2005 Relacion Del Funcionamiento Npsi y La Competencia en La Conduccion

8/18/2019 2005 Relacion Del Funcionamiento Npsi y La Competencia en La Conduccion

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Archives of Clinical Neuropsychology

20 (2005) 217–228

The relationship of neuropsychological functioning todriving competence in older persons with

early cognitive decline

William M. Whelihana,b∗,1, Margaret A. DiCarloa,b, Robert H. Paula

a Brown University School of Medicine, RI, USAb Roger Williams Medical Center—Psychiatry, 50 Maude Street, Providence, RI 02908, USA

Accepted 8 July 2004

Abstract

The study focused on the role of traditional and computer-administered visual attention and executive

measures in the prediction of driving competence in older individuals with early-stage cognitive decline.

A group of 23 patients with questionable dementia by Clinical Dementia Rating (CDR = 0.5) was

evaluated with a group of 23 age-matched controls. For the patient group, correlational analyses revealed

that road-test performance was significantly related to a number of executive and visual attention

measures but not to other neuropsychological measures. For the control group, road-test performance

was only significantly related to age. A hierarchical regression procedure was utilized to further explore

the contribution of specific executive and visual attention measures and 46% of the variance in road-test

performance was attributable to these measures for the patient group. A discriminant function analysis

utilizing executive and visual attention measures for the entire group of participants classified those whopassed and failed the road test with 80% accuracy. Neuropsychological executive and visual attention

measures may play a useful role in determining competence to drive in older individuals with early-stage

cognitive decline.

© 2004 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.

Keywords: Driving; Executive functioning; Computerized assessment; Competence; Elderly; Mild cognitive im-

pairment

∗ Corresponding author. Tel.: +1 401 456 2201; fax: +1 401 247 2582.

E-mail address: [email protected] (W.M. Whelihana,b).1 Roger Williams Medical Center—Psychiatry, 825 Chalkstone Ave., Providence, RI 02908.

0887-6177/$ – see front matter © 2004 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.acn.2004.07.002


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218 W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228

1. Background

Elderly drivers are at higher risk than all other age groups for motor vehicle accidents(MVA) on a per-mile basis (Graca, 1986; Klein, 1992; Vernon, 1995), and elderly individualswith moderate to severe dementia are at even greater risk (Rabins et al., 1997). What is unclearis the extent to which driving ability is compromised in individuals with early-stage cognitivedecline, and whether neuropsychological assessment can assist in the determination of drivingcompetency in these individuals. Specifically, the relationship between cognitive factors anddriving competence has not been adequately explored to date.

Brief mental status examinations, often insensitive to early changes in dementia (Whelihan,Lesher, Kleban, & Granick, 1984), have yielded variable results. Some researchers have found

that impaired elderly drivers scored lower on the Mini-Mental State Examination (MMSE;Folstein, Folstein, & McHugh, 1975) than non-impaired drivers (Carr, Jackson, & Alguire,1990; Fitten et al., 1995; Fox, Bowden, Bashford, & Smith, 1997); whereas others have notfound such a relationship between global measures of cognitive status and driving ability(Foley, Wallace, & Eberhard, 1995; Odenheimer et al., 1994; Trobe, Waller, Cook-Flannagan,Teshima, & Bieliauskas, 1996).

The few studies investigating the relationship between driving ability and neuropsycho-logical measures have also yielded inconsistent results. In their study of on-road driving per-formance in 25 older adults, Hunt, Morris, Edwards, and Wilson (1993) found that severalneuropsychological measures [Wechsler Memory Scale-R Logical Memory, Benton VisualRetention Test (BVRT), Boston Naming Test, Trails A, Wechsler Adult Intelligence Scale-RDigit Symbol] were significantly related to driving performance, but Verbal Fluency was not.However, Rebok, Keyl, Bylsma, Blaustein, and Tune (1994), using driving simulation, foundthat Verbal Fluency was correlated with driving performance. Furthermore, Fox, Bowden, andSmith (1997) did not find a relationship between neuropsychological measures (Visual FormDiscrimination Test, Judgment of Line Orientation Test, Trails A and B, BVRT, and WAIS-Rsubtests) and results of an on-road driving evaluation.

