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Memory White Paper - 2009

by Peter V. Rabins, M.D., M.P.H.

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Excerpts below
ABOUT THE AUTHOR
LETTER FROM THE AUTHOR
A DRIVING CONCERN

ABOUT THE AUTHOR

Peter V. Rabins, M.D., M.P.H., received his medical degree from Tulane University School of Medicine and his degree in public health (M.P.H.) from the Tulane University School of Public Health. He completed his residency in psychiatry at the University of Oregon. Currently, he is codirector of the Division of Geriatric Psychiatry and Neuropsychiatry at the Johns Hopkins University School of Medicine, as well as a professor of psychiatry with a joint appointment in the Department of Internal Medicine and the Bloomberg School of Public Health. Dr. Rabins is serving as the principal investigator on a National Institute of Mental Health study of Alzheimer’s disease in the community and a National Institute of Neurological Disorders and Stroke study of late-stage care for Alzheimer’s disease patients.

Dr. Rabins has spent his career studying psychiatric disorders in the elderly. His current research includes the development of scales to measure impairment in people with severe dementia and the study of visual hallucinations in a variety of psychiatric and neurological conditions. He has published extensively in such journals as the American Journal of Psychiatry, the Journal of the American Geriatrics Society, and the Journal of Mental Health.

LETTER FROM THE AUTHOR

Dear Reader:

Welcome to the 2009 Memory White Paper—your personal guide to the prevention, diagnosis, and management of memory problems, ranging from age-associated memory issues to mild cognitive impairment and Alzheimer’s disease. You will also find helpful advice on caring for someone with memory problems.

This year’s highlights include:

How strong social networks can protect your cognitive function.
Wake up to a better memory: Is it possible?
Going off road: When is it time to stop driving?
Why hypothyroidism could be causing your memory problems.
Predicting the course of Alzheimer’s disease: The clues to watch for.
Helpful resources for coping with early-stage Alzheimer’s disease.
Why exercise is so important for people with Alzheimer’s.
Do concussions earlier in life raise the risk of dementia?
How to adapt to the changing nature of intimacy with Alzheimer’s.
An experimental treatment called Rember. Does it look promising?
How safe are antipsychotics for behavior problems?
Strategies for making mealtimes easier for people with dementia.
Habilitation: A better caregiving approach.

If you have any memory or Alzheimer’s-related queries you would like answered in the White Papers or comments about the White Papers in general, please send an e-mail to the editors at whitepapers@johnshopkinshealthalerts.com.

Sincerely,
Peter V. Rabins, M.D., M.P.H.

The Biology of Memory
Age-Associated Memory Impairment
Preventing Dementia
Mild Cognitive Impairment
Dementia
Reversible Memory Loss
Irreversible Dementias
Alzheimer’s Disease
Coping With Caregiving

Chart: Medications for Treating Alzheimer’s Disease 2008

Glossary
Health Information Organizations and Support Groups
Leading Hospitals for Neurology and Neurosurgery
Index

