The Canadian Alzheimer - STA Communications · The Canadian Alzheimer Disease Reviewwelcomes letters from its readers. Address all correspondences to Letters, The Canadian Alzheimer

And Now, Are There Any Questions? 3Bernard Groulx, MD, FRCPC

The Prognosis of Delirium 4Kenneth Rockwood, MD, FRCPC

Ginkgo Biloba and Alternative Therapies 9Peter Lin, MD

Driving with Dementia 14Peter N. McCracken, MD, FRCPC; Jean A. Caprio Triscott, MD, CCFP, FAAFP-Geriatrics; and

Allen R. Dobbs, PhD

Windows Into Alzheimer Disease 22The Alzheimer Society of Canada

The Canadian

AlzheimerDisease ReviewVolume 4, Number 5 December 2001

Art

by

Lynn

Ann

Bus

sey

CHAIRMANPeter N. McCracken, MD, FRCPCGeriatric Medicine Staff,Glenrose Rehabilitation Hospital Part Director, Division of Geriatric Medicine and Professor of Medicine, University of Alberta Edmonton, Alberta

Paul J. Coolican, MD, CCFP Family Physician, St. Lawrence Medical ClinicMorrisburg Ontario Active Staff,Winchester District Memorial HospitalWinchester, Ontario

Shannon Daly, RN, MNCommunity NurseNorthern Alberta Regional Geriatric ProgramEdmonton, Alberta

Howard Feldman, MD, FRCPCClinical Associate Professor of MedicineUniversity of British ColumbiaDivision of Neurology UBCDirector, UBC Alzheimer Clinical Trials UnitVancouver, British Columbia

Serge Gauthier, MD, CM, FRCPCProfessor of Neurology and Neurosurgery,Psychiatry and Medicine, McGill UniversityMcGill Centre for Studies in AgingMontreal, Quebec

Bernard Groulx, MD, CM, FRCPC Chief Psychiatrist, Ste-Anne-de-Bellevue HospitalAssociate Professor, McGill UniversityMcGill Centre for Studies in AgingMontreal, Quebec

Nathan Herrmann, MD, FRCPCAssociate Professor, University of TorontoHead of the Division of Geriatric Psychiatry,Sunnybrook Health Science CentreToronto, Ontario

Peter Lin, MD, CCFPMedical DirectorUniversity of TorontoHealth & Wellness Centre at ScarboroughScarborough, Ontario

Kenneth J. Rockwood, MD, FRCPCProfessor of Medicine, Dalhousie UniversityGeriatrician, Queen Elizabeth II Health Sciences CentreHalifax, Nova Scotia

Steve Rudin, MEd, MSPHNational Executive DirectorAlzheimer Society of CanadaToronto, Ontario

The Canadian Alzheimer Disease Review is published by STA Communications Inc., through an educational grant provided by Pfizer Canada.The opinions expressedherein are those of the authors and do not necessarily reflect the views of the publisher or the sponsor. Physicians should take into account the patient’sindividual condition and consult officially approved product monographs before making any diagnosis or treatment, or following any procedure based onsuggestions made in this document. Publications Agreement Number 40063348. Copyright 2001.All rights reserved.

Publishing Staff

EDITORIAL BOARD

The editorial board has complete independence in reviewing the articles appearing in this publication and is responsible for theiraccuracy. Pfizer Canada exerts no influence on the selection or the content of material published.

We’d Like to Hear From You!The Canadian Alzheimer Disease Review welcomes letters from its readers. Address all correspondences to Letters, The Canadian Alzheimer Disease Review, 955 Boul. St. Jean, Suite 306, Pointe Claire, Quebec, H9R 5K3. The Review also acceptsletters by fax or electronic mail. Letters can be faxed to 514-695-8554 and address electronic mail to [email protected]. Pleaseinclude a daytime telephone number. Letters may be edited for length or clarity.

Paul F. BrandExecutive Editor

Russell KrackovitchEditorial Director,Custom Communications

Stephanie Costello Managing Editor

Marie LalibertéEditor-proofreader, French

Donna GrahamProduction Manager

Dan OldfieldDesign Director

Jennifer BrennanFinancial Services

Jamie TolisAccounting Assistant

Barbara RoyAdministrative Assistant

Ian W.D. Henderson, MDMedical Consultant

John L. Liberman, QCForensic Consultant

Robert E. PassarettiPublisher

ON THE COVERThe Nucleus by Lynn Ann BusseyAs I learn to become a doctor, I am overwhelmed by the endless information that I am required to memorize regarding the patho-physiology, and signs and symptoms of various disorders. I am swamped trying to put all the facts together to form logical questions asked in the perfect sequence. I put so much effort into reasoning through countless details, hoping that someday it willmake a difference. In the midst of the continual fascination with the disorder, it is difficult to find the time to step back and see thepeople affected...a patient who is confused and suffering...a family that feels scared and helpless. These problems are difficult todeal with, since the cures are not listed in tables or presented in graphs. My logical approach to medicine fails me when I need toaddress the patient’s experience, and I long to retreat into my world of endless tangible and concrete facts.

I painted this neuron with the patient centrally located in the nucleus as a reminder to myself to make the effort to stop thinkingabout the diagnosis and start seeing the people affected. This is exceptionally difficult with Alzheimer’s disease, as the medicine issimple compared to the emotional turmoil that the patient and family experience. Understanding the pathology of Alzheimer’s disease is a small part of the patient’s care, and I don’t want to be the kind of physician that fails to see the illness through thepatient’s eyes.

2 • The Canadian Alzheimer Disease Review • December 2001

E D I T O R I A L

While reviewing the articles in this issue ofThe Canadian Alzheimer Disease Review, I

had “flashbacks” of all the question periods thathave followed conferences given by myself, or oth-ers, on Alzheimer’s disease. Regardless of whetherthe conferences are presented to family physicians,nurses, other paramedical personnel or the generalpublic, three questions almost always arise: “Whatis the difference between delirium and dementia?,”“What about all these ‘natural’ therapies likeGinkgo biloba?” and “When is it time to take awaysomeone’s driving privileges if he or she is suffer-ing from dementia, and how can a family or gener-al practitioner do it?” These are the topics specifi-cally addressed in this issue. As well, the articlefrom the Alzheimer Society of Canada (page 22)provides clear, informative material and, in thiscase, the point of view of the sufferer.

Although the article from the AlzheimerSociety is a frequent favorite among readers, thistime the other three articles, as mentioned above,really hit home for me.

Dr. Kenneth Rockwood’s piece on delirium(page 4) is very comprehensive and concise. Hereminds us that study after study shows that a highnumber of patients in hospitals or nursing homessuffer from delirium that is misunderstood, misdi-agnosed, mistreated or simply ignored. Theseunfortunate facts come with a heavy price—extremely morbid and even mortal consequencesfor our patients. The tables Dr. Rockwoodincludes in his article are useful for serving as aconstant reminder of the adverse outcomes, eithernear-term or long-term, associated with delirium. Iknow that is how I will use them.

In terms of alternative therapies, I have beenwaiting—or hoping, rather—for someone to takethe time and effort to research the topic and give

an expert opinion on the value of these therapiesfor dementia. Questions on these therapies arefrequently asked and I have been notorious in my“slip-sliding” maneuvers to answer. Dr. Peter Lindoes a superb job of explaining the nature andpossible advantages of Ginkgo biloba (page 9).He also is equally efficient in his plea for pru-dence and common sense. There are, of course,potential side effects, but he mainly reminds usthat the lack of regulation for Ginkgo biloba andother herbal products introduces a risk to ourpatients. We need to be fully aware of this andany/all other risks.

