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Background: Digital dementia risk reduction interventions are cost-effective and scalable. However, it is unknown how they are perceived by people already experiencing cognitive concerns or decline., Objective: To understand the current use, interest, and preferences for online learning courses and interest in learning about factors influencing brain health and dementia risk among adults ≥45. To explore potential differences between individuals experiencing cognitive concerns and those without., Methods: Adults aged 45 and older completed a survey on technology use and healthy ageing ( n  = 249, Mean age = 65.6, 76.3% female). The Memory Assessment Clinic-Questionnaire was used to assess subjective memory decline, and 153 participants met the study criteria for cognitive concerns (≥25)., Results: Almost all participants (98.4%) reported using two or more digital devices, and 51.8% reported increasing device usage following COVID-19. Most (92.1%) were interested in learning about healthy living and memory within an online course, and over 80% indicated a high interest in learning about dementia risk factors. People with cognitive concerns were more likely to report using a 'routine or system' to aid memory than people without (82.4% versus 62.9%, p  = 0.001). However, no significant difference was found in technology use, course preferences, or interest in learning about different risk factors., Conclusions: We conclude that adults 45 years and over are interested in online methods for learning about brain health and offer unique insights into adapting dementia prevention programs for cognitive concerns., Competing Interests: KJA declares speaker honorarium from Roche. No other conflicts of interest to report., (© 2024 – The authors. Published by IOS Press.)

Introduction: Recent evidence suggests that the influence of verbal intelligence and education on the onset of subjective cognitive decline may be modulated by gender, where education contributes less to cognitive resilience (CR) in women than in men. This study aimed to examine gender differences in the association between CR and mild cognitive impairment (MCI) incidence in an Australian population-based cohort., Methods: We included 1,806 participants who had completed at least the first two waves and up to four waves of assessments in the Personality and Total Health (PATH) Through Life study (baseline: 49% female, male = 62.5, SD = 1.5, age range = 60-66 years). CR proxies included measures of educational attainment, occupation skill, verbal intelligence, and leisure activity. Discrete-time survival analyses were conducted to examine gender differences in the association between CR proxies and MCI risk, adjusting for age and apolipoprotein E4 status., Results: Gender differences were only found in the association between occupation and MCI risk, where lower occupation skill was more strongly associated with higher risk in men than in women (odds ratio [OR] = 1.30, 95% confidence interval [CI] [1.07, 1.57]). In both genders, after adjusting for education and occupation, one SD increase in leisure activity was associated with lower MCI risk by 32% (OR = 0.76, 95% CI [0.65, 0.89]). Higher scores in verbal intelligence assessment were associated with reduced risk of MCI by 28% (OR = 0.78, 95% CI [0.69, 0.89])., Conclusion: Occupational experience may contribute to CR differently between genders. Life course cognitive engagement and verbal intelligence may be more protective against MCI than education and occupation for both men and women., (© 2024 S. Karger AG, Basel.)

Introduction: Digital health interventions are cost-effective and easily accessible, but there is currently a lack of effective online options for dementia prevention especially for people at risk due to mild cognitive impairment (MCI) or subjective cognitive decline (SCD)., Methods and Analysis: MyCOACH (COnnected Advice for Cognitive Health) is a tailored online dementia risk reduction programme for adults aged ≥65 living with MCI or SCD. The MyCOACH trial aims to evaluate the programme's effectiveness in reducing dementia risk compared with an active control over a 64-week period (N=326). Eligible participants are randomly allocated to one of two intervention arms for 12 weeks: (1) the MyCOACH intervention programme or (2) email bulletins with general healthy ageing information (active control). The MyCOACH intervention programme provides participants with information about memory impairments and dementia, memory strategies and different lifestyle factors associated with brain ageing as well as practical support including goal setting, motivational interviewing, brain training, dietary and exercise consultations, and a 26-week post-intervention booster session. Follow-up assessments are conducted for all participants at 13, 39 and 65 weeks from baseline, with the primary outcome being exposure to dementia risk factors measured using the Australian National University-Alzheimer's Disease Risk Index. Secondary measures include cognitive function, quality of life, functional impairment, motivation to change behaviour, self-efficacy, morale and dementia literacy., Ethics and Dissemination: Ethical approval was obtained from the University of New South Wales Human Research Ethics Committee (HC210012, 19 February 2021). The results of the study will be disseminated in peer-reviewed journals and research conferences., Trial Registration Number: ACTRN12621000977875., Competing Interests: Competing interests: KJA reports speaking honoraria from Nutricia and Roche. DP and JGA were paid research staff on the MyCOACH trial. There are no other conflicts of interest in this work., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