More consistent findings have been reported with computer-administered visual attentiontests. Ball and Roenker (1998) and Ball and Owsley (1993) developed the Useful Field of

View (UFOV), a test now available commercially that shows promise as a predictor of drivingability. Using logistic regression models, Sims, Owsley, Allman, Ball, & Smoot (1998) foundthat a 40% reduction in useful field of view (the visual area available in a single glance, withouthead or eye movements) was associated with increased crash involvement. In addition, Owsleyet al. (1991, 1994) reported that statistical models incorporating the UFOV and the DementiaRating Scale (Mattis, 1976) have been useful in predicting accident frequency in samples of older drivers.

Duchek, Hunt, Ball, Buckles, and Morris (1998) studied healthy elderly and elderly withvery mild or mild DAT using three computerized tasks (Visual Search, Visual Monitoring,

UFOV) as predictors of on-road driving ability. While the study incorporated a number of neuropsychological tests, there was none beyond a mental control measure from the WechslerMemory Scale that could be considered an executive measure. The authors found that error rateand reaction time on the Visual Search task were the best predictors of driving performance. Itis interesting to note that while UFOV performance was significantly correlated with on-road


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W.M. Whelihan et al. / Archives of Clinical Neuropsychology 20 (2005) 217–228 219

driving performance, it was far too difficult for the majority of individuals with dementia tocomplete. The authors proposed that a simpler version of the UFOV would be necessary to

adequately assess its predictive utility in a dementia sample.Interestingly, neuropsychological studies of driving competence in the elderly have for

the most part neglected or limited the assessment of executive functioning. Yet, intuitivelyit would appear that higher level executive and visuoperceptual functions are critical to thecomplex skill of driving. Results of two recent studies suggest that executive abilities areimportant determinants of driving ability among elderly drivers. A study of Daigneault, Joly,and Frigon (2002) showed that elderly drivers with a history of accidents had difficulty onseveral executive measures compared to participants without an accident history. In a secondstudy, Ott et al. (2003) reported strong correlations between subjective ratings of driving ability

obtained from a care-provider and performance on an executive maze task among individualswith mild cognitive difficulties.

To our knowledge, no study has examined relationships between executive abilities androad-test driving performance among elderly individuals with mild cognitive impairment. Tofurther explore the inconsistencies in the literature and to assess more thoroughly the role of executive and visual attention functions in driving ability, we investigated which measures ina traditional and computer-administered neuropsychological battery were predictive of olderparticipants driving ability determined by actual road-test performance. We hypothesized thatexecutive and visual attention measures (specifically, a novel Maze Navigation Test, a visualscanning/divided attention test (Trails B), a visual scanning/attention Letter Cancellation Test,and the UFOV) would be critical determinants of driving ability in patients with early-stagecognitive decline.

2. Method

2.1. Participants

All 46 participants gave informed consent, had a corrected visual acuity of 20/40 or better

in both eyes, had unrestricted driving licenses, and had performed well on a screening measureof rules of the road and traffic sign recognition. No participant had a major medical illness(e.g., seizure disorder) or sensorimotor impairment that would preclude driving. In addition,no participant was taking sedative medication.

The 23 participants in the patient group (12 males, 11 females) were referred by their pri-mary care physician or neurologist to the Memory Disorders Clinic at Roger Williams MedicalCenter, Providence, RI, USA. They were recruited sequentially for the study if they met thecriteria indicated above and if they had a Clinical Dementia Rating (CDR; Morris, 1993) of 0.5 [questionable dementia] and a collateral source available to provide additional informa-

tion about driving history and functional ability. Fifteen patients had primary cerebrovascularetiologies, confirmed by documented changes on neuroimaging and/or histories of cerebrovas-cular events. The remaining patients had possible Dementia of the Alzheimer’s Type (DAT; n= 1), mixed etiology of cerebrovascular disorder and possible DAT (n = 1) or other cognitiverisk factors (n = 6; remote histories of alcohol abuse or head trauma).