Finally, is there anything more delicate or dif-ficult than deciding when a patient cannot driveanymore? The majority of my patients are maleVeterans (although I am sure the following alsoholds true for female patients) and not being ableto drive is perceived as a true tragedy. Manypatients have equated freedom, autonomy andperhaps, sadly, personal value with being able todrive a car for themselves and their spouse. Thedecision to terminate driving always leads tointerminable and sometimes painful discussionswithin families and in the doctor’s office.However, Dr. Peter McCracken (nobody else, inmy mind, could have written such an intelligentarticle on this topic) starts by exposing the “otherside of the coin”—the consequences of not beingattentive to the driving issue and/or not doing any-thing about it (page 14).

So... are there any questions? Because thisReview certainly answers three of the most impor-tant ones.

Bernard Groulx, MD, FRCPCChief Psychiatrist, Ste-Anne-de-Bellevue HospitalMontreal, Quebec

And Now, Are There Any Questions?by Bernard Groulx, MD, FRCPC

The Canadian Alzheimer Disease Review • December 2001 • 3


Delirium is a common prob-lem among older adults, and

its routine care has proven to besurprisingly difficult to imple-ment effectively.1 The obstacles toeffective routine care are many,but importantly include an under-appreciation by healthcare pro-viders about the adverse outcomesof delirium in both the near andlong term. This paper will reviewsome of these adverse outcomes,the mechanisms by which theymight occur and ways in whichthey might be ameliorated. A sub-sequent paper will address theclinical recognition of delirium,and provide an approach to itsmanagement.

What is Delirium?Delirium is an acquired globalsyndrome that results in impairedcognition. It is distinguished fromdementia by its more acute onsetand by being chiefly a disorder ofconsciousness, with prominentimpairment of attention and con-centration. Most often, delirium

has an identifiable cause, arisingusually from a disorder outside thecentral nervous system (such as ametabolic problem, an infection,or exposure to a toxic medication).Occasionally delirium can arise inthe setting of direct brain injury,such as a stroke.2 The risk of delir-ium is increased by the presenceof an underlying neurological dis-order, especially dementia, butalso by physical frailty.

Adverse Outcomes of Delirium in the Near TermDelirium is associated with anumber of adverse effects in thenear term (Table 1). Most recentcohort studies report that anepisode of delirium in older adultsis associated with a two- to three-time relative risk (RR) of func-tional impairment, compared withthose who did not have a deliriousepisode. Worse functional perfor-mance has been found in bothbasic and instrumental activitiesof daily living, in both medicaland surgical settings.3-8

Considering this, it is perhapsnot surprising that delirium also isassociated with an increased riskof nursing home admission as the

outcome of the index hospitaliza-tion.5-10 In the studies under consid-eration, the RR ranged from 2.87 to4.510 and the median proportion ofdelirious patients who were institu-tionalized was 38%. Delirium hada particularly malign effect amongpatients who had experienced a hipfracture, where it was associatedwith very poor recovery of mobili-ty, and an institutionalization rateof 46%.5 Institutionalization itselfalso was associated in these studieswith an increased hospital stay.

As much as patients and theircaregivers may fear poor functionalrecovery and institutionalization, itcan be argued that they fear cogni-tive impairment even more. Hereagain, the news is grim. Amongpatients who experience an episodeof delirium, even when there is res-olution of some symptoms (usuallyinattention), others persist (usuallymemory and disorientation).7,11 Forexample, Kelly et al12 reported that,of 214 nursing home deliriumpatients admitted to acute care,72% had persistence of symptomsprior to death or discharge, 55% ofsurvivors had symptom persistenceat one month, and 25% had symp-tom persistence at three months.

Dr. Rockwood is a professor ofmedicine at Dalhousie Universityin Halifax, Nova Scotia.

The Prognosis of DeliriumDelirium is a common manifestation of disease among elderly people, especially those who have dementia.Delirium often reflects that a medical illness is severe. An episode of delirium increases the near-term risk ofdeath, prolonged hospital stay, and new admission to a nursing home. In the longer term, it also increases therisk of death and institutionalization. Among older adults who are otherwise cognitively and functionallyunimpaired, an episode of delirium also increases the risk of dementia. At present, it is not clear how theserisks can be ameliorated, but there is some suggestion that appropriate medical care of patients while theyare delirious has substantially beneficial effects in the near term.

by Kenneth Rockwood, MD, FRCPC

Similarly, in a cohort of olderadults with hip fractures, 39% hadpersistence of their symptoms atdischarge or death, 32% at onemonth, and 6% at six months.These findings are consistent withan earlier large cohort study13

which found that 58% of patientswho developed delirium duringadmission still met research criteriafor delirium at discharge. Similarly,a meta-analysis of eight in-patientstudies14 estimated that only 55% ofpatients had some degree of mentalrecovery at one month. A recentstudy of hip fracture patients foundthat delirium still was present in32% at one month and 6% at sixmonths following surgery.5

Delirium also is associated withan increased risk of death in thenear term, with near-term mortali-ty rates of almost half of patientsso affected being reported.12 Wemust be cautious, however, wheninterpreting these data, as deliriumalso is commonly seen among veryold patients15 and terminally illpatients as they are dying. Forexample, in a cohort of dying pa-tients, Lawlor et al16 reported that88% had a “terminal delirium.” Inconsequence, cohort studies ofnear-term outcomes—which in-clude patients who become deliri-ous as they are dying—serve toover-estimate the lethality of thecondition. For this reason, it is per-haps more realistic to considerlonger-term mortality rates amonghospital survivors of deliriumwhen attempting to understand itstrue impact on mortality.

Adverse Outcomes of Delirium in the Longer TermTable 2 shows that delirium alsohas been associated with each of

the above adverse outcomes in longer-term studies (12 months ormore).9,10,15,17-19 Notably, delirium isassociated with an increased riskof death among those who survivethe index delirium episode—inother words, an increased riskremains (the median RR is three-fold, even after adjusting for ageand comorbidity).

Of some additional interest is therole of delirium in relation to cogni-tive impairment. Recent studieshave clarified what many cliniciansare likely to have reckoned formany years: that, in a patient with-out prior cognitive impairment, anepisode of delirium increases therisk of dementia, and that, in apatient with prior cognitive impair-ment, the extent of decline is worseafter a delirium. Both of these cir-cumstances appear to occur evenwhen there is interval recovery.

McCusker et al9 examined cog-nitive decline, as measured by theMini-Mental State Examination(MMSE)20 in more than 1,500elderly medical patients admittedto a Montreal hospital. Amongthose who had delirium, even

when interval recovery occurred,the MMSE score was betweenthree to five points lower (depend-ing on whether it had co-existedwith dementia) at follow-up (up to12 months later) than in patientswhose illness had not been com-plicated by delirium. These resultsappear to have been clinicallyimportant, as they were seen inparallel with declines in function-al ability.

Our group21 followed 203 pa-tients in the intervention-half ofa before/after study11 designed toincrease the recognition of delir-ium and improve its outcomes.In consequence, the results arelikely conservative, as they referto a group of patients in whommanagement had been opti-mized. Nevertheless, among el-derly medical inpatients with noprior history of cognitive orfunctional impairment, thosewith delirium during the indexhospital admission had a three-


Table 1

Near-term (up to six months)adverse events associatedwith an episode of delirium

1. Impaired function in basic activitiesof daily living.

2. Impaired function in instrumentalactivities of daily living.

3. Poor recovery of mobility after hipfracture.

4. A higher rate of admission to a nursing home.

5. Persisting problems with memoryand other aspects of cognition.

6. A higher rate of death.

Table 2

Longer-term (12 months ormore) adverse events associated with an episode of delirium

1. Impaired function in basic activitiesof daily living.

2. Impaired function in instrumentalactivities of daily living.

3. Poor recovery of mobility after hipfracture.

4. A higher rate of admission to a nursing home.

5. A higher rate of death.

6. A higher rate of incidence of dementia in those without dementiaat baseline.

7. Worse dementia in those withdementia at baseline.


fold increase in RR of dementia(RR = 3.23; 95% CI, 1.86-5.63).The absolute risk of dementiaamong those with delirium wasapproximately 18% per year.