There is a clear need to identify older drivers at increased crash risk, without additional burden on the individual or licensing system. Brief off-road screening tools have been used to identify unsafe drivers and drivers at risk of losing their license. The aim of the current study was to evaluate and compare driver screening tools in predicting prospective self-reported crashes and incidents over 24 months in drivers aged 60 years and older. 525 drivers aged 63-96 years participated in the prospective Driving Aging Safety and Health (DASH) study, completing an on-road driving assessment and seven off-road screening tools (Multi-D battery, Useful Field of View, 14-Item Road Law, Drive Safe, Drive Safe Intersection, Maze Test, Hazard Perception Test (HPT)), along with monthly self-report diaries on crashes and incidents over a 24-month period. Over the 24 months, 22% of older drivers reported at least one crash, while 42% reported at least one significant incident (e.g., near miss). As expected, passing the on-road driving assessment was associated with a 55% [IRR 0.45, 95% CI 0.29-0.71] reduction in self-reported crashes adjusting for exposure (crash rate), but was not associated with reduced rate of a significant incident. For the off-road screening tools, poorer performance on the Multi-D test battery was associated with a 22% [IRR 1.22, 95% CI 1.08-1.37] increase in crash rate over 24 months. Meanwhile, all other off-road screening tools were not predictive of rates of crashes or incidents reported prospectively. The finding that only the Multi-D battery was predictive of increased crash rate, highlights the importance of accounting for age-related changes in vision, sensorimotor skills and cognition, as well as driving exposure, in older drivers when using off-road screening tools to assess future crash risk., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Importance: While the Australian National University-Alzheimer Disease Risk Index (ANU-ADRI), Cardiovascular Risk Factors, Aging, and Dementia (CAIDE), and Lifestyle for Brain Health (LIBRA) dementia risk tools have been widely used, a large body of new evidence has emerged since their publication. Recently, Cognitive Health and Dementia Risk Index (CogDrisk) and CogDrisk for Alzheimer disease (CogDrisk-AD) risk tools have been developed for the assessment of dementia and AD risk, respectively, using contemporary evidence; comparison of the relative performance of these risk tools is limited., Objective: To evaluate the performance of CogDrisk, ANU-ADRI, CAIDE, LIBRA, and modified LIBRA (LIBRA with age and sex estimates from ANU-ADRI) in estimating dementia and AD risks (with CogDrisk-AD and ANU-ADRI)., Design, Setting, and Participants: This population-based cohort study obtained data from the Rush Memory and Aging Project (MAP), the Cardiovascular Health Study Cognition Study (CHS-CS), and the Health and Retirement Study-Aging, Demographics and Memory Study (HRS-ADAMS). Participants who were free of dementia at baseline were included. The factors were component variables in the risk tools that included self-reported baseline demographics, medical risk factors, and lifestyle habits. The study was conducted between November 2021 and March 2023, and statistical analysis was performed from January to June 2023., Main Outcomes and Measures: Risk scores were calculated based on available factors in each of these cohorts. Area under the receiver operating characteristic curve (AUC) was calculated to measure the performance of each risk score. Multiple imputation was used to assess whether missing data may have affected estimates for dementia risk., Results: Among the 6107 participants in 3 validation cohorts included for this study, 2184 participants without dementia at baseline were available from MAP (mean [SD] age, 80.0 [7.6] years; 1606 [73.5%] female), 548 participants without dementia at baseline were available from HRS-ADAMS (mean [SD] age, 79.5 [6.3] years; 288 [52.5%] female), and 3375 participants without dementia at baseline were available from CHS-CS (mean [SD] age, 74.8 [4.9] years; 1994 [59.1%] female). In all 3 cohorts, a similar AUC for dementia was obtained using CogDrisk, ANU-ADRI, and modified LIBRA (MAP cohort: CogDrisk AUC, 0.65 [95% CI, 0.61-0.69]; ANU-ADRI AUC, 0.65 [95% CI, 0.61-0.69]; modified LIBRA AUC, 0.65 [95% CI, 0.61-0.69]; HRS-ADAMS cohort: CogDrisk AUC, 0.75 [95% CI, 0.71-0.79]; ANU-ADRI AUC, 0.74 [95% CI, 0.70-0.78]; modified LIBRA AUC, 0.75 [95% CI, 0.71-0.79]; CHS-CS cohort: CogDrisk AUC, 0.70 [95% CI, 0.67-0.72]; ANU-ADRI AUC, 0.69 [95% CI, 0.66-0.72]; modified LIBRA AUC, 0.70 [95% CI, 0.68-0.73]). The CAIDE and LIBRA also provided similar but lower AUCs than the 3 aforementioned tools (eg, MAP cohort: CAIDE AUC, 0.50 [95% CI, 0.46-0.54]; LIBRA AUC, 0.53 [95% CI, 0.48-0.57]). The performance of CogDrisk-AD and ANU-ADRI in estimating AD risks was also similar., Conclusions and Relevance: CogDrisk and CogDrisk-AD performed similarly to ANU-ADRI in estimating dementia and AD risks. These results suggest that CogDrisk and CogDrisk-AD, with a greater range of modifiable risk factors compared with other risk tools in this study, may be more informative for risk reduction.