Excerpt from page 12

A DRIVING CONCERN
When is it time for an older person to stay off the road?
Convincing an elderly or cognitively impaired driver to hand over the car keys is a delicate and difficult task. But it’s one that many adult children and caregivers will have to face sooner or later, especially when the loved one has dementia.
Driving is a cherished privilege and a symbol of independence and competence. It’s no wonder that older drivers are often hurt, angry, hostile, or obstinate in response to any suggestion that they shouldn’t be driving. The implications of stopping driving can be immense, particularly for those who don’t live in an area that’s easily walkable or has mass transportation, and include becoming entirely dependent on others for everyday activities like grocery shopping or visiting friends. Notsurprisingly, being forced to stop driving has been associated with depression and social isolation among the elderly.
But continued driving presents serious safety issues. Surveys show that 30% of older people with dementia are still driving. Moreover, despite driving less often than healthy younger people, older drivers with dementia are twice as likely to have a crash. They’re also more likely than middle-aged drivers to be involved in a fatal accident. In addition, a
driver with dementia can easily become lost while driving.
To Drive With Mild Dementia?
For the purposes of evaluating driving ability as well as other daily functioning, doctors often use a scale called the Clinical Dementia Rating (CDR) system to determine dementia severity. Severe dementia has a CDR score of 3; moderate is at 2; mild dementia is a 1, and very mild is 0.5.
Decisions about driving are clear-cut for people with CDR scores of 3 or 2: Professionals agree that anyone whose dementia is beyond the mild stage should not be allowed to drive. And some experts, such as the American Academy of Neurology, recommend that people in the mild stage (a CDR of 1) not drive either, and that only individuals with very mild dementia (a CDR of 0.5) consider getting behind the wheel.
For those with mild to very mild dementia who continue to drive, a 2008 study reported in Neurology cautions that driving skills can deteriorate rapidly among people with mild dementia and that these individuals must be re¬evaluated frequently. Participants with mild Alzheimer’s became unsafe dri¬vers an average of 11 months after their initial evaluation; those with very mild Alzheimer’s remained safe drivers for an average of 1.8 years. The researchers concluded that a small group of people with very mild disease might be able to drive safely up to three years.
Testing Driving Skills
Road tests are the most accurate way to determine an individual’s capacity to drive. The most thorough driving evaluations are “performance-based road tests” administered by driving rehabilitation specialists or the state department of motor vehicles (DMV). These tests are often expensive (as much as $500), however, and they need to be repeated every six to 12 months, depending on the person’s initial performance.
If performance-based road testing isn’t possible, the results of some standard cognitive tests may provide insights into how well a person can drive. The American Medical Association recommends the well-known Clock Drawing test (see “Simple Tests for Measuring Cognitive Impairment” on pages 24-25) and the Trail Making Test Part B, in which patients must take numbers and letters scattered in circles on a piece of paper or computer screen and connect them in an alternating pattern (1-A-2-B, etc.) as quickly as possible. Your family physician may be able
to administer these tests, which evaluate visual/spatial ability, attention, executive function, and memory—important skills for driving. Poor results on these tests alone should not lead to taking away driving privileges, but they do indicate a need for further evaluation.
Signs of Trouble
Perhaps the simplest way to determine if a person is fit to drive is to let common sense be your guide. Many warning signs, from subtle to strong, indicate that an individual shouldn’t be driving. Keep an eye out for the following behaviors when an aging family member gets behind the wheel:
driving too slowly or too fast
receiving traffic tickets
being honked at or yelled at by other drivers
becoming upset or angry while driving
dents, dings, or scraped paint on the car.
And be sure to take action if he or she exhibits any of these dan¬gerous signs:
misunderstanding or not noticing signs on the road
getting lost in familiar places
stopping at a green light
changing lanes without looking
drifting into another lane
having difficulty making left turns
misjudging distances
mistaking the gas pedal for the brake
any crash or near crash.
You can also go by the rule of thumb known as the “grandchild test”: If you would not feel safe having this person drive his or her grandchild, it’s time to have a talk about handing over the keys.
Having “The Talk”
Ideally, conversations about an inevitable decline in driving ability should begin long before deterio-rating skills become a crisis. This is true for all aging family mem¬bers, not just those with obvious declines in cognitive functioning.
Starting these talks early allows the person to adjust to the idea that eventually he or she will need to stop driving completely. You should discuss the importance of periodic reassessments of driving performance as well as changes in driving habits that may be neces¬sary over time, such as no driving at night, no highway driving, driv¬ing only in familiar areas, and driv¬ing only for short distances. You can also make plans for alternative means of transportation.
What do you do when an obviously impaired family member refuses to stop driving? Enlist the help of your family physician, who can instruct the person not to drive and write out a “prescription” that says “No Driving.” He or she can also inform the individual of the personal and financial risks if he or she continues to drive while cognitively impaired.
Healthcare professionals in some states must report to the state DMV that a person in their care has a medical condition that interferes with driving ability. The state may then test the person and revoke the person’s driver’s license if that is appropriate. If necessary, contact your DMV to find out what steps can be taken to get an impaired driver off the road.
Here at Hopkins, we often advise families to “blame the doc¬tor” or the DMV rather than put themselves in the position of being the person who says they cannot drive: “The DMV took away your license. Maybe we can appeal it or ask the doctor on your next visit.”
If nothing else works, you may have to resort to drastic measures: Hide the car keys, disable the car by removing the battery or distrib¬utor cap, park the car where the person can’t see it, or sell the vehicle.
If appropriate and financially feasible, moving your loved one to an assisted-living facility also can solve the problem. Many facilities provide transportation to grocery stores, doctor appointments, and community events — which enables your loved one to continue to feel socially engaged and independent.