Cognitive impact - Reducing the long term impact of cognitive problems

2014 Behavioural activation therapy for depression after stroke (BEADS). This is a NIHR-HTA funded study evaluating the feasibility of undertaking a randomised controlled trial to evaluate the clinical and cost-effectiveness of behavioural activation for people with post-stroke depression. The study is led by Dr Shirley Thomas in collaboration with colleagues from the University of Nottingham (Dr Roshan das Nair, Professor Nadina Lincoln, Professor Avril Drummond, Professor Patrick Callaghan and Dr Timothy England), the University of Sheffield and Sheffield Clinical Trials Research Unit.

2014 HTA Project:12/190/05 - Cognitive Rehabilitation for Attention and Memory in people with Multiple Sclerosis (CRAMMS). Nadina Lincoln, Roshan Das Nair, Cris Constantinescu, Avril Drummond, Alan Montgomery, Ceri Phillips. £1,167,000 from Sept 2014- August 2018.

ReMemBrIn (Rehabilitation of Memory in Brain Injuries): An NIHR-HTA funded Phase III multi-centre randomised controlled trial exploring the clinical and cost-effectiveness of a manualised memory rehabilitation group programme for civilians and military personnel who have had head injuries. This is the largest study of cognitive rehabilitation in the UK, and is currently recruiting from centres in Nottingham, Birmingham, Chester, and Epsom. (More information.)

NeuroText (Evaluation of NeuroText as a memory aid for people with multiple sclerosis): A pilot randomised controlled trial funded by the MS Society, NeruoText uses mobile phone technology to deliver reminders to help people with memory problems related to multiple sclerosis. This trial is part of a PhD project in collaboration with the Oliver Zangwill Centre for Neuropsychological Rehabilitation.

CALM (Communication and Low Mood) study: multicentre RCT to evaluate behaviour therapy for treating low mood in people with aphasia after stroke, funded by the Stroke Association. CALM involves evaluating a psychological intervention (behaviour therapy for low mood in stroke patients with aphasia, a communication problem. The study focuses on assessing and treating mood problems in this group. This is a unique and important study in that it deliberately works with people with communication problems who are typically excluded from research into mood problems after stroke. [More information: http://www.ukctg.nihr.ac.uk/trialdetails/ISRCTN56078830]

NOTFast (Nottingham Fatigue after stroke): This study s is examining factors related to fatigue in stroke patients who are not depressed. It is a multi-centre study coordinated by Professor Avril Drummond, School of Health Sciences, and in collaboration with researchers in London and Manchester. [More information: http://www.nottingham.ac.uk/research/groups/rehabilitation/projects/notfast.aspx]

Screening for anxiety in older people with stroke (SAOPS): This study is designed to assess the validity and the reliability of the Geriatric Anxiety Inventory in screening for post-stroke anxiety in older people. It is being conducted in conjunction with researchers from University of Western Sydney, University of Surrey and Virgin Care.

Understanding how group-based interventions work: A social identity approach to adjustment groups for people with multiple sclerosis: This project consists of three interlinked projects: A pilot randomised controlled trial comparing the delivery of an adjustment group intervention delivered in group vs. individual format (funded by Nottingham University Hospitals Charity) and two studies examining social and family identity change in people with multiple sclerosis. These are funded by MS Society and ESRC PhD studentships.

Two MS Society funded PhD Studentships

• Understanding how group-based interventions work: a social identity approach to adjustment groups for people with multiple sclerosis (2012-2015)
• Evaluation of Neuropage as a memory aid for people with multiple sclerosis (2013-2016)

1. Lincoln NB, Radford KA, Lee E, Reay AC, The Assessment of Fitness to Drive in People with Dementia, International Journal of Geriatric Psychiatry, 2006; 21:1044-1051*
People with dementia can drive in the early stages of disease. Research has not yet identified the level of cognitive impairment associated with unacceptable risk. In view of the growing number of older drivers and inevitable increase in drivers with dementia the question of whether a simple, cognitive assessment can predict fitness to drive is important.