Background: Traditional longitudinal aging research involves studying the same individuals over a long period, with measurement intervals typically several years apart. App-based studies have the potential to provide new insights into life-course aging by improving the accessibility, temporal specificity, and real-world integration of data collection. We developed a new research app for iOS named Labs Without Walls to facilitate the study of life-course aging. Combined with data collected using paired smartwatches, the app collects complex data including data from one-time surveys, daily diary surveys, repeated game-like cognitive and sensory tasks, and passive health and environmental data., Objective: The aim of this protocol is to describe the research design and methods of the Labs Without Walls study conducted between 2021 and 2023 in Australia., Methods: Overall, 240 Australian adults will be recruited, stratified by age group (18-25, 26-35, 36-45, 46-55, 56-65, 66-75, and 76-85 years) and sex at birth (male and female). Recruitment procedures include emails to university and community networks, as well as paid and unpaid social media advertisements. Participants will be invited to complete the study onboarding either in person or remotely. Participants who select face-to-face onboarding (n=approximately 40) will be invited to complete traditional in-person cognitive and sensory assessments to be cross-validated against their app-based counterparts. Participants will be sent an Apple Watch and headphones for use during the study period. Participants will provide informed consent within the app and then begin an 8-week study protocol, which includes scheduled surveys, cognitive and sensory tasks, and passive data collection using the app and a paired watch. At the conclusion of the study period, participants will be invited to rate the acceptability and usability of the study app and watch. We hypothesize that participants will be able to successfully provide e-consent, input survey data through the Labs Without Walls app, and have passive data collected over 8 weeks; participants will rate the app and watch as user-friendly and acceptable; the app will allow for the study of daily variability in self-perceptions of age and gender; and data will allow for the cross-validation of app- and laboratory-based cognitive and sensory tasks., Results: Recruitment began in May 2021, and data collection was completed in February 2023. The publication of preliminary results is anticipated in 2023., Conclusions: This study will provide evidence regarding the acceptability and usability of the research app and paired watch for studying life-course aging processes on multiple timescales. The feedback obtained will be used to improve future iterations of the app, explore preliminary evidence for intraindividual variability in self-perceptions of aging and gender expression across the life span, and explore the associations between performance on app-based cognitive and sensory tests and that on similar traditional cognitive and sensory tests., International Registered Report Identifier (irrid): DERR1-10.2196/47053., (©Brooke Brady, Shally Zhou, Daniel Ashworth, Lidan Zheng, Ranmalee Eramudugolla, Md Hamidul Huque, Kaarin Jane Anstey. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 06.07.2023.)