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Table 1

Means and standard deviations for patients and controls for age, education, cognitive screening examinations, and

Rhode Island Driving Evaluation (RIDE) scoreGroup

Patient (n = 23; 12 males,

11 females )

Control (n = 23; 7 males,

16 females)

Test scores M S.D. M S.D. t

Age 78.2 9.3 74.3 7.3 1.6

Education 12.7 2.9 14.3 2.4 −2.0∗

MMSE 25.7 2.4 29.3 0.8 −6.8∗∗∗

DRS 130.9 9.0 141.6 2.6 −5.0∗∗∗

RIDE 130.4 84.1 46.1 34.5 4.5∗∗∗

∗ P < .05∗∗∗ P < .001.

Nine additional patients who met inclusion criteria for the study declined full participation.While these individuals (seven men and two women) willingly completed neuropsychologicalassessment, they refused to complete road-test examinations. They expressed concern thatthe road test would result in driving restrictions or revocation of their driving licenses. Inaddition, their family members expressed concerns about restrictions of their freedom andindependence. All nine of these individuals demonstrated early signs of possible DAT based

on their histories, clinical presentations, and performances on neuropsychological testing.The 23 participants in the control group (7 males, 16 females) were recruited from local

senior centers and advertisements in local media sources. They were required to have a CDRof zero [cognitively intact], to be living independently, and to be without a significant currentpsychiatric condition or sensorimotor impairment.

Demographic data and performance on screening measures of global cognitive impairment[Mini Mental Status Examination (MMSE) and Dementia Rating Scale (DRS)] for the twogroups are presented in Table 1. The control group consisted of several more women thanmen, unlike the patient group that had an approximately equal number of male and female

participants. A number of potential male volunteers in thesenior centers utilized for recruitmentdeclined participation, due to fear of losing their driving privileges.

2.2. Procedure

After informed consent, participants and family members completed interviews and ques-tionnaires to provide data on medical, educational and social history, activities of daily living,and driving history. Participants in both the patient and control groups were then administeredthe following battery of traditional and computer-administered neuropsychological tests:

General screening measures:

• Mini Mental Status Examination (Folstein et al., 1975)• Dementia Rating Scale (Mattis, 1976)• Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983)


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Intellectual functioning/premorbid marker:

• AMNART (American version of the National Adult Reading Test; Grober & Sliwinski,1991).

Attention/executive measures:

• Useful Field of View (UFOV; Ball & Roenker, 1998) [computer-administered]• Wisconsin Card Sort Test (WCST, 64-item short form; Axelrod, Henry, & Woodward,

1992)• Action Fluency (Piatt, Fields, Paolo, & Troster, 1999)• Ruff Figural Fluency (Ruff, Light, & Evans, 1987)• Trail Making Test (A and B)• Maze Navigation Test (Whelihan, DiCarlo, Comparetto, & Donovan, 2001)

Language measures:

• Generative Naming [Controlled Oral Word Association (COWA; Benton & Hamsher,1989)]

• Generative Naming (Animals)

Learning/memory measures:

• Brief Visual Memory Test—Revised (BVMT-R; Benedict, 1997)

Visual–spatial measures:

• BVMT-R Copy

• Letter Cancellation Test (random As),• Visual Form Discrimination Test (VFDT; Benton, Hamsher, Varney, & Spreen., 1983)

The Action Fluency test, a purported measure of executive functioning analogous to otherword generation tasks, requires participants to name as many action words (verbs) as theycan within 1 min. The Maze Navigation Test is an instrument developed by our group that isa modification of the Porteus Mazes Test (Porteus, 1965). It consists of a sample maze andeight additional paper and pencil mazes. The mazes are thought to be a reasonable analogof driving, because the participant is required to plan a route and arrive at a goal efficiently

while staying within the lines. A number of the mazes have obstacles, as one might en-counter while driving. All mazes are administered, and both time to completion and numberof errors committed are recorded. WISC-III criteria were utilized in scoring the mazes. De-scriptions of other tests in the battery are available in Lezak (1995) and Spreen and Strauss(1998).


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The computer-administered UFOV utilized a touch screen interface to eliminate potentialparticipant difficulties with mouse or keyboard. This test was administered on a single Pentium

desktop computer in a darkened room, after participants were oriented to the touch screeninterface.