Mechanisms by WhichDelirium is Associated withAdverse OutcomesDoes delirium cause adverse out-comes, or is it mainly a marker ofa worse physical illness which isthe real cause of the problems?The answer is not clear. In princi-ple, a number of mechanisms canoperate, and at present, none canbe excluded, suggesting that somewill be true for at least somepatients, while in other patients,more than one mechanism is like-ly to be involved. Delirium mightgive rise to brain injury whichresults in the predisposition todementia. Indeed, if we consider

that many forms of dementia mayresult from aberrant repair mecha-nisms,22 delirium may even giverise to a process that initiatesdementia. Alternately, consideringthat the initiating events indementia may be preceded bydecades of late-life disease ex-pression,23 delirium might unmaskdementia. Finally, delirium mayin fact serve as a marker of sub-clinical dementia.

Can the Risk of AdverseOutcomes from Delirium beMitigated?As reviewed elsewhere, a numberof studies have pointed to inter-ventions that might reduce therisk of the adverse outcomes asso-ciated with delirium.19 Perhaps themost persuasive is the multicom-ponent trial of Inouye et al.24 Withrespect to specific therapy, how-

ever, the role of a deliriousepisode implicated in the patho-physiology of dementia meansthat patients who have had deliri-um might be a particularly suit-able group for an interventionstudy. The study could be basedon an anti-inflammatory strategy,the use of 3-hydroxy-3-methyl-glutaryl coenzyme A (HMG CoA)reductase inhibitors (“statins”), abeta-secretase inhibition (whensuch therapies become available),or some other directly disease-modifying strategy. For now,however, the lessons of Inouye etal24 suggest that there is much tobe gained from less esoteric prac-tices. Heightened vigilance aboutdelirium, a systematic search forits cause, humane care and avoid-ance of unnecessary psychotropicmedications each offer a moreimmediate promise of benefit.

References:1. Inouye S, Schlesinger MJ, Lydon TJ. Delirium: A symptom of how

hospital care is failing older persons and a window to improvequality of hospital care. Am J Med 1999; 106:565-73.

2. Henon H, Lebert F, Durieu I, et al. Confusional state in stroke:relation to pre-existing dementia, patient characteristics and out-come. Stroke 1999; 30:773-9.

3. Rolfson DB, McElhaney JE, Rockwood K, et al. Incidence andrisk factors for delirium and other adverse outcomes in olderadults after coronary artery bypass graft surgery. Can J Cardiol1999; 15:771-6.

4. Galanakis P, Bickel H, Gradinger R, et al. Acute confusionalstate in the elderly following hip surgery: incidence, risk factorsand complications. Int J Geriatric Psychiatry 2001; 16:349-55.

5. Marcantonio ER, Flacker JM, Michaels M, et al. Delirium isindependently associated with poor functional recovery after hipfracture. J Am Geriatr Soc 2000; 48:618-24.

6. Inouye S, Rushing J, Foreman M, et al. Does delirium contributeto poor hospital outcomes? A three-site epidemiologic study. J Gen Intern Med 1998; 13:234-42.

7. O’Keefe ST, Lavin J. The prognostic significance of delirium inolder hospital patients. J Am Geriatric Soc 1997; 45:174-8.

8. Jarrett PG, Rockwood K, Carver D, et al. Illness presentation inelderly patients. Arch Intern Med 1995; 155:1060-4.

9. McCusker J, Cole M, Dendukuri N, et al. Delirium in oldermedical inpatients and subsequent cognitive and functional status: a prospective study. CMAJ 2001; 165:575-83.

10. George J, Bleasdale S, Singleton SJ. Causes and prognosis of delirium in elderly patients admitted to a district general hospi-tal. Age Ageing 1997; 26:423-7.

11. Rockwood K, Cosway S, Stolee P, et al. Increasing the recognitionof delirium in elderly patients. J Am Geriatr Soc 1994; 42:252-6.

12. Kelly KG, Zisselman M, Cutillo-Schmitter T, et al. Severity andcourse of delirium on medically hospitalized nursing facility

residents. Am J Geriatr Psychiatry 2001; 9:72-7.13. Levkoff SE, Evans DA, Liptzin B, et al. Delirium. The occurrence

and persistence of symptoms among elderly hospitalisedpatients. Arch Int Med 1992; 152:334-40.

14. Cole M, Primeau FJ. Prognosis of delirium in elderly hospitalpatients. CMAJ 1993; 149:41-6.

15. Rahkonen T, Luukkainen-Markkula R, Paanila S, et al. Deliriumepisode as a sign of undetected dementia among community-dwelling elderly subjects: a 2 year follow-up study. J NeurolNeurosurg Psychiatry 2001; 69:519-21.

16. Lawlor PG, Gagnon B, Mancini IL, et al. Occurrence, causes,and outcome of delirium in patients with advanced cancer: aprospective study. Arch Intern Med 2000; 160:786-94.

17. Curyto KJ, Johnson J, TenHave T, et al. Survival of hospitalized elder-ly patients with delirium. Am J Geriatr Psychiatry 2001; 9:141-7.

18. Rahkonen T, Makela H, Paanila S, et al. Delirium in elderly peoplewithout severe predisposing disorders: etiology and 1-year progno-sis after discharge. Int Psychogeriatr 2000; 12:473-81.

19. Rockwood K. Educational interventions in delirium. DementGeriatr Cogn Disord 1999; 10:426-9.

20. Folstein MF, Folstein S, McHugh PR. “Mini mental state:” apractical method for grading the cognitive state of patients forthe clinician. J Psychiatry Res 1975; 12:189-98.

21. Rockwood K, Cosway S, Carver D, et al. The risk of dementiaand death after delirium. Age Ageing 1999; 28:551-6.

22. Rockwood K. Lessons from mixed dementia. Int Psychoger1997; 9:245-9.

23. Bookheimer SY, Strojwas MH, Cohen MS, et al. Patterns of brainactivation in people at risk for Alzheimer’s disease. N Engl JMed 2000; 343:450-6.

24. Inouye S, Bogardus ST, Charpentier PA, et al. A multicomponentintervention to prevent delirium in hospitalised older patients.N Engl J Med 1999; 340:669-76.


The explosion of herbal prod-ucts/remedies into the con-

sumer market has taken grip ofWestern society over the past sev-eral years. There is a perceptionamong the general public that“herbal” is analagous to “natural,”and that herbal products have noside effects. There also is a beliefthat herbal products will act exact-ly how their labels say they will,regardless of whether they havebeen tested and/or passed food anddrug laws. In this age of “smart-shopping,” however, healthcareprofessionals and lay-people alikeshould be asking, “What is the evi-dence? What are the pitfalls ofthese products? If an herb is effi-cacious and has no side effects,shouldn’t everyone be taking it?”The information that follows mayhelp clarify these questions.

What is Ginkgo Biloba?The Ginkgo biloba tree originatedin China thousands of years agoand is one of the oldest trees onearth. It produces a fruit which hasa seed in the centre. Gingkoextract was originally taken fromboth this seed and the leaves of thetree. The very popular Ginkgobiloba currently available in storesis an extract of just the leaves. Thestandardized extract, EGb 761,contains ginkgo-flavonol glyco-sides (24%) and terpene lactones(6%), such as ginkgolides A, B, Cand J and bilobalide.1

The hype over this herb, amongthe general public, is due to claimsof it’s ability to improve concen-tration and memory.