Objective: Previous research has indicated that cognition and executive function are associated with decision-making, however the impact of mild cognitive impairment (MCI) on decision-making under explicit risk conditions is unclear. This cross-sectional study examined the impact of MCI, and MCI subtypes, on decision-making on the Game of Dice Task (GDT), among a cohort of older adults., Method: Data from 245 older adult participants (aged 72-78 years) from the fourth assessment of the Personality and Total Health Through Life study were analyzed. A diagnostic algorithm identified 103 participants with MCI, with subtypes of single-domain amnestic MCI (aMCI-single; n = 38), multi-domain amnestic MCI (aMCI-multi; n = 31), and non-amnestic MCI ( n = 33), who were compared with an age-, sex-, education-, and income-matched sample of 142 cognitively unimpaired older adults. Decision-making scores on the GDT (net score, single number choices, and strategy changes) were compared between groups using nonparametric tests., Results: Participants with MCI showed impaired performance on the GDT, with higher frequencies of single number choices and strategy changes. Analyses comparing MCI subtypes indicated that the aMCI-multi subtype showed increased frequency of single number choices compared to cognitively unimpaired participants. Across the sample of participants, decision-making scores were associated with measures of executive function (cognitive flexibility and set shifting)., Conclusion: MCI is associated with impaired decision-making performance under explicit risk conditions. Participants with impairments in multiple domains of cognition showed the clearest impairments. The GDT may have utility in discriminating between MCI subtypes.

Although APOE ɛ4 has been identified as the strongest genetic risk factor for Alzheimer's Disease, there are some APOE ɛ4 carriers who do not go on to develop Alzheimer's disease or cognitive impairment. This study aims to investigate factors contributing to this "resilience" separately by gender. Data were drawn from APOE ɛ4 positive participants who were aged 60 + at baseline in the Personality and Total Health Through Life (PATH) Study (N = 341, Women = 46.3%). Participants were categorised into "resilient" and "non-resilient" groups using Latent Class Analysis based on their cognitive impairment status and cognitive trajectory across 12 years. Logistic regression was used to identify the risk and protective factors that contributed to resilience stratified by gender. For APOE ɛ4 carriers who have not had a stroke, predictors of resilience were increased frequency of mild physical activity and being employed at baseline for men, and increased number of mental activities engaged in at baseline for women. The results provide insights into a novel way of classifying resilience among APOE ɛ4 carriers and risk and protective factors contributing to resilience separately for men and women., (© 2023. The Author(s).)

Background: Despite rising interest in sex differences in dementia, it is unclear whether sex differences in dementia incidence and prevalence are apparent globally., Objective: We examine sex differences in incidence and prevalence of Any dementia, Alzheimer's disease (AD), and vascular dementia (VaD), and evaluate whether country-level indicators of gender inequality account for differences., Methods: Systematic review with meta-analysis was used to obtain estimates of incidence and prevalence of Any dementia, AD, and VaD using random effects meta-analysis, and population-based studies with clinical or validated dementia measures. Meta-regression was used to evaluate how country-specific factors of life expectancy, education, and gender differences in development, unemployment, and inequality indices influenced estimates., Results: We identified 205 eligible studies from 8,731 articles, representing 998,187 participants across 43 countries. There were no sex differences in the incidence of Any dementia, AD, or VaD, except in the 90+ age group (women higher). When examined by 5-year age bands, the only sex difference in prevalence of Any dementia was in the 85+ group and there was no sex difference in VaD. AD was more prevalent in women at most ages. Globally, the overall prevalence of dementia in adults 65 + was higher for women (80.22/1000, 95% CI 62.83-97.61) than men (54.86/1000, 95% CI 43.55-66.17). Meta-regression revealed that sex differences in Any dementia prevalence were associated with gender differences in life expectancy and in education., Conclusion: Globally, there are no sex differences in age-specific dementia incidence, but prevalence of AD is higher in women. Country-level factors like life expectancy and gender differences in education may explain variability in sex differences.

Objective: Social cognition is impaired in mild cognitive impairment (MCI) and dementia. However, its relationship to social functioning and perceived social support has yet to be explored. Here, we examine how theory of mind (ToM) relates to social functioning in MCI and dementia., Methods: Older adults (cognitively normal = 1272; MCI = 132; dementia = 23) from the PATH Through Life project, a longitudinal, population-based study, were assessed on the Reading the Mind in the Eyes Test (RMET), measures of social functioning, and social well-being. The associations between RMET performance, social functioning, and cognitive status were analysed using generalised linear models, adjusting for demographic variables., Results: Participants with MCI ( b =-.52, 95% CI [-.70, -.33]) and dementia ( b =-.78, 95% CI [-1.22, -.34]) showed poorer RMET performance than cognitively normal participants. Participants with MCI and dementia reported reduced social network size ( b =-.21, 95% CI [-.40, -.02] and b =-.90, 95% CI [-1.38, -.42], respectively) and participants with dementia reported increased loneliness ( b = .36, 95% CI [.06, .67]). In dementia, poorer RMET performance was associated with increased loneliness ( b =-.07, 95% CI [-.14, -.00]) and a trend for negative interactions with partners ( b =-.37, 95% CI [-.74, .00]), but no significant associations were found in MCI., Conclusions: MCI and dementia were associated with poor self-reported social function. ToM deficits were related to poor social function in dementia but not MCI. Findings highlight the importance of interventions to address social cognitive deficits in persons with dementia and education of support networks to facilitate positive interactions and social well-being.