We assessed 42 people with dementia and 37 healthy elderly volunteers on a battery of cognitive tests, then tested their ability to drive on the public road. Safety to drive in people with dementia could be predicted from a combination of 6 tests, which correctly identified 67% of safe drivers in a validation sample of 17 people with dementia. . This study is important clinically because it identified a battery of tests useful for identifying which people need their driving abilities to be tested on the public road.

In a further study funded by The Alzheimer’s Society (Assessing Fitness to drive in people with dementia, Lincoln NB, Bowman W, Radford KA, Reay A) we set out to validate and reduce the length of this assessment battery to facilitate clinical application. 

2. NB Lincoln, JL Taylor1, K Vella1, WP Bouman2 and KA Radford. A prospective study of cognitive tests to predict performance on a standardized road test in people with dementia. International Journal of Geriatric Psychiatry, Published online in Wiley InterScience (www.interscience.wiley.com). http://dx.doi.org/10.1002/gps.2367

Seventy five people with dementia were recruited and completed a cognitive test battery that included measures of concentration, executive function, visuospatial perception, verbal recognition memory, and speed of information processing. They were then assessed on the Nottingham Neurological Driving Assessment by an Approved Driving Instructor, blind to the cognitive test results. Of these, 65 were assessed on the road and ten refused. These 65 participants were age 59 to 88 (mean=75.2, SD=6.7) and 50 were men. Most (51.5%) had Alzheimer’s dementia, 21.2% vascular and 27.3% other dementias. Thirteen participants were unsafe and 52 safe to drive. Using a cut-off of 5, the original predictive equations correctly classified 79.0% of participants (Sensitivity=81.6%; Specificity=69.2%; PPV=90.9%; NPV=50.0%). Discriminant function analysis on the current data revealed no improvement in accuracy by including additional tests.

In the present study, a lower proportion of participants were found to be unsafe on the road than in previous studies. Despite this, the previously identified equations reliably predicted safety to drive.
We suggest that the cognitive test battery might be used in routine clinical practice for identifying those patients with dementia who would benefit from an on-road assessment.

3. LINCOLN, N.B. and RADFORD, K.A., 2008, Cognitive abilities as predictors of safety to drive in people with multiple sclerosis. Multiple Sclerosis 2008, 14(1) 123-128.

Cognitive impairments resulting from multiple sclerosis (MS) may affect driving performance. We set out to determine whether cognitive tests predict safety to drive in people with MS. Participants
were recruited from people referred to Derby Regional Mobility Centre for assessment of their fitness
to drive. They were assessed on tests of cognitive abilities related to driving including: the Stroke
Drivers Screening Assessment, Paced Auditory Serial Addition Test, Stroop, Motor Impersistence and
Adult Memory and Information Processing Battery (AMIPB). Participants’ safety to drive on the public
road was tested by an approved driving instructor blind to the results of the cognitive assessment.

There were 34 participants with MS, 17 were men, mean age 46 (SD 10.4) years. Safe and unsafe drivers were compared.. Significant differences were found on tests of executive function (Road Sign
Recognition, P < 0.01), visual memory (Design Learning Interference, P < 0.05) Information
Processing (AMIPB Task A, P < 0.05 and B, P < 0.05), concentration (Dot Cancellation false positive errors, P < 0.01) and visuospatial abilities (AMIPB Figure copy). An equation was generated using discriminant function analysis with an overall predictive accuracy of 88% (Sensitivity for pass 90%,, Specificity 90%). Cognitive abilities were predictors of safety to drive in people with MS.

4. Radford KA, Lincoln NB. The Effects Of Cognitive Abilities On Driving In People With Parkinson's Disease, Disability and Rehabilitation, 2004, 26 (2) 65 - 70.*

We looked at the effects of cognitive abilities on driving safety in a group of people with Parkinson's disease, recruited through neurology clinics and a specialist driving assessment centre. They were assessed on a battery of cognitive tests and their ability to drive was independently tested by an approved driving instructor. We found most of the people with Parkinson’s disease were safe drivers and that cognitive tests were poor predictors of driving ability in this group. However, tests of disease severity were able to differentiate between safe and unsafe drivers.

This research supports earlier findings suggesting people with PD are conscientious and more likely to limit their own driving activities than to drive when unsafe. However, it is possible that the recruitments methods meant that more ‘safe’ drivers volunteered to take part.