Because Ginkgo biloba is acombination of several comp-ounds, it has several effects:

Ginkgo Biloba and Alternative TherapiesBy improving blood flow in arteries and capillaries and enhancing blood flow to thebrain, Ginkgo biloba is said to be effective in treating ailments associated withdecreased cerebral blood flow, particularly in older individuals. As with all othertherapies, however, potential benefits of this herbal product must be balanced againstpossible risks.

by Peter Lin, MD

Dr. Lin is Medical Director for theUniversity of Toronto Health andWellness Centre in Scarborough,Ontario.


Antioxidative. Ginkgo biloba’santioxidant effects have been sug-gested as the mechanisms behindthe protection of neurons fromoxidative stress.

Promotes vasodilation. Ginkgobiloba helps increase blood flowand has been studied in patientswith peripheral vascular disease.

Antiplatelet activity also hasbeen associated with Ginkgobiloba.

With this host of effects,Ginkgo biloba has been used in avariety of conditions includingcerebral insufficiency, tinnitus,vertigo, claudication and dementia.

What is the Evidence forthe Use of Ginkgo Biloba in Dementia?A major study in Ginkgo biloba’sfavor was conducted by Le Barset al in 1997.2 This study con-tributed some evidence to thememory-enhancing componentsof Ginkgo biloba. The studyassessed and compared EGb 761

(120 mg/day) to placebo inAlzheimer’s disease (AD) andmulti-infarct dementia. The trialtook place over a 52-week period.A total of 309 patients wererecruited but only 202 providedevaluable data at 52 weeks. Theprimary outcome measures usedwere the Alzheimer’s DiseaseAssessment Scale-Cognitive sub-scale (ADAS-Cog), the GeriatricEvaluation by Relative’s Rating

Instrument (GERRI), and theClinical Global Impression ofChange (CGIC).

In the intent-to-treat analysis,the EGb group had an ADAS-Cog score 1.4 points higher thanthe placebo group (p = 0.04) anda GERRI score 0.14 points high-er than the placebo group (p = 0.004). With the evaluabledata set, 27% of patients treatedwith EGb achieved at least afour-point improvement on theADAS-Cog, compared to 14%treated with placebo (p = 0.005).

On the GERRI, 37% of thepatients taking EGb were consid-ered to be improved, compared toa 23% improvement in patientstaking placebo (p = 0.003). Nodifference was seen betweenEGb and placebo groups usingthe CGIC.

The results above led to the con-clusion that EGb induced positivechanges in cognitive performanceand social functioning, althoughthese changes were modest at best.

Side EffectsObviously, most (if not all) prod-ucts with medicinal propertieshave side effects. The role ofphysicians is to balance the bene-fits versus the side effects of anyproduct they prescribe. If a producthas modest benefits but no sideeffects, then it is still worth using.

Although the clinical trial byLe Bars et al reported equal side-effect profiles for both groups of

patients, throughout the literaturethere have been sporadic casereports of bleeding complicationswith Ginkgo biloba because of itsantiplatelet effects. A product withantiplatelet properties can causespontaneous bleeding on its own,or can cause bleeding complica-tions by enhancing the effects ofother antiplatelet or anticoagulantagents, such as warfarin, acetylsal-icylic acid (ASA) and/or non-steroidal anti-inflammatory drugs(NSAIDs). Hence, these combina-tions must be avoided.

What are the ConcernsRegarding Use of GinkgoBiloba?As mentioned above, there havebeen a number of cases of compli-cations associated with Ginkgobiloba. Some of these complica-tions are itemized below.

Bleeding. One case involved a56-year-old man who suffered aspontaneous intracerebral hemor-rhage after self-medicating on aregular basis with herbal prepara-tions of Ginkgo biloba.3

Another case involved a post-laparoscopic cholecystectomypatient. The patient had post-operative bleeding complica-tions, possibly related to Ginkgobiloba usage.4 In view of a casereport such as this, physicians areurged to inquire about Ginkgobiloba usage and to recommendstopping it at least one weekprior to surgery.

Seizures. There also is con-cern about the ingestion of largequantities of ginkgo nuts (seedsof Ginkgo biloba). A 36-year-old woman reportedly consumed70 to 80 ginkgo nuts and beganexperiencing generalized con-

The role of physicians is to balance the benefits versus the side effects of any product they prescribe. If a product has modest benefits but no side effects,then it is still worth using.


vulsions four hours after eatingthem.5 Apparently, she was tak-ing the nut to improve her mem-ory. She had no prior seizurehistory.

Drug-drug interactions. Pat-ients with AD are elderly and aretypically taking multiple med-ications—including ASA. Alldrugs have the potential to inter-act with each other and causeadverse effects. Adding Ginkgobiloba to a therapeutic regimen(e.g., ASA) increases an alreadyheightened risk for adverse inter-actions—particularly bleedingcomplications.

Lack of regulation. Unfortu-nately, herbal products, includingGinkgo biloba, are not regulated,which means they do not have tobe proven safe or effective to besold. The ingredients and themanufacturing process do nothave to follow or meet any specif-ic guidelines. The active ingredi-ents may or may not be in thesame proportions from one prepa-

ration to the next and, in someinstances, contaminants may passundetected into the product.

ConclusionDespite the fact that Ginkgobiloba has some beneficial prop-erties (e.g., antioxidant effects),the risk of using this drug is too

high at the present time. Thebenefits are marginal but therisks are quite real and signifi-cant. Further research needs tobe done to find the active ingre-dient in Gingko biloba. Thisingredient could then be purifiedin order to eliminate some of itsassociated side effects. The opti-

mum dosing range also needs tobe determined.

The human body does not dis-criminate between a drug and aherb. Both are recognized andmetabolized in much the sameway. Before physicians can startrecommending Ginkgo biloba topatients as a treatment for demen-

tia, the herb needs to be studiedand tested thoroughly—just asconventional medicines. Thesame rules and regulations shouldapply. In other words, the healingpowers of one of the world’s old-est trees are still a mystery thatrequires further study in order toensure safe usage by patients.

References:1. Clostre F. Ginkgo biloba extract (EGb 761). State of know-

ledge in the dawn of the year 2000. Ann Pharm Fr 1999;57(Suppl 1):158-88.

2. Le Bars PL, Katz MM, Berman N, et al. A placebo-controlled,double-blind, randomized trial of an extract of Ginkgo bilobafor dementia. JAMA 1997; 278(16):1327-32.

3. Benjamin J, Muir T, Briggs K, et al. A case of cerebral

haemorrhage - can Ginkgo biloba be implicated? PostgradMed J 2001; 77(904):112-3.

4. Fessenden JM, Wittenborn W, Clarke L. Ginkgo biloba: a casereport of herbal medicine and bleeding postoperatively from alaparoscopic cholecystectomy. Am Surg 2001; 67(1):33-5.

5. Miwa H, Iijima M, Tanaka S, et al. Generalized convulsionsafter consuming a large amount of ginkgo nuts. Epilepsia2001; 42(2):280-1.

Patient’s with AD are elderly and are typically takingmultiple medications—including ASA...Adding

Ginkgo biloba to a therapeutic regimen (e.g., ASA)increases an already heightened risk for adverse

interactions—particularly bleeding complications.


Norelli Ipsum,Alzheimers and delFulliare Dolor

The scenario above, althoughfabricated, should chill any

physician who has renewed anelderly patient’s driving license.By now, most physicians are atleast vaguely aware of the in-creased prevalence of car crashesinvolving older drivers. However,on a per-patient basis, older dri-vers surprisingly have relativelyfew crashes; when distance drivenis taken into account, the crash

rate of drivers over the age of 70years rivals or exceeds that of theyoung high-risk group of driversaged 16 to 24 years.1,2 There areserious consequences of thesecrashes and such injuries are onthe increase for older drivers.

The Contribution ofAdvancing AgeThere are numerous, well-described, age-related changes inphysical and mental abilities thatare relevant to driving. However,most experts agree it is unlikely thatthe changes associated with normalaging account for older-driver

crashes. It is much more likely thatage-associated medical conditions,or their treatments, result inimpaired driving competence.