Introduction: We aimed to develop a comprehensive risk assessment tool for Alzheimer's disease (AD), vascular dementia (VaD), and any dementia, that will be applicable in high and low resource settings., Method: Risk factors which can easily be assessed in most settings, and their effect sizes, were identified from an umbrella review, or estimated using meta-analysis where new data were available., Results: Seventeen risk/protective factors met criteria for the algorithm to estimate risk for any dementia including age, sex, education, hypertension, midlife obesity, midlife high cholesterol, diabetes, insufficient physical activity, depression, traumatic brain injury, atrial fibrillation, smoking, social engagement, cognitive engagement, fish consumption (diet), stroke, and insomnia. A version for AD excluded atrial fibrillation and insomnia due to insufficient evidence and included pesticide exposure. There was insufficient evidence for a VaD risk score., Discussion: Validation of the tool on external datasets is planned. The assessment tool will assist with implementing risk reduction guidelines., Competing Interests: K.J.A. received a speaker honorarium from Nutricia in 2021. There are no other conflicts of interest., (© 2022 The Authors. Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring published by Wiley Periodicals, LLC on behalf of Alzheimer's Association.)

Background: There is an increasing awareness of the need to understand the interaction between long-term blood pressure patterns and their impact on the brain and cognition., Methods: Our aim was to investigate the relationship between repeated blood pressure measures and change in cognitive performance over 12 years and imaging data at 12 years using a longitudinal population study. The data consisted of 2 cohorts, one midlife and one later life. Using linear regression, we examined the relationship between blood pressure (systolic, diastolic, change in blood pressure between visits, and visit-to-visit variability), change in cognitive performance and imaging at 12 years., Results: Data on cognitive change were available in 1054 at midlife, baseline age 42.7 (SD 1.5) and 1233 in later life, 62.5 (1.5) years. Imaging data were available in 168 and 233, respectively. After adjustment for multiple comparisons greater diastolic blood pressure variability in later life was associated with a -1.95 point decline (95% CI, -2.89 to -1.01) on an attention-based task and a -0.42 point (95% CI, -0.68 to -0.15) decline in performance on a psychomotor task. A higher SD in diastolic pressure across follow-up was associated with greater white matter hyperintensity volume (%increase per 10 mm Hg increase in the SD [1.50 (95% CI, 1.16-1.94])., Conclusions: In a largely normotensive/mildly hypertensive population, our analyses reported no relationships between blood pressure and cognition in midlife but a potential role for diastolic blood pressure variability in later life as a risk marker for cognitive decline. This may indicate an at-risk period or a means to identify an at-risk population at the age where diastolic pressure is starting to decline.

Background/objectives: To examine the validity of high-contrast visual acuity and the Mini-Mental State Exam (MMSE) as tools for identifying at-risk older drivers., Design: Prospective multi-site observational cohort study., Setting: Community sample drawn from cities of Brisbane and Canberra, Australia., Participants: 560 licensed drivers aged 65-96 years recruited between 2013 and 2016, from the community, an optometry clinic and driver referral service., Measurements: 50-minute standardized on-road driving test conducted on a standard urban route in a dual-brake vehicle with a driver trained Occupational Therapist assessor masked to participants' cognitive, visual and medical status., Results: Of 560 participants who completed the on-road test, 68 (12%) were classified as unsafe. Binary logistic regression models adjusted for age, gender, site, comorbidity and driving exposure indicated that a 1-point decrease in MMSE score was associated with a 1.35 (95%CI: 1.12-1.63) increase in odds of unsafe driving, and for each line reduction in binocular visual acuity (increase of 0.1 logMAR) was associated with 1.39 (95%CI: 1.07-1.81) increased odds of unsafe driving. However, Receiver Operating Characteristic (ROC) analysis showed low discriminative power for both measures (MMSE: AUC = 0.65 (95%CI: 0.58-0.73), visual acuity: AUC = 0.65 (95%CI: 0.59-0.72)) and typical cut-offs were associated with very low sensitivity for identifying unsafe drivers (MMSE <24/30: 2%; visual acuity worse than 6/12 Snellen (logMAR >0.30): 3%)., Conclusion: The MMSE and high-contrast visual acuity tests do not reliably identify at-risk older drivers. They have extremely low sensitivity for detecting unsafe drivers, even when used together, and poor prognostic properties relative to validated screening instruments that measure cognitive, vision and sensorimotor functions relevant to driving. Clinicians should select alternate validated driver screening tools where possible., (Copyright © 2022. Published by Elsevier Ltd.)

