Driving Ability of People with Cognitive Impairment Difficult to Assess: Research Review

Newswise, August 10, 2016--No single assessment tool is able to consistently determine driving ability in people with Alzheimer's disease and mild cognitive impairment, a St. Michael's Hospital research review has found.

Individuals with very mild and mild Alzheimer's disease who took a road test had a failure rate of 13.6 and 33.3 per cent respectively, compared to a failure rate of 1.6 per cent in drivers without Alzheimer's disease.

However, in general, patients with any degree of Alzheimer's disease still had a pass rate of almost more than 46 per cent.

The comprehensive research review, published today in the Journal of Alzheimer's Disease, found largely inconsistent results across 32 studies that looked at various cognitive tests in conjunction with driving outcomes, on-road evaluations and driving simulations.

Executive function, attention, visuospatial function and global cognition emerged as the strongest predictors for driving performance in these individuals; however there was no consistent measure across all studies that could determine safe driving ability.

"Many individuals with Alzheimer's disease and mild cognitive impairment are at an increased risk of driving collisions and crashes compared to other seniors," said Megan Hird, a researcher at the Li Ka Shing Knowledge Institute of St. Michael's, a Master's student at the University of Toronto and co-author of the study, along with Dr. Tom Schweizer.

"Despite this, some patients are able to retain the ability to drive safely. But the complex nature of these conditions and of driving itself makes deeming a patient an unsafe driver extremely difficult for clinicians."

Hird said physicians and other health-care professionals often are not confident in assessing the driving ability of patients with cognitive impairment, as there is no single valid assessment tool to discern who is safe to drive and who is not.

Studies using neuro-imaging have found that driving uses extensive networks of the brain, requiring certain degrees of attention, executive function and visuospatial function to drive safely. If any of these functions become compromised from Alzheimer's or dementia, the driver may no longer be safe.

"The other challenge in cognitive impairment and driving ability is that they are degenerative conditions," said Hird.

"Patients can have very mild to severe cognitive impairments that can vary over time, making it difficult for clinicians to accurately assess their safety as a driver without having a consistent assessment tool."

Of the 32 studies included in the review, 29 assessed driving performance of patients with Alzheimer's and four in patients with mild cognitive impairment.

Among the findings:

In a study of on-road assessments, patients with Alzheimer's disease had a failure rate 10 times higher than individuals without Alzheimer's disease.

Three tests emerged as the best single predictors of driving performance, looking at a patient's planning, attention, speed and visuospatial functions, requiring participants to: connect a series of numbered circles, alternate between and connect a series of encircled numbers and letters, and draw a path through a maze from start to finish.

Studies looking at driving tests found that individuals with Alzheimer's most commonly received a pass rating (46.5 per cent), rather than a marginal (34.6 per cent) or fail rating (18.9 per cent).

 In both on-road and simulator testing, studies showed that patients with mild cognitive impairment demonstrated minor rather than definitive driving impairments.

Hird said future large-scale studies should investigate driving performance and associated brain patterns in multiple subgroups of Alzheimer's disease and mild cognitive impairment, as cognitive function is highly variable within these populations.

"This would be an important step to determine if certain driving behaviours are associated with different severities in these patients, and may serve as a first step to creating a valid and reliable tool for clinicians to use with their patients."

Researchers Learn How to Grow Old Brain Cells

Newswise, October 12, 2015 — For the first time, scientists can use skin samples from older patients to create brain cells without rolling back the youthfulness clock in the cells first. 

The new technique, which yields cells resembling those found in older people’s brains, will be a boon to scientists studying age-related diseases like Alzheimer’s and Parkinson’s.

“This lets us keep age-related signatures in the cells so that we can more easily study the effects of aging on the brain,” says Rusty Gage, a professor in the Salk Institute’s Laboratory of Genetics and senior author of the paper, published October 8, 2015 in Cell Stem Cell.