In 1996, the Ontario Ministryof Transportation indicated thatone of the two best predictors ofan older driver having had a crashduring the previous five years wasthe presence of at least one med-ical condition.3 However, suchmedical conditions usually do notprevent a senior from obtaining alicense to drive. Table 1 shows thata wide variety of medical condi-tions increase the risk of an at-fault crash. The greatest increase

Driving with Dementiaby Peter N. McCracken, MD, FRCPC, Jean A. Caprio Triscott, MD, CCFP, FAAFP-Geriatrics, and Allen R. Dobbs, PhD

Dr. McCracken is Part Director of theDivision of Geriatric Medicine andProfessor of Medicine at the Universityof Alberta in Edmonton, Alberta.

SCENARIO:You have been Mr. JP’s family physician for the past20 years. He is 86 years old and has been relativelyhealthy, having had only mild hypertension, osteo-arthritis of the knees, and peptic ulcer disease in theway of previous illnesses. Twelve years ago, you referred him to a general surgeon for an electivecholecystectomy, a procedure that he toleratedextremely well. You have always considered him as awell adult, mainly because the principal reason forhis visits to your office have been for the renewal ofhis driving license. Such visits usually are brief andhave not raised significant concerns on your partabout his overall condition.

Mr. JP’s current medications include hydro-chlorothiazide (HCTZ) one tablet every morning,rofecoxib 25 mg daily for his osteoarthritis, andlorazepam 1 mg every night before sleeping. Hehas taken this triad of medication for at least thepast seven years, and you have had no hesitation inproviding him with refills.

One Sunday night you receive a telephone callfrom your hospital emergency room informing youthat Mr. JP has been involved in a serious car accident. He is alive, but semi-comatose, havingstruck another car while turning left across anintersection. Both vehicles were extensively damaged, probably beyond repair, and the otherdriver has sustained a head injury.

You hurry to the hospital to evaluate yourpatient. In the hospital corridors you encounter Mr. JP’s son. He surprises you with an angry outburst, telling you he had phoned you ninemonths earlier to express concern about his father’sdriving ability. He also mentions a message his sister left with your secretary six months earlierabout Mr. JP’s declining memory, judgement andability to care for himself. He says his family isupset about this accident and asks how you couldhave renewed his father’s driver’s license severalmonths earlier.


in risk occurs when cognition isaffected. However, general practi-tioners should be aware that awide variety of medical conditionscan affect mental abilities impor-tant for safe driving. Notwith-standing that, individual medicalconditions have not been found tobe good predictors of driving safe-ty. For example, Johansson4 com-pared the crash rate of seniors inFinland, where medical examina-tions are required for licenserenewal, with crash rates ofseniors in Sweden, where there areno restrictions in renewing dri-vers’ licenses. The study showedcomparable crash statistics for thetwo countries, indicating the med-ical evaluations were not effectivein reducing crash rates. Despitethese limitations, medical condi-tions continue to be used as keycriteria for determining fitness todrive. It might be more sensible toconsider these conditions, as wellas certain medications, as red flagsto raise medical concern ratherthan as absolute criteria.

Demographic ConsiderationsIn Canada, major injuries to roadusers aged 65 years and overincreased by 21% between 1989and 1994.5 The recent statistics forsenior drivers are more strikingwhen considering that majorinjuries for young road users havedecreased during this same timeperiod. Furthermore, older per-sons are potentially at more riskwhen they are in a crash; they aremore likely than younger peopleto be killed or injured6-8 and, wheninjuries do occur, are four-timesmore likely to be hospitalized.9

Also, recovery time takes longerand is less complete in seniors.

How concerned should familyphysicians be about the risk ofsenior drivers? What is the role offamily physicians in terms of pro-moting patient autonomy andindependence versus the consid-eration for public health and safe-ty? What tools are available tohelp family physicians assesscompetency to drive? Are thereuniform laws across Canada thatobligate physicians to report im-paired drivers?

The number of older driverswill more than double by the year2020. In fact, the number of driversover the age of 70 years is increas-ing faster than any other age group.In addition to there being more

senior drivers than ever before,they are driving more and longerinto old age, where the risk of acci-dent is highest.10 With no change incurrent accident-related fatalityrates, the number of older drivers’fatalities in 2030 could be three tofour times greater than in 1995—arate that would exceed the numberof alcohol-related traffic fatalitiesin 1995.11

Dementia and DrivingIn 1995, the Alzheimer Society ofCanada established a task force onethics which considered the issueof dementia and driving. It wascomposed of experts from themedical, legal, research, ethics,

and caregiving communities. Draftguidelines for “tough issues” weredeveloped and distributed as sur-veys to a broad cross-section ofrelevant persons. These surveys

produced well over 500 responses.The issue drawing the secondhighest number of responses (oneresponse less than the central issueof communicating the diagnosis)concerned driving. Driving wasincluded as a “tough issue”because effective processes toevaluate driving competence sim-ply were not available.

After considering the responses,the final version of Tough Issues:Ethical Guidelines was preparedand made available in 1997 by theAlzheimer Society of Canada.

In discussing the issue of dri-ving, the guidelines emphasizethe need for monitoring apatient’s driving ability and

Table 1

Risk Factors for Elderly DriversHaving At-Fault CrashesRisk factor Relative RiskDiabetes 2.2Vascular 1.8Pulmonary 2.1Psychiatry 2.5Neurology 5.1Cognition 7.6

Adapted from: Diller E et al. NHTSA TechnicalReport HS 809023; Washginton 1998.19

Furthermore, older persons are potentially at morerisk when they are in a crash; they are more likelythan younger people to be killed or injured6-8 and,

when injuries do occur, are four-times more likely tobe hospitalized.9 Also, recovery time takes longer and

is less complete in seniors.


state that “when driving is rec-ognized as dangerous, autono-mous automobile access mustbe removed immediately.” Italso is noted that a diagnosis ofAlzheimer’s disease (or anyother dementia) does not auto-matically mean the individual isincompetent to drive.

Although the guidelines high-light the importance of monitoringand evaluating driving compe-tence, the lack of appropriate eval-uation tools has been widelyacknowledged. This shortcomingleaves physicians and others in avery difficult position.

The Status QuoThe responsibility for patientmonitoring and reporting by phy-sicians is legislated in someprovinces;12 in other provinces,medical examinations for drivingmust be completed by physiciansbased on patient age or some other

requirement. There is, however, noconsensus on a tool to use in eval-uating driving competence in thecase of dementia or other causesof cognitive impairment. The mostcommonly recommended tool isthe Folstein Mini-Mental StatusExamination (MMSE).13 This isdisconcerting, given the evidencefrom retrospective studies show-ing that the MMSE is of very lim-ited usefulness for this goal as it is

a poor predictor of crashes.14-17

When MMSE scores have beencompared to road-test perfor-mance, the correlations have typi-cally been in the 0.5 to 0.6 range.In this range, the MMSE is ac-counting for less than 40% of thevariance and is, therefore, clearlyinsufficient for making decisionsabout individual patients.

Physicians commonly assumethat sending patients with cogni-tive impairment and dementia forconventional licensing road tests issufficient to determine fitness todrive. Unfortunately, these roadtests have not been effective inrevealing the driving problems ofthose with cognitive impairment.Undoubtedly, this is because theroad tests focus on assessing basicskills which, for the experienceddriver, already are highly learned.Overlearned skills tend to be pre-served when mental competencedeclines. Specialized driving eval-

uations have been developed insome urban areas but, sadly, thefocus has been on evaluating phys-ical disabilities and ameliorativevehicle modifications rather thanthe cognitively impaired individ-ual’s competence to drive.