The literature on subjective memory concerns (SMC) as a predictor for future cognitive decline is varied. Furthermore, recent research has pointed to additional complexity arising from variability in the experience of SMC themselves (i.e. whether they are remitting or sustained over time). We investigated the associations between SMC and objectively measured cognition in an Australian population-based cohort. Four waves (4-year intervals between waves) of data from 1236 participants (aged 62.4 ± 1.5 years, 53% male) were used. We categorized participants as experiencing SMC, when they indicated that their memory problems might interfere with their day-to-day life and/or they had seen a doctor about their memory. SMC was categorized as "no" reported SMC, "remitting", "new-onset" or "sustained" SMC. Cognitive assessment of immediate and delayed recall, working memory, psychomotor speed, attention and processing speed were assessed using a neuropsychological battery. Eighteen percent of participants were characterised as having SMC: 6% (77) "remitting", 6% (77) "new-onset" and 6% (69) "sustained" SMC. There was no consistent evidence for an association between SMC and subsequent decline in cognition. However, SMC was associated with poorer performance on contemporaneous tasks of attention and processing speed compared to "no" SMC. Asking about SMC may indicate a current decline in cognitive function but, in this sample at least, did not indicate an increased risk of future decline., Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00694-2., Competing Interests: Conflict of interestThe Authors declare that there is no conflict of interest., (© The Author(s) 2022.)

Objective: Despite theoretical models emphasizing the likely importance of adaptive decision-making to maintaining safety on the roads, there has been a lack of research investigating this topic. This exploratory study aimed to determine if decision-making under risk conditions, as measured by the Game of Dice Task (GDT), can explain additional variance in on-road driving safety beyond other well-validated predictors. Method: Two hundred and thirty-nine cognitively normal Australian drivers aged 65-96 completed demographic and health questionnaires, vision testing, a neurocognitive test battery assessing cognitive flexibility, cognitive interference, episodic memory, verbal working memory, verbal fluency, and visuospatial function, the GDT-a lab-based assessment of decision-making under risk conditions, validated off-road driver screening measures and an on-road driving assessment along a standard route in urban traffic conditions administered by a trained Occupational Therapist (OT). Results: The number of risky choices made, but not the number of strategy changes, across trials of the GDT independently predicted on-road safety ratings after controlling for visual acuity, cognitive test performance, and off-road driver screening measures, B = -.146, 95% CI [-.276 to -.016]. Conclusion: Overall, this study offers the first evidence that decision-making is related to older adults' on-road driving safety, and makes recommendations for future research exploring the contribution of decision-making to on-road safety. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Understanding gender differences in human cognitive development may contribute to understanding the gender differences in outcomes in cognitive ageing. However, evaluation of this topic has been hindered by a lack of representative, longitudinal data from different aged cohorts measured on the same cognitive tests. Gender differences in cognitive abilities were evaluated in three population-based cohorts (baseline age-span 20 to 76, 52% female, 94% Caucasian, 5% Asian and 1% other ethnic background, baseline N = 7,485), initially drawn from the electoral role in Australia where voting is compulsory, that were assessed four times over 12 years on measures of verbal memory, processing speed, working memory, verbal ability, and reaction time. Linear mixed models showed that within each cohort, women had better verbal memory and men had better working memory and faster reaction times. Verbal ability and processing speed showed variable gender differences in the young and middle-aged cohorts but no difference in the oldest cohort. In young and middle age, there were no gender differences in rates of change in verbal memory, processing speed, reaction time, verbal ability, or working memory. In old age, the gender differences were only observed in rates of change in verbal memory. Women showed more verbal memory decline between the 8-year and 12-year follow-ups than men, despite retaining higher average memory performance than men. We conclude that from ages 20-76, gender differences in cognitive abilities are stable except for faster memory ageing among women in the eighth decade. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Sex differences in late-life memory decline may be explained by sex differences in dementia risk factors. Episodic memory and dementia risk factors were assessed in young, middle-aged and older adults over 12 years in a population-based sample (N = 7485). For men in midlife and old age, physical, cognitive and social activities were associated with less memory decline, and financial hardship was associated with more. APOE e4 and vascular risk factors were associated with memory decline for women in midlife. Depression, cognitive and physical activity were associated with memory change in older women. Incident midlife hypertension (β = - 0.48, 95% CI - 0.87, - 0.09, p = 0.02) was associated with greater memory decline in women and incident late-life stroke accounted for greater memory decline in men (β = - 0.56, 95% CI - 1.12, - 0.01), p = 0.05). Women have fewer modifiable risk factors than men. Stroke and hypertension explained sex differences in memory decline for men and women respectively.

