptoms of visual neglect among patients who recently survived a stroke in the right hemisphere (RH), and to contribute to the understanding of change in symptoms during the first months after a RH stroke. Thirteen patients with a RH stroke and twenty controls were assessed by using standard neglect tests. Five patients were followed up by repetitive test sessions during the next four months. To assess more subtle symptoms, reaction-time (RT) measures derived from an experimental cue-target paradigm were included in the final test session. A high frequency of neglect symptoms was documented at the first test session. The changes in performance during the first weeks were characterized by a high inter-individual as well as a high intra-individual variability. Although the remission rate on standard tests was high in the follow-up study, the RT measures indicated sustained symptoms of visual extinction in all patients. The long-term implication of the changes of neglect symptoms during the first weeks after a stroke and signs of sustained symptoms of visual extinction calls for further longitudinal studies including a larger group of patients.     

The Ecological Validity of Neuropsychological Tests: A Review of the Literature on Everyday Cognitive Skills

Evaluating the ecological validity of neuropsychological tests has become an increasingly important topic over the past decade. In this paper, we provide a comprehensive review of the research on the ecological validity of neuropsychological tests, as it pertains to everyday cognitive skills. This review is presented in the context of several theoretical issues facing ecological validity research. Overall, the research suggests that many neuropsychological tests have a moderate level of ecological validity when predicting everyday cognitive functioning. The strongest relationships were noted when the outcome measure corresponded to the cognitive domain assessed by the neuropsychological tests. Several other factors that may moderate the degree of ecological validity established for neuropsychological tests are in need of further exploration. These factors include the effects of the population being tested, the approach utilized (verisimilitude vs. veridicality), the person completing the outcome measure (significant other vs. clinician), illness severity, and time from injury until evaluation. In addition, a standard measurement of outcome for each cognitive domain is greatly needed to allow for comparison across studies.     

Sources of variability in sequelae of very low birth weight.

Few investigations have examined the specificity of sequelae of very low birth weight (VLBW, <1500 g) or sources of variability in outcome. To better understand the nature and determinants of outcome, we assessed neuropsychological and achievement skills at mean age 11 years in 62 children with <750 g birth weight, 54 with 750-1499 g birth weight, and 66 term-born controls. Distinct cognitive constructs were identified by factor analysis, and the three birthweight groups were compared on these constructs and on composite measures of achievement. Although the group with <750 g birth weight performed less well on all tests than term-born controls, group differences in a perceptual planning factor and in mathematics remained even when IQ was controlled, and deficits were more pronounced in mathematics than in reading. Results from structural equation modeling were consistent with the hypothesis that neuropsychological skills mediated the relationship between birth weight and achievement. The findings confirm the differential deficit hypothesis, support the need to consider multiple sources of variability in VLBW outcomes, and highlight the importance of neuropsychological constructs in developing an explanatory framework.     

Sources of Variability in Sequelae of Very Low Birth Weight

Few investigations have examined the specificity of sequelae of very low birth weight (VLBW, &lt;1500 g) or sources of variability in outcome. To better understand the nature and determinants of outcome, we assessed neuropsychological and achievement skills at mean age 11 years in 62 children with &lt;750 g birth weight, 54 with 750-1499 g birth weight, and 66 term-born controls. Distinct cognitive constructs were identified by factor analysis, and the three birthweight groups were compared on these constructs and on composite measures of achievement. Although the group with &lt;750 g birth weight performed less well on all tests than term-born controls, group differences in a perceptual planning factor and in mathematics remained even when IQ was controlled, and deficits were more pronounced in mathematics than in reading. Results from structural equation modeling were consistent with the hypothesis that neuropsychological skills mediated the relationship between birth weight and achievement. The findings confirm the differential deficit hypothesis, support the need to consider multiple sources of variability in VLBW outcomes, and highlight the importance of neuropsychological constructs in developing an explanatory framework.     

Neuropsychological sequelae following pediatric stroke: A nonlinear model of age at lesion effects

Aim: The distribution and quality of brain recovery following pediatric arterial ischemic stroke remains controversial. The literature suggests that age at stroke may be an important modulator of neuropsychological outcome, with reports inferring either greater vulnerability or plasticity in the nascent brain. Our aim was to investigate neuropsychological outcomes following pediatric stroke in a clinical sample with reference to age at lesion, lesion laterality, elapsed time from stroke to assessment, and persistent neurological sequelae.