Effective Driver EvaluationsMore than 10 years ago, Dr. AllenDobbs and his coworkers believedthe issue of driving competence

was of critical importance. Tog-ether with physicians, neuropsy-chologists and rehabilitation ther-apists in the Northern AlbertaRegional Geriatric Program(NARG), he moved towards thedevelopment of an effective evalu-ation procedure. The algorithmicsteps, implemented over years ofsenior driver tests, included:1. Establishment of a clinical

driving consultation.2. Drawing in partners (e.g.,

NARG, the Canadian Auto-mobile Association [Alberta], theAlberta Solicitor General, Al-berta Health and Wellness,Alberta Transportation and Util-ities, and the City of Edmonton)to develop a collaborative re-search program.

3. The articulation of a two-prongedstand-alone driving evaluationthat included: (i) a competencescreen, and (ii) on-road testing toidentify driving errors that regularly decline with driving competence.

4. Validation of the competencescreen and on-road test with anentirely new sample of seniordrivers.Soon after launching their res-

earch, Dobbs’ group discoveredthat the major impediment to dri-ver evaluation was the lack ofinformation regarding the differ-ent types of driving errors. Theworking premise soon becamethat not all errors could be pre-sumed to indicate declining com-petence to drive. Some drivingerrors, they theorized, might justreflect bad habits of competentdrivers. Therefore, before any in-car driver evaluation could be justified, there first had to beempirical documentation of errors

Physicians commonly assume that sending patientswith cognitive impairment and dementia forconventional licensing road tests is sufficient todetermine fitness to drive. Unfortunately, these roadtests have not been effective in revealing the drivingproblems of those with cognitive impairment.


that do and do not signal decliningcompetence. Hence, comparisonswere developed to study the dri-ving abilities of hundreds of med-ically compromised drivers (vs.normal, healthy drivers). The dri-ving performance of potentiallyunsafe drivers needed to be com-pared with that of controls, sincedementia patients, as a group, areunsafe drivers. Numerous citationsin the medical literature attest tothe increased prevalence of carcrashes in drivers with demen-tia.14,18 Accordingly, comparisonsto identify those errors which dif-ferentiate the two groups would beuseful in developing a road test toevaluate driving competence ofindividuals.

Road tests, however, in additionto being expensive, are dangerouswhen a driver is incompetent andunnecessary if a driver is compe-tent. For these reasons, a secondgoal of the research was toimprove the economy and safety ofthe drivers’ evaluations. Accord-ingly, a competence screen thataccurately predicted road-test per-formance—at least for the morecompetent drivers and the moredangerous drivers—was devel-oped. The strategy was to create acompetence screen identifying twocut-off scores. The high score cri-terion would identify the perfor-mance level needed to accuratelypredict passing performance. Thelow score criterion would identifythe performance level below whichaccurate predictions of a failingperformance would be achieved(road test result). Driving errorswere categorized using a conceptmapping technique. This resultedin 12 categories of specific errors(e.g., positioning on turns, signal-

ing, speed errors) and a category ofhazardous or potentially catastro-phic errors. These latter areas aredefined as areas which require traf-fic to adjust or the examiner to takecontrol to avoid a crash or danger-ous situation. The frequency andseverity of errors within each cate-gory were tallied and then ana-lyzed for each of three groups:1) above the higher cut-off,2) below the lower cut-off, and 3) indeterminate (between the two

cut-offs). Such comparisons resulted in

the identification of three groupsof driving-error categories.

The first group was labeled nondiscriminating errors becausethese errors were made equally bycompetent and incompetent dri-vers. These errors reflect the badhabits of experienced drivers—notcompromised driving skills. Anyevaluation utilizing these errors as

indicators of driving incompetencewould be inappropriate.

The severity scores for the sec-ond group of errors (e.g., positioningon turns, observational errors) reli-ably discriminated between cogni-tively impaired elder drivers andhealthy control groups, and reliablydifferentiated healthy older driversfrom healthy younger drivers. Thesediscriminating errors are defined as“potentially dangerous,” and are sig-nals of declining competence.

The final group (e.g., wrongway on a freeway, stopping at agreen light, going through a redlight) was labeled as criterionerrors. These errors were dis-played only by drivers from thecognitively impaired group.

The identification of the errorcategories, and the discovery of thegroupings of these categories, pro-vided the basis for understandingthe meaning of different types of

Table 2

Targeted Medical History for Driving Assessments

• Prescription medications (narcotics, anticholinergic medications, benzodiazepines, psychotropics, anti-spasmodics, anti-Parkinson medications)

• Nonprescription medications (alcohol, illicit drugs)• Visual problems (cataracts, glaucoma, macular degeneration, diabetic

retinopathy)• Hearing problems• Cardiovascular disease (aortic aneurysm, arrhythmias, sick sinus syndrome,

pacemaker, postural blood pressure changes causing dizziness, myocardialinfarct, unstable angina)

• Cerebrovascular disease (transient ischemic attacks, strokes)• Nervous system diseases (e.g., seizures, central sleep apnea, labyrinthitis or

Meniere’s disease, Parkinson’s disease, dementia, head injury/subdural, multiple sclerosis)

• Respiratory diseases (chronic obstructive pulmonary disease, obstructive sleep apnea)

• Endocrine and metabolic conditions (diabetes, hyperparathyroidism, hypo- andhyperthyroidism, electrolyte disturbances [e.g., sodium])

• Psychiatric conditions (depression, schizophrenia, bipolar disorder, psychosis)• Musculoskeletal diseases (osteoarthritis, osteoporosis, rheumatoid arthritis,

peripheral neuropathy)• Infectious diseases (respiratory, urosepsis, acquired immune deficiency syndrome)• Driving history (infractions, motor vehicle accident)


driver errors. This knowledge en-abled the development of an empir-ically justifiable scoring schemeand provided the criteria for layingout road courses at sites whichreveal the important differentiatingerrors. These findings also provid-ed the empirical basis for specify-ing an unsafe-driver criterion.

What has emerged is a compe-tence screen consisting of a set ofcomputer-presented tests. Succes-sful performance requires memo-ry, judgement, decision-making,attention, motor-speed abilitiesand integration or shifting amongthese domains. The road test isgiven on a specifically designedcourse that requires 40 minutes tocomplete. The vehicle used is anautomatic mid-sized car equippedwith dual brakes. The maneuvershave been designed to reveal the

driving errors of medically com-promised drivers.

To validate the utility of thecompetence screen, two outcomesare required:1. Competence screen scores

above the upper cut-off pointand below the lower cut-offpoint must accurately predictpassing and failing road testperformance, respectively.

2. The number of drivers left in theindeterminant category (be-tween the two cut-off points) arethose who do need a road test,and substantially reduce fromthe total the number of individu-als who did in fact require it.This two-step procedure is now

utilized in a number of differentlocales across the country, four ofwhich are in Alberta. The evalua-tion has been commencerated

under the name Driveable Assess-ment Centres. The procedure isstand-alone in that it does notrequire specially-trained personnelto administer it. The test is exact-ing: many individuals with pre-sumed mild cognitive impairmentfail the evaluation. Therefore, thetest takes pressure off family phy-sicians to come to a decision com-pletely on their own about asenior’s driving competence.

The cost involved, assumed bythe patient or family, has been apoint of contention. Hope persiststhat the provincial governmentwill eventually assume the cost ofthis evaluation.