5. Radford KA, Lincoln NB Concurrent validity of the Stroke Drivers Screening Assessment, Archives of Physical Medicine and Rehabilitation, 2004, 85(2) 324-326.*

The Stroke Drivers Screening Assessment is a cognitive screening device used to predict whether people who have suffered a stroke are fit to resume driving. Although commercially available and widely used clinically for screening stroke patients and known to be a better predictor of on road driving ability than the advice of the GP or DVLA, two of the SDSA subtests had been developed by the research team for inclusion in the battery and it remained unclear which cognitive abilities they assessed. We therefore examined the content and concurrent validity of two of the SDSA sub tests by testing 93 stroke patients on the SDSA and other established cognitive tests. Results showed the SDSA primarily measures executive functions and attention.

These findings help clinicians in their choice and interpretation of tests for screening brain injured drivers.
The development and validation of these cognitive screening tests, which have predictive validity for on road driving performance has influenced occupational therapists, psychologists and other health care professionals, including those employed in specialist driving assessment centres, in their choice of cognitive assessments for driver screening and in adopting more systematic procedures for screening drivers with brain injuries.

6. Radford KA, Lincoln NB, Murray-Leslie C. Validation of the Stroke Drivers Screening Assessment for People with Traumatic Brain Injury, 2004 18(8),775-786*

The SDSA is a cognitive screening device used to predict whether people are fit to drive following stroke. We aimed to determine, whether the SDSA predict fitness to drive in people with acquired neurological disabilities other than stroke'. 52 drivers with Traumatic Brain Injury (TBI) were assessed on the SDSA then their driving ability was tested on the public road by an approved driving instructor. The SDSA alone was not good at predicting driving ability in people with TBI but when combined tests of executive abilities and attention prediction accuracy increased to 87%. However, it remained better at predicting safe drivers than unsafe.

The development and validation of these cognitive screening tests, which have predictive validity for on road driving performance has influenced occupational therapists, psychologists and other health care professionals, including those employed in specialist driving assessment centres, in their choice of cognitive assessments for driver screening and in adopting more systematic procedures for screening drivers with brain injuries.

The SDSA introduces some form of cognitive assessment to the routine screening of brain injured drivers that previously did not exist. Many clinicians now use the tests to assist in identifying which people need further assessment and on road testing at specialist driving assessment centres and for advising brain injured drivers about their abilities. The tests are available through our web ages and have been translated into Dutch, French and German.

The Department for Transport have considered these measures for routine screening purposes and have conducted their own investigations into their use. As a follow on from this work, Professor Lincoln and I have continued to develop and validate cognitive assessment batteries for people with Parkinson's disease, MS and dementia. This work is on going.

7. NB Lincoln1, J Taylor1 and KA Radford1 Inter-rater reliability of the Nottingham Neurological Driving Assessment for people with dementia – a preliminary evaluation. Clinical Rehabilitation 2012; 26:836-839
This study was designed to examine the inter-rater reliability of the Nottingham Neurological Driving Assessment, the road test used in previous research. Six drivers with dementia were assessed for their safety to drive on a set route while being observed by two driving assessors, who were experienced in assessing safety to drive in people with dementia.

There was perfect agreement in the overall decisions about safety to drive. There were significant discrepancies between correct or minor error and major error on six of the 25 items of the road test involving three participants. This shows overall disagreement on 4% of observations, indicating high agreement between assessors. 

Present Research

The Rookwood driving Battery was developed for assessing fitness to drive for people who attended a specialist driving assessment centre. Current studies are comparing the classification of safety to drive made using the Rookwood Battery with the Dementia Drivers Screening Assessment for drivers with dementia and the Multiple Sclerosis Drivers Screening Assessment for drivers’ with multiple sclerosis.

The results so far suggest the Rookwood Driving Battery assess more people with dementia as unsafe to drive compared to the Dementia Drivers Screening Assessment and fewer people with multiple sclerosis as unsafe to drive compared to the Multiple Sclerosis Drivers Screening Assessment. Therapists need to be aware of these discrepancies when assessing patients. These results also indicate that further validation studies are needed.