Participants returned within one week of the neuropsychological assessment for the RhodeIsland Driving Evaluation (RIDE) that was standardized as a 4-mile course through city streets,in a vehicle with automatic transmission, power steering and dual controls. All road tests wereconducted by the same professional examiner during daylight hours, satisfactory weatherconditions, and light to moderate urban traffic. The driving examiner had over 35 years of experience conducting examinations and providing driving instruction to individuals of allages in the state of Rhode Island.

The driving examiner, who was blinded to the neuropsychological data, CDR status andgroup membership, provided participants with an orientation to the vehicle prior to each roadtest. He judged the performance of each participant on a pass/fail basis, according to his trainingand expertise. In addition, the driving examiner rated the driving behavior of each participantaccording to the RIDE scale, a measure similar to one developed by Hunt et al. (1993, 1997a,1997b) in the Washington University driving studies.

The 31 items on this RIDE scale include an assessment of operations (inserting key, turningon ignition, checking seat and mirrors), maneuvers (turns, stops, negotiating through intersec-tions), adherence to traffic signs and regulations, speed and distance from objects, awareness of driving environment (obstacles, events, how one’s driving affects others), and general cognition

(comprehension of instructions, concentration on task). The examiner rated participants’ per-formance on each item according to frequency of occurrence (always, sometimes, not enough).In addition, each item was weighted by level of importance for driving safety, as determinedby review of the Washington University Road Test (Hunt et al., 1993), various occupationaltherapy-based driving protocols, and the official Rhode Island State driving examination. Forexample, failure to pay attention to a stop sign was weighted higher than failure to use a turnsignal. Possible scores on the RIDE scale range from 0 to 570, with higher scores indicatingpoorer performance.

All methods and procedures included in the current study were approved by the Institu-

tional Review Board and legal counsel of the Roger Williams Medical Center, Providence, RI.Participants in both groups were provided feedback regarding their performance on neuropsy-chological assessment and road-test evaluation. In the event of marginal or failed performanceon the road-test evaluation, participants were warned of the risks of continued driving. Inaddition, participants in the patient group and their caregivers were aware at the onset of the evaluation that their referring physicians would receive reports, and that their physicianshad the right to inform the Department of Motor Vehicles (DMV) of the findings. Moreover,patient participants were provided verbal and written feedback that included specific recom-mendations for driving. Such recommendations may have included the following: (a) drive

only under optimal conditions (non-highways, familiar routes, short distances, daylight hours,non-rush hour traffic, good weather, with accompaniment); (b) drive under optimal conditionsand participate in re-evaluation in 6–9 months time; (c) stop driving, given the risk of accidentor injury on the road. Finally, patient participants were provided with information regardingcommunity resources and alternate methods of travel, whenever necessary.


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3. Results

Significant differences between the patient and control groups were found in terms of years of education, MMSE, DRS, and RIDE error scores but not age (see Table 1). Table 2provides means and standard deviations for patient and control participants on the cognitivetest measures.

MANCOVAs were computed to compare the two groups on the cognitive measures, control-ling for differences in education. Three separate MANCOVAs were conducted that separatelyincluded measures of attention, executive function, and visual memory. Performances on TrailsA, Letter Cancellation (omissions), Visual Form Discrimination total score, Visual Form Dis-crimination peripheral errors, and the three conditions of the UFOV test were included in the

first MANCOVA. Results of this analysis revealed significant group differences on the cogni-tive tests (Wilks’ Lambda = 0.40, F (7, 25) = 5.29, P < .001). Univariate comparisons revealedthat the patient group performed significantly more poorly than the healthy control participantson each of the dependent measures. Dependent variables in the second MANCOVA includedTrails B, Maze Navigation (time to complete and errors), WCST perseverative responses andperseverative errors, Ruff Figural Fluency unique designs and perseverative errors, COWA,animal naming, and Action Fluency. The omnibus test was significant (Wilks’ Lambda = 0.18,F (10, 18) = 8.0, P < .001). Univariate comparisons revealed that the patient group performedsignificantly more poorly than the control group on each of the dependent measures exceptRuff perseverative errors. The final MANCOVA included BVMT-R total learning score and

Table 2

Means and standard deviations for patients and controls for cognitive test measures

Group

Test Patient, mean (S.D.) Control, mean (S.D.)