Most of the statistical datafrom the NARG/University ofAlberta research on driving andthe cognitively impaired/dement-ed was presented at the 1998Canadian Consensus Conferenceon Dementia. Following a livelydiscussion period, the Conferenceissued five recommendations per-taining to this issue:1. While caring for patients with

cognitive impairment, physi-cians should apply a focusedmedical history and examina-tion (see Tables 2 and 3). “Go-ing through the motions” ofevaluating blood pressure withvery cursory physical examina-tions does not suffice. A muchmore targeted approach is rec-ommended if those seniorsincompetent to drive are to beidentified in the future. A spe-cific medical history whichincorporates questions aboutdriving should be a routine partof the evaluation of elderlypatients with suspected demen-tia. The history should includequestions about driving pat-

Table 3

Targeted Physical Examination for Driving Assessments

Parameter Test(s)Vision Visual fields, Snellen acuityHearing Whisper testCardiovascular Normal exam, electrocardiogram (ECG) if needed,

postural blood pressurePulmonary Normal exam, oximetry if needed (test and exercise)Gastrointestinal Standard examMusculoskeletal Range of motion (ROM) cervical spine, strength, tone,

extension and flexion (shoulder, wrist, ankles, hipsand knees)

Balance and gait Get-up-and-go test (subject rises from chair, stands,then walks three meters, turns around and sits down)

Central nervous system Normal exam, cerebellar (finger-nose, heel-shin),lower motor and upper motor findings, proprioception, sensory

Cognitive MMSE, especially the intersecting pentagons—clock face, the praxis (ability to do a planned series of motor action on command), agnosia(ability to identify objects), executive function ability(Trails A and B test), judgement, insight

Psychiatric Normal exam, geriatric depression scale (if appropriate)

Functional decline Assess decline in activities of daily living (ADL) andinstrumental ADL (e.g., shopping, cooking, finances)


terns (e.g., how many kilome-ters driven per week and timeof day when driving is usuallydone). Other specific queriesshould include whether or notthere have been “near misses,”documentation of all accidentsand citations, and whether thepatient becomes lost while dri-ving. Probing for those factorswhich worsen the cognitiveimpairment should also beincluded in the medical assess-ment (see Table 4). Records ofpatient driving status and thecompetence-altering potentialof illnesses and/or treatmentsshould be specifically noted onpatient charts.

2. Physicians must be aware thatdriving difficulties may indi-cate other cognitive and func-tional problems that need to beaddressed. Although it is morecommon for memory concernsand details of impaired judge-ments to alert physicians to theneed for an evaluation of dri-ving competence, the oppositealso holds true. Practitionersmust keep in mind that occa-sional reports of poor drivingor car crashes signal the needfor a thorough cognitiveassessment.

3. Physicians should encouragepatients with dementia andtheir caregivers to plan early foreventual cessation of driving.This should be mentioned tosuch individuals as early aspossible since it is certain totranspire with the passage oftime. Family physicians shouldprovide continuing support forthose who lose their capacity todrive. It is important to discusspossible options for transporta-

tion and mobility, to be awareof the stress and isolation that acaregiver might feel, and to rec-ommend any services that areavailable to seniors in theirlocale.

4. Physicians should notify therespective licensing bodies re-garding competency to drive,even in provinces that do not

have mandatory reporting. 5. Healthcare professionals should

advocate strongly for access toaffordable, valid, performance-based driving assessments.It follows clearly to require a

thorough evaluation of cognitiveimpairment in patients with ques-tionable driving competence.This step often will uncover thepresence of a dementia, neurode-generative disease or other cogni-

tive impairment. Furthermore,seniors are more susceptible tothe development of delirium dueto decreased central nervous sys-tem reserve and reduced home-ostasis caused by the agingprocess. The fact that dementedpatients are more predisposed tothe development of delirium alsohas been well-established. Delir-

ium compromises driving safety.All patients with an unresolveddelirium should be prohibitedfrom driving until the conditionclears completely.

All practicing physicians areaware that “the involved” seniorpatient may not agree with dis-continuing his or her driving,primarily due to a loss of insightinto his or her own deficits. It isextremely important, therefore,

Table 4

Illnesses and Medications Impairing Safe Operation of a Vehicle

• Cardiovascular disease (e.g., cardiac arrhythmia, congestive heart failure, valvularheart disease)

• Cerebrovascular disease (e.g., stroke)• Neurologic (e.g., head injury, Parkinson’s, multiple sclerosis, tumor, narcolepsy,

sleep apnea)• Respiratory diseases (e.g., chronic obstructive pulmonary disease, respiratory

failure)• Metabolic diseases (e.g., hypothyroidism, diabetes)• Renal disease (chronic renal failure)• Dementia (e.g., Alzheimer’s disease, multi-infarct dementia, frontal temporal, Pick’s,

Huntington’s, alcoholic, poisonings)• Psychiatric illnesses (e.g., schizophrenia)• Medications (e.g., particularly those with central nervous system effects)

Physicians should encourage patients with dementiaand their caregivers to plan early for eventual

cessation of driving. This should be mentioned to suchindividuals as early as possible since it is certain to

transpire with the passage of time.


for physicians to deal with theemotional and broad-reachingimplications the loss of drivinghas on the patient and the patient’sfamily. It is imperative that prima-ry care physicians notify licenseauthorities with any concerns re-garding competence to drive, evenin those provinces that have notlegislated mandatory reporting byphysicians. Although the respon-sibility is not a pleasant one, fam-ily physicians should understand

that they are well-placed to moni-tor the driving competence oftheir patients. In the case ofdementia, monitoring is particu-larly important since the diagnosisof dementia by itself is not suffic-ient for drawing conclusionsabout a patient's driving compe-tence. The emergence of an emp-irical basis for driver evaluationsby DriveAble Testing offers hopeof clarifying the muddy waterssurrounding this issue.

ConclusionWhile the issue of driving in thecognitively impaired and/or de-mented patient remains a huge chal-lenge to physicians, it is encourag-ing to note that definite progress onthis front has been made. With thefurther availability of DriveAbleTesting and/or the initiation of sim-ilar, empirically based evaluationsof driving competence, the issueshould become less problematicfurther downstream.

References:1. O’Neill D. The doctor’s dilemma: the aging driver and demen-

tia. Int J Geriatr Psychiatry 1992; 7:297-301. 2. U.S. Department of Transportation: The effects of age on the dri-

ving habits of the elderly. National Transportation Library.Available at: http://www.bts.gov/smart/cat/t-95.html.

3. Tasca L. Self-reported exposure and crash involvement on alarge sample of Ontario drivers aged 79 and over. Paper pre-sented at the 75th Annual meeting of the TransportationResearch Board.

4. Johansson K. Older automobile drivers: Medical aspects.Doctoral Dissertation, Karolinska Institute. Stockholm 1997.

5. Gutoskie P. Trends in highway safety. Transport Canada,Ottawa, 1997.

6. Barr RA. Recent changes in driving among older adults. HumFactors 1991; 33:597-600.

7. McCoy GF, Johnston RA, Duthie RB. Injury to the elderly inroad traffic accidents. Trauma 1989; 29:494-7.

8. Retchin S, Cox J, Fox M, et al. Performance-based measure-ments among elderly drivers and nondrivers. J Amer Geriatr Soc1988; 36:813-9.

9. Baranick JI, Chatterjie BF, Greene-Cradden YC, et al. Motorvehicle trauma in northeastern Ohio: Incidence and outcome byage, sex, and roadway use category. Am J Epidemiol 1986;123:846-61.

10. Stutts JC, Waller PF, Martell C. Older driver population andcrash involvement trends. 1974-86. 33rd Annual Proceedings:Association for the Advancement of Automotive Medicine,

Baltimore. October 2-4, 1989; pp 137-53.11. Burkhardt JE, Berger AM, Creedon MA, et al. Safe mobility for a

maturing society: A strategic plan and national agenda. Paperpresented at the 79th Annual Transportation Research Meeting.Washington, D.C.

12. Coopersmith HG, Korner-Bitensky NA, Mayo NE. Determiningmedical fitness to drive: Physicians’ responsibilities in Canada.CMAJ 1989; 140:375-8.

13. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: A prac-tical method for grading the psychiatric status of patients for theclinician. Psychiatric Research 1975; 12:189-98.

14. Friedland RP, Koss E, Kumar A, et al. Motor vehicle crashes indementia of the Alzheimer’s type. Annals of Neurol 1988;24:782-6.