Introduction : Previous research has suggested that individual differences in executive functions, memory and reinforcement sensitivity are associated with performance on behavioral decision-making tasks. Decision-making performance may also decline with age, however there is a lack of research on the interplay of cognitive and affective processes, and their impact on older adult decision-making. This study examined associations between executive functions, memory and reinforcement sensitivity on the Game of Dice Task (a measure of decision-making under explicit risk) among older adults. Method : One thousand and two older adults without cognitive impairment (aged 72-78 years) participated as part of an Australian longitudinal cohort study (the Personality and Total Health Through Life study). Decision-making sub-types were identified through cluster analysis and multinomial logistic regression was used to assess associations with measures of cognition and reinforcement sensitivity. Results : Cluster analysis identified three decision-making sub-types, which we label "advantageous," "disadvantageous" and "switching." Multivariate analyses found that relative to the mid-performing "switching" sub-type, advantageous decision-makers were more likely to be younger, male and have higher scores on a test of verbal learning. Disadvantageous decision-makers were more likely to have poorer scores on some components of executive function (set shifting, but not working memory or inhibitory control), although this effect was partly attenuated by a measure of reinforcement sensitivity (reward responsiveness). Conclusion : These results indicate that specific components of learning and executive functions are influential in decision-making under explicit risk among a sample of older adults.