Trails A time 57.0 (18.2) 35.9 (12.3)

Trails B time 209.7 (74.5) 77.5 (23.6)

Maze Navigation errors 11.7 (7.9) 4.1 (2.4)

Maze Navigation time 626.

9 (270.9) 298.

4 (111.2)WCST perseverative responses 21.9 (12.5) 9.9 (4.6)

WCST perseverative errors 18.9 (9.6) 8.9 (3.4)

Ruff unique designs 38.8 (10.2) 74.2 (23.2)

Ruff perseverative errors 19.4 (19.0) 8.6 (10.3)

Letter Cancellation (omissions) 5.5 (10.2) 1.2 (1.2)

Generative Naming (COWA) 27.5 (10.1) 40.8 (12.2)

Generative Naming (Animals) 12.8 (4.8) 19.4 (5.1)

Action Fluency 10.5 (5.0) 17.6 (5.6)

VFDT Total score 27.3 (2.5) 30.8 (1.7)

VFDT peripheral errors 2.5 (2.1) 0.4 (0.8)

BVMT-R Total learning 11.

3 (5.5) 21.

5 (6.1)BVMT-R delayed recall 4.1 (3.2) 8.5 (2.0)

UFOV—Part I 97.8 (69.5) 34.8 (65.8)

UFOV—Part II 370.5 (167.3) 147.4 (102.6)

UFOV—Part III 449.9 (103.4) 275.1 (110.5)


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delayed recall score. The omnibus test was significant (Wilks’ Lambda = 0.60, F (2, 41) =13.65, P < .05), with the patient group performing significantly more poorly on both dependent

measures.Zero-order correlations are presented in Table 3 for both the patient and control groups. For

the patient group, significant relationships were found only between RIDE and the executiveand visual attention measures [Trails B time, Maze Navigation time, and UFOV (parts I–III)].Letter Cancellation (omissions), which we had hypothesized would be related, were not signif-icantly related to RIDE performance. For the control group, only age was significantly relatedto RIDE performance.

Maze Navigation time, Trails B time, and UFOV—Part I were entered into a hierarchicalregression analysis to explore the relative contribution of each measure to RIDE performance;

these were selected based on initial hypotheses and significant zero-order correlations withRIDE. These three measures accounted for 46% of the variance in RIDE performance [F (3, 19)= 5.5, P < .01; see Table 4]; however, Trails B time added insignificantly to the variance. OnlyPart I of the UFOV was utilized in this analysis since 11 of the participants in the patient groupwere unable to complete the more challenging Part II and Part III of the UFOV. The t -tests wereutilized to compare patients who failed and those who passed the more challenging parts of theUFOV. No significant difference between the groups was found for any of the selected measures

Table 3

Zero-order correlations: RIDE score and selected demographic and cognitive test measures

Patients Controls

r P r P

Age .40 .45 ∗

Education −.04 −.22

Trails A time .32 .09

Trails B time .46 ∗ −.03

Maze Navigation errors .08 .25

Maze Navigation time .52 ∗∗ −.27

WCST perseverative responses −.32 −.13

WCST perseverative errors −.30 −.07Ruff unique designs −.16 −.19

Ruff perseverative errors −.27 −.02

Letter Cancellation (omissions) −.16 .09

Generative Naming (COWA) .06 −.03

Generative Naming (Animals) −.25 −.11

Action Fluency .25 −.24

VFDT Total score −.13 −.06

VFDT peripheral errors .20 −.11

BVMT-R Total learning −.17 −.32

BVMT-R delayed recall −.28 −.28

UFOV—Part I .61 ∗∗ −.23UFOV—Part II .46 ∗ −.15

UFOV—Part III .46 ∗ .06

∗ P < .05∗∗ P < .01.


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Table 4

Hierarchical regression analysis using executive and visual attention measures to predict RIDE performance

Test entry order R2 F Significant F change d.f.