“By using this powerful approach, we can begin to answer many questions about the physiology and molecular machinery of human nerve cells—not just around healthy aging but pathological aging as well,” says Martin Hetzer, a Salk professor also involved in the work.

Historically, animal models—from fruit flies to mice—have been the go-to technique to study the biological consequences of aging, especially in tissues that can’t be easily sampled from living humans, like the brain. Over the past few years, researchers have increasingly turned to stem cells to study various diseases in humans. 

For example, scientists can take patients’ skin cells and turn them into induced pluripotent stem cells, which have the ability to become any cell in the body. From there, researchers can prompt the stem cells to turn into brain cells for further study. But this process—even when taking skin cells from an older human—doesn’t guarantee stem cells with ‘older’ properties.

“As researchers started using these cells more, it became clear that during the process of reprogramming to create stem cells the cell was also rejuvenated in other ways,” says Jerome Mertens, a postdoctoral research fellow and first author of the new paper.

Epigenetic signatures in older cells—patterns of chemical marks on DNA that dictate what genes are expressed when—were reset to match younger signatures in the process. 

This made studying the aging of the human brain difficult, since researchers couldn’t create ‘old’ brain cells with the approach.

Gage, Hetzer, Mertens and colleagues decided to try another approach, turning to an even newer technique that lets them directly convert skin cells to neurons, creating what’s called an induced neuron. 

“A few years ago, researchers showed that it’s possible to do this, completely bypassing the stem cell precursor state,” says Mertens.

The scientists collected skin cells from 19 people, aged from birth to 89, and prompted them to turn into brain cells using both the induced pluripotent stem cell technique and the direct conversion approach. Then, they compared the patterns of gene expression in the resulting neurons with cells taken from autopsied brains.

When the induced pluripotent stem cell method was used, as expected, the patterns in the neurons were indistinguishable between young and old derived samples. But brain cells that had been created using the direct conversion technique had different patterns of gene expression depending on whether they were created from young donors or older adults.

“The neurons we derived showed differences depending on donor age,” says Mertens. “And they actually show changes in gene expression that have been previously implicated in brain aging.” 

For instance, levels of a nuclear pore protein called RanBP17—whose decline is linked to nuclear transport defects that play a role in neurodegenerative diseases—were lower in the neurons derived from older patients.

Now that the direct conversion of skin cells to neurons has been shown to retain these signatures of age, Gage expects the technique to become a valuable tool for studying aging. And, while the current work only tested its effectiveness in creating brain cells, he suspects a similar method will let researchers create aged heart and liver cells as well.

Other researchers on the study were Apua C.M. Paquola, Manching Ku, Emily Hatch, Lena Bohnke, Shauheen Ladjevardi, Sean McGrath, Benjamin Campbell, Hyungjun Lee, Joseph R. Hardy, J. Tiago Goncalves, Tomohisa Toda and Yongsung Kim of the Salk Institute; Jurgen Winkler of Friederich-Alexander University Erlangen-Nuremberg; and Jun Yao of Tsinghau University.

The work and the researchers involved were supported by grants the G. Harold & Leila Y. Mathers Charitable Foundation, the JPB Foundation, the Leona M. and Harry B. Helmsley Charitable Trust, Annette Merle-Smith, CIRM, the German Federal Ministry of Education and Research and the Glenn Foundation for Medical Research.

About the Salk Institute for Biological Studies:

The Salk Institute for Biological Studies is one of the world's preeminent basic research institutions, where internationally renowned faculty probes fundamental life science questions in a unique, collaborative and creative environment. 

Focused both on discovery and on mentoring future generations of researchers, Salk scientists make groundbreaking contributions to our understanding of cancer, aging, Alzheimer's, diabetes and infectious diseases by studying neuroscience, genetics, cell and plant biology and related disciplines.

Faculty achievements have been recognized with numerous honors, including Nobel Prizes and memberships in the National Academy of Sciences. Founded in 1960 by polio vaccine pioneer Jonas Salk, MD, the Institute is an independent nonprofit organization and architectural landmark