Objectives: Dementia increases the risk of unsafe driving, but this is less apparent in preclinical stages such as mild cognitive impairment (MCI). There is, however, limited detailed data on the patterns of driving errors associated with MCI. Here, we examined whether drivers with MCI exhibited different on-road error profiles compared with cognitively normal (CN) older drivers., Design: Observational., Setting and Participants: A total of 296 licensed older drivers [mean age 75.5 (SD = 6.2) years, 120 (40.5%) women] recruited from the community., Method: Participants completed a health and driving history survey, a neuropsychological test battery, and an on-road driving assessment including driver-instructed and self-navigation components. Driving assessors were blind to participant cognitive status. Participants were categorized as safe or unsafe based on a validated on-road safety scale, and as having MCI based on International Working Group diagnostic criteria. Proportion of errors incurred as a function of error type and traffic context were compared across safe and unsafe MCI and CN drivers., Results: Compared with safe CN drivers (n = 225), safe MCI drivers (n = 45) showed a similar pattern of errors in different traffic contexts. Compared with safe CN drivers, unsafe CN drivers (n = 17) were more likely to make errors in observation, speed control, lane position, and approach, and at stop/give-way signs, lane changes, and curved driving. Unsafe MCI drivers (n = 9) had additional difficulties at intersections, roundabouts, parking, straight driving, and under self-navigation conditions. A higher proportion of unsafe MCI drivers had multidomain subtype [n = 6 (67%)] than safe MCI drivers [n = 11 (25%)], odds ratio 6.2 (95% confidence interval, 1.4-29.6)., Conclusion and Implications: Among safe drivers, MCI and CN drivers exhibit similar on-road error profiles, suggesting driver restrictions based on MCI status alone are unwarranted. However, formal evaluation is recommended in such cases, as there is evidence drivers with multiple domains of cognitive impairment may require additional interventions to support safe driving., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: There is an urgent need to develop evidence-based assessments to identify older individuals who may be unsafe drivers., Objective: To validate 8 off-road brief screening tests to predict on-road driving ability and to identify which combination of these provides the best prediction of older adults who will not pass an on-road driving test., Design, Setting, and Participants: This prognostic study was conducted between October 31, 2013, and May 10, 2017, using the criterion standard for screening tests, an on-road driving test, with analysis conducted from August 1, 2019, to April 2, 2020. A volunteer sample of older drivers was recruited from community advertisements, rehabilitation and driver assessment clinics, and an optometry clinic in Canberra and Brisbane, Australia., Exposures: Off-road driver screening measures, including the Useful Field of View, DriveSafe/DriveAware, Multi-D battery, Trails B, Maze test, Hazard Perception Test, DriveSafe Intersection test, and 14-item Road Law test., Main Outcomes and Measures: Classification as unsafe on a standardized 50-minute on-road driving assessment administered by a driving instructor and an occupational therapist masked to the participant's clinical diagnosis and off-road test performance., Results: A total of 560 drivers aged 63 to 94 years (mean [SD] age, 74.7 [6.2] years]; 350 [62.5%] men) were assessed. Logistic regression and receiver operating characteristic analyses indicated the area under the curve was largest for a multivariate model comprising the Multi-D, Useful Field of View, and Hazard Perception Test, with an area under the curve of 0.89 (95% CI, 0.85-0.94), sensitivity of 80.4%, and specificity of 84.1% for predicting unsafe drivers. The Multi-D battery was the most accurate individual assessment and had an area under the curve of 0.85 (95% CI, 0.79-0.90), sensitivity of 77.1%, and specificity of 82.1%. The multivariate model had sensitivity of 83.3% and specificity of 91.8% in the cognitively impaired group and sensitivity of 87.5% and specificity of 70.8% in the visually impaired group., Conclusions and Relevance: These findings suggest that off-road screening tests can reliably identify older drivers with a strong probability of failing an on-road driving test. Implementation of these measures could enable better targeting of resources for managing older driver licensing and support injury prevention strategies in this group.

Introduction: Associations between the Mediterranean-DASH diet Intervention for Neurological Delay (MIND) diet and incidence of cognitive impairment have not been evaluated outside the United States., Methods: We investigated MIND and Mediterranean diet relations with 12-year incidence of Alzheimer's disease/Vascular dementia (National Institute of Neurological Disorders criteria) and mild cognitive impairment (Winbald criteria) in the Personality and Total Health (PATH) Through Life cohort (n = 1220) set in Canberra, Australia: wave-1 2001-2002; wave-2 2005-2006; wave-3 2009-2010; and wave-4 2013-2014. MIND diet and two alternate Mediterranean diet scores were calculated from the baseline food frequency questionnaire responses. Higher dietary scores signified greater adherence., Results: In adjusted logistic regression models, MIND diet (OR = 0.47, 95% CI 0.24, 0.91), but not Mediterranean diet, was associated with reduced odds of 12-year cognitive impairment., Discussion: Preliminary evidence suggests that protective effects of the MIND diet are geographically generalizable. Additional prospective studies are needed in diverse samples to determine the relative effects of the MIND and the Mediterranean diets against cognitive decline., (Copyright © 2019 the Alzheimer's Association. All rights reserved.)

Purpose: We investigated the association of the Australian National University Alzheimer's Disease Risk Index (ANU-ADRI) and an Alzheimer disease (AD) genetic risk score (GRS) with cognitive performance., Methods: The ANU-ADRI (composed of 12 risk factors for AD) and GRS (composed of 25 AD risk loci) were computed in 1061 community-dwelling older adults. Participants were assessed on 11 cognitive tests and activities of daily living. Structural equation modeling was used to evaluate the association of the ANU-ADRI and GRS with: (1) general cognitive ability (g), (2) dementia-related variance in cognitive performance (δ), and (3) verbal ability (VA), episodic memory (EM), executive function (EF), and processing speed (PS)., Results: A worse ANU-ADRI score was associated with poorer performance in "g" [β (SE)=-0.40 (0.02), P<0.001], δ [-0.40 (0.04), P<0.001], and each cognitive domain [VA=-0.29 (0.04), P<0.001; EM=-0.34 (0.03), P<0.001; EF=-0.38 (0.03), P<0.001; and PS=-0.