Methods: Using comprehensive neuropsychological assessment batteries, we investigated retrospectively a large (n?=?44) and evenly distributed group of children who had ischemic stroke during “infancy” (1 month to 1 year), “early childhood” (1 to 6 years), and “late childhood” (6 to 16 years).

Results: Children who suffered a stroke performed significantly worse on a range of neuropsychological measures when compared to a normative sample. However, children who suffered a stroke between 1 and 6 years old demonstrated better preserved neuropsychological profiles than either the earlier (before age 1) or later (after age 6) age groups. In addition, those children suffering a left hemisphere lesion performed more poorly on a range of neuropsychological measures than did children with right hemisphere lesions.

Interpretation: Age at stroke is an important determinant of recovery following insult and may modulate neuropsychological and cognitive outcome.     

The assessment of fitness to drive after a stroke: the Nordic Stroke Driver Screening Assessment

The British Stroke Driver Screening Assessment (SDSA) is a set of four simple cognitive tests to evaluate driving fitness in stroke patients. To evaluate its usefulness in a Scandinavian context, we adapted the tests and assessed a group of 97 stroke patients from Sweden and Norway, using a driving test as the criterion. When results were calculated according to the original method, based on a discriminant function, less than 70% of the participants were correctly classified. To improve the predictive potential, a new discriminant analysis was performed, using the scores of a subsample of 49 patients, and validated on the remaining 48 participants. In total, 78% of the patients were correctly classified, but specificity was superior to sensitivity. We conclude that the Nordic version of the SDSA is a useful instrument, provided that test scores are interpreted in a balanced manner, taking into account the possibility of compensatory traffic behavior.     

A comparison of implicit memory tests in schizophrenic patients and normal controls

The objective of the current study was to compare the performance of schizophrenic patients and normal controls on implicit memory tests. Two neuropsychological tasks were administered to 29 patients and normal participant samples. The implicit tests were: Word fragment completion and Word production from semantic categories. The priming score was the variable of interest. Priming effects are obtained in normal subjects and schizophrenia patients, regardless of the implicit test used. However, a dissociation in priming between normal and patient groups was observed, depending on the test used. For word fragment test, priming was identical between the two groups. However, for word production, priming obtained in schizophrenics was lower than priming in normal controls. Results confirm a dissociation effect in implicit memory tests. These results could be explained in the context of the Roediger and Blaxton (1987) distinction between data-driven and conceptually-driven processing. This evidence suggests that a complete neuropsychological assessment of memory in schizophrenia should include different kinds of implicit memory tests (procedural, perceptual, and conceptual tasks).     

Performance on the Test of Memory Malingering in children with neurological conditions

Despite increasing interest in the use of performance validity tests with youth, relatively little is known about how children and adolescents with neurological diagnoses perform on these measures. The purpose of this study was to examine performance on the Test of Memory Malingering (TOMM) in a general pediatric neurologic sample. Data were obtained from 266 consecutive patients (mean age = 13.0, SD = 3.7, range = 5–18) referred for a neuropsychological assessment in a tertiary care pediatric hospital. As part of a broader neuropsychological battery, patients were administered the TOMM. In this sample, 94% of children passed the TOMM. Pass rate was 87% for 5–7 year-olds but was ≥ 90% for all other ages. Children with a history of stroke had the lowest pass rate (86%), with other diagnostic groups scoring ≥ 90%, including epilepsy, traumatic brain injury, and hydrocephalus. Lower TOMM performance was related to slower processing speed and weaker memory performance. The results support using the TOMM with children and adolescents who have neurological diagnoses. Caution may still be warranted when interpreting scores in those who are younger and/or who have more significant cognitive difficulty.     

Common neuropsychological deficits associated with stroke survivors' impaired performance on a useful field of view test

Useful field of view is a measure of information processing in peripheral vision that has potential for predicting impaired driving performance. The present study was performed to examine whether common neuropsychological deficits resulting from stroke might be associated with useful field of view impairment. 46 stroke survivors had impaired useful field of view test performance when compared to individuals without stroke (t30.6= -4.33, p<.001). The impairments in useful field of view of stroke survivors were associated with impaired peripheral fields, slowed processing speeds, and diminished attention. Such impairment was not localized to lesions in any particular brain area. Results allow the inference that common neuropsychological impairments may have contributed to inefficient extraction of visual information from peripheral vision.     