Maze Navigation (time) .27 7.7∗∗ .01 1, 21

Trails B time .28 3.9∗ .55 2, 20

UFOV—Part I .46 5.5 ∗∗ .02 3, 19

∗ P< .05∗∗ P ≤ .01.

utilized in the hierarchical regression analysis other than Part I of the UFOV. Furthermore,there was no significant difference in RIDE scores between patients who failed and those who

passed the more challenging parts of the UFOV (t = −1.68; n.s.).A discriminant function analysis was utilized to explore which subset of the measures

chosen for the hierarchical regression best categorized the entire group of patient and controlparticipants in terms of pass/fail status on the RIDE examination. Only Maze Navigation timeentered the analysis with a classification accuracy of 80%; (Wilk’s lamda = 0.69; chi-square= 11.6, P = .001). Cross validation classification accuracy was also 80%.

4. Discussion

The purpose of the current study was to examine neuropsychological predictors of drivingability in older individuals with early-stage cognitive impairment. Previous studies,for the mostpart, have utilized global or non-executive measures of cognitive functioning and have focusedon participants with more extensive cognitive impairments. The current findings demonstratethat a novel executive measure (Maze Navigation Test) and a visual attention test (UFOV—PartI) are significantly related to driving ability, as measured by actual road-test performance, inindividuals with early-stage cognitive decline. The findings lend further support to the efficacyof the UFOV, with the caveat that some subtests of the latter may in fact be too challengingfor individuals with even early-stage cognitive impairment.

In regard to study limitations, it is important to consider the relatively restricted samplesizes included in this study, and the possibility that some relationships did not meet statisticalsignificance due to reduced power, or the possibility that our findings reflect a biased samplingof the distributions. Fortunately, we do not believe that power was insufficient consideringthe very small effect sizes for most variables as signified by the results of the correlationanalyses. Further, the robust relationship between Maze navigation and RIDE evident in thisstudy is consistent with previous reports (Ott et al., 2003); this suggests that our findingsare reliable. A larger study will be important to determine this with greater certainty, how-ever, this will be a difficult task given individuals’ reluctance to participate in a study where

they risk losing their driving license. This reluctance, unfortunately, is going to be a factor inany studies of this kind where samples may be biased toward higher functioning participantswho can be persuaded to participate by researchers or physician gatekeepers. While it wouldbe important to replicate findings by means of additional empirical studies, it is importantto keep this potential bias in mind. Furthermore, our patient group was composed primar-


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ily of individuals with cerebrovascular disorders, thus limiting our findings to this clinicalpopulation.

Neuropsychological assessment may have the potential to identify deficits that are notevident in an on-road driving examination. In several cases, patient participants passed theroad test but demonstrated significant executive deficits on testing. For those, the investigatorswere able to raise concerns with participants and family members during the feedback sessionthat resulted in restrictions or termination of driving. Longitudinal studies of these individuals,in conjunction with acquisition of accident data and motor vehicle department records, mayhelp to further address this issue.

It is noteworthy that we had difficulty recruiting males in our control group and individualswith possible early DAT in our patient group, most likely due to fears of loss of driving

privileges. Moreover, family members of this latter group appeared to be more reluctant thanother participant families to restrict independence. These issues further highlight the need forclinical neuropsychologists to focus on intervention strategies with patients and families andto collaborate with other healthcare professionals to affect a balance between safety concernson the one hand and autonomy on the other.

Clearly, older persons who continue to drive with cognitive impairments present a seriouspublic health problem. Some studies report that even individuals with serious cognitive impair-ments and history of motor vehicle accidents continue to drive (Carr et al., 1990; Odenheimeret al., 1994). Professionals who would like to intervene are often restricted, since only physi-cians are protected from litigation in a number of states. Many state governments have nottaken a proactive role in assessing the driving competence of older persons or individuals withdementia. This is a major issue for older individuals, their families, and for society at large.Further research is necessary, but it appears that neuropsychologists can play an importantrole in the assessment and treatment of older individuals with early-stage cognitive decline byproviding objective data related to driving competence.

Acknowledgement

This research was funded by a grant from the National Academy of Neuropsychology.

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