15. Gilley DW, Wilson RS, Bennett DA, et al. Cessation of drivingand unsafe motor vehicle operation by dementia patients. ArchInt Med 1991; 151:941-6.

16. Lucas-Blaustein MJ, Filipp L, Dungan C, et al. Driving inpatients with dementia. J Amer Geriatr Soc 1988; 36:1087-91.

17. Cooper PJ, Tallman K, Tuokko H, et al. Vehicle crash involve-ment and cognitive deficits in older drivers. Safety Research1993; 24:9-17.

18. Dubinsky RM, Williamson A, Gray CS, et al. Driving inAlzheimer’s disease. JAGS 1992; 40:1112-16.

19. Diller E, Cook L, Leonard JM, et al. Evaluating drivers licensedwith medical conditions in Utah 1992-96. NHTSA TechnicalReport HS 809023; Washington 1998.

Deck Deck Deck Deck Deck

Dr. Cohen is geriatric psychiatrist, SunnybrookHealth Science Centre, Toronto, Ontario.


What Helped Me Come to Terms with My Illness and Lead a Full Life?Many things helped me to make these adjustments. As Italk about these factors, I’d like you to think of how theymay relate to other people with early-stage dementias.

The First Factor Was a Supportive FamilyI am truly blessed to have a wonderful, patient husbandand children. Indeed, these are luxuries; not all familiesare supportive, and not all patients have a family aroundto help them. Some people have no one at all.

My family reassured me constantly and helped me tofocus on what I could do, rather than what I couldn’t do.They encouraged me to try doing things and not worryabout making mistakes. So now I try to challenge my-self in small ways and not to worry that I might dothings wrong.

The Second Factor was Excellent andKnowledgeable DoctorsMy family physician, Dr. Lois MacGibbon, in Dundas,Ontario, took my memory complaints seriously right fromthe beginning. She has now made questions about memo-ry problems part of her routine diagnostic procedure. Thequestions have been developed into a written question-naire that is being used by many local family physicians.

Dr. MacGibbon referred me to a wonderful and com-passionate neurologist, Dr. Sandra Black, who is head ofNeurology at Sunnybrook Hospital in Toronto. Dr. Blackis a renowned researcher and clinician, and keeps at theforefront of research and drug developments. My familyand I knew we were in the best of hands, and that wewould be presented with the most appropriate and well-considered options.

To help my doctors understand the degree of myproblems and the changes and patterns associated withmy disease, I kept a running list of my daily problems,including descriptions of how the impairment was affect-ing my daily life and working life. I use this “notebook”approach with all my doctors and it works very well. Myhusband (or daughter) also accompanies me to myappointments, to be my “extra brain” and advocate.

Again, it is a luxury to have such an excellent medicalsupport system. I live in a large city, where there are exten-sive medical resources and a medical school, surroundedby other cities with medical schools and resources. Manypeople in our country live in small communities wherespecialized medical help is not so readily available.

The Third Factor was Alzheimer MedicationI can’t overemphasize the importance of medication forme. Right after I was diagnosed, Dr. Black entered mein a Phase II trial for the drug propentofylline. My dete-rioration seemed to stop and some of my symptomsimproved. I was functioning better at home. I used tosay, “now I’m faster at giving the wrong answer.” Lateron, Dr. Black added donepezil. This made an incredibledifference in quality of life for me; it reduced much ofmy confusion and improved my focus and concentra-tion. I was sharper mentally and had more mental sta-mina to carry out activities and social conversations. Myword-finding problems improved, as did my day-to-dayfunctioning.

Unfortunately, current medications only help to reduceor control symptoms in some patients. They are not a cure,nor do they halt the inevitable progress of the disease.There have been some exciting and encouraging

Windows Into Alzheimer Disease Marilyn was one of three women in the early stages of Alzheimer Disease who delivered the

keynote address at the Alzheimer Society of Canada’s national conference in April 2001. Part 1 ofher speech appeared in the July 2001 issue of The Canadian Alzheimer Disease Review. In this

issue, we present Part 2 of an edited version of her speech.

News from the Alzheimer Society of Canada

If you are interested in receiving a copy of the guidelines, please call your local Alzheimer Society,look on the Internet at www. alzheimer.caor call 1-800-616-8816.


announcements, however, regarding trials for a vaccineand plaque inhibitors. We pray these treatments will provesuccessful. But the reality is that we’re still waiting for acure. I encourage pharmaceutical researchers to workharder and faster for that cure.

The Fourth Factor was Additional TherapiesAlong with the two drugs I mentioned, my neurologistadvised me to take vitamin E. I also take hormonereplacement therapy and see naturopathic physicians fora comprehensive program of nutritional, botanical andother alternative therapies, exercise that supports brainfunction, and managing drug side-effects. This “combi-nation therapy” approach focuses on total brain, body,and spiritual health. I also do my own little “brain exer-cises,” such as simple word puzzles and games.

The Fifth Factor was the Alzheimer Society and My Early-Stage FriendsAround the time I was diagnosed, I was visiting my motherin Kelowna, British Columbia. I went into the localAlzheimer Society and this is where I met Norma. It waswonderful to meet someone who was going through thesame thing and who could completely understand my anxi-eties and frustrations. We shared our problems, the crazythings we were doing, the tests and doctors, coping strate-gies and, most important, we shared a lot of laughter. WhenI left that meeting, I felt for the first time that I was not aloneon this disease path and that, in fact, I was very normal.

Back at home in Hamilton, I asked the Alzheimer Societyto help start an Early-Stage Support Group. With time, thiswas accomplished. We now have nine members, and we planto extend our meetings to groups in neighbouring towns.

I hope the Alzheimer Society will push for and encour-age the formation of Early-Stage peer support groups inevery community in our country. And I hope that doctorswill recommend the services of the Alzheimer Society totheir patients and encourage them to join these supportgroups.

ConclusionThe incidence of Alzheimer Disease (AD) and other de-mentias is increasing at an ever-steepening rate as ourlarge, older population ages. My plea to everyone is tolobby with us for funding and tax incentives to encourageresearch and drug development. We also need govern-ment health offices and the medical community to beopen to complementary treatments, including drugs andtherapies from abroad. The combined expertise of allhealth professionals needs to be incorporated into effec-tive health treatment programs.

We also need help to lobby for the free and readyavailability of current drugs for patients—in all parts ofCanada—who may benefit.

I try hard to be optimistic and upbeat. Norma and Iregularly share our optimism that a cure will come in timefor us. However, I am, at the core, a realist and a scientist,and the stark reality today is that there is no cure; there isnothing to slow down the progress of this disease.

The Big BoatI tend to think in pictures. Sometimes I think of myself asbeing on a journey in a huge boat. The boat is filled withpeople with AD and other dementias. This is by no meansa luxury cruise ship! There is no first-class service, norentertainment. This boat is more like a leaky old tub,tossing aimlessly about on stormy seas, in danger of sink-ing with all hands on deck.

The only thing that I am certain of—very certain of—is that every day, the “big lottery machine in the sky” willrandomly pick more people to join us on the boat. Sadly,these people will include someone you know, someoneyou love, maybe even yourself. Apparently, there will bemore than 100,000 Canadian passengers joining us thisyear alone. Anyone in denial about the impact of AD onour society needs to think of this image. This is not agood trip. And the boat is getting very crowded. Pleasejoin together and work to help us stop the lottery andreach a safe harbour.

For more information on Alzheimer Disease and related dementias, Alzheimer Society programs and services,and how you can help, contact your local Alzheimer Society, visit the Society’s Web site at www. alzheimer.ca,or call 1-800-616-8816.

Documents

The Canadian Alzheimer - STA Communications · The Canadian Alzheimer Disease Reviewwelcomes letters from its readers. Address all correspondences to Letters, The Canadian Alzheimer