The interhemispheric transcallosal-transversal approach to the lesions of the anterior and middle third ventricle: surgical validity and neuropsychological evaluation of the outcome

Based on the observation of the course of callosal fibres and of their artero-venous support as appearing in a microanatomic study, the Authors propose a variant of standard callosotomy procedure by the introduction of the transverse section of callosal fibres. This technique would allow the surgeon to spare a larger number of callosal fibres by the combined effect of a lower direct mechanical traction on fibres and a lower impact on artero-venous microcircle. The neuropsychological outcome of the patients who underwent this kind of procedure was evaluated. Fourteen patients affected by occupying-space lesions involving the anterior and middle third ventricle were included in the study. Ten patients underwent transverse callosotomy, four subjects received standard sagittal callosotomy. A control group was also included in the study. All patients underwent a pre-operative and six months post-operative neuropsychological evaluation focused on performance at cognitive and attentional tasks. No disturbances in executive function were observed in either group. Patients receiving transverse callosotomy performed as well as control group subjects in attentive tasks, which is not the case of patients undergoing sagittal callosotomy who show a marked deficit in selective attention for left side visual field. The observed more favourable neuropsychological outcome supports transverse callosotomy as a valid alternative method to standard longitudinal callosotomy in third ventricle surgery.     

Hypercoagulable states and stroke: a selective review

Blood disorders have been implicated in approximately 5% to 10% of ischemic stroke, with an increased frequency in younger patients. Most disorders are associated with an increased thrombotic tendency and, therefore, an increased risk of ischemic stroke. Less commonly, a bleeding diathesis may predispose a patient to intracranial hemorrhage. While many conditions predisposing to thrombosis have been associated with stroke, there are relatively few prospective, epidemiological studies addressing hypercoagulable states and arterial stroke compared with the number of studies on the genetic thrombophilias, which are predominantly associated with venous thrombosis. When ordering tests of coagulation in stroke patients, one should keep in mind whether the results will influence therapy and/or patient outcome. It is generally not advocated to screen all stroke patients for a "hypercoagulable workup". Typically, patients to be screened for coagulation defects will have a prior history of one or more unexplained thromboembolic events. The yield for diagnosing a hypercoagulable state is typically greatest for young stroke patients or those with a family history of thrombosis and who have no other explanations for their stroke (cryptogenic stroke). The yield in typically low in unselected ischemic stroke patients and older patients. Treatment of a first stroke with a documented hypercoagulable state is typically long-term or indefinite duration warfarin, although there is a paucity of clinical trial data supporting this clinical approach.     

Functional amnesia: clinical description and neuropsychological profile of 10 cases

We carried out the first neuropsychological study of a series of patients with functional amnesia. We evaluated 10 patients, first with a neurological examination and then with three tests of anterograde amnesia and four tests of retrograde amnesia. Excluding one patient who later admitted to malingering, all patients had a significant premorbid psychiatric history and one or more possible precipitating factors for their amnesia. Eight of the 10 patients still had persistent retrograde amnesia at our last contact with them (median = 14 mo after the onset of amnesia). On tests of anterograde amnesia, the patients performed normally as a group, though some patients scored poorly on tests of verbal memory. On tests of retrograde amnesia, all patients had difficulty re-collecting well-formed autobiographical memories of specific events from their past. In contrast, patients performed as well as controls at distinguishing the names of cities from fictitious city names. On remote memory tests for past public events and famous faces, different patients exhibited different but internally consistent patterns of impaired and spared performance. The variability in the clinical and neuropsychological findings among our patients may be understood by supposing that memory performance is poor in proportion to how directly a test appears to assess a patient's common sense concept of memory. The presentation of patients with functional amnesia is as variable as humankind's concept of what memory is and how it works.     

The role of verbal behavior in the establishment of comparative relations

Twelve college students received conditional discrimination training with nonarbitrary and arbitrary stimuli, and derived comparative and transformation of function tests with a think-aloud condition across 2 experiments. Participants who failed these tests received remedial verbal operant training. Four control participants received verbal operant training alone. Across both experiments, only 1 participant passed the derived comparative test after conditional discrimination training. However, all participants passed derived comparative tests and 11 out of 12 participants passed transformation of function tests following verbal operant training, including the 4 control participants. Participants who passed derived comparative tests engaged in a high percentage of correct vocalizations during the think-aloud condition, while participants who failed did not. These results suggest that mediating verbal behavior could have played a crucial role in participants' responses during derived stimulus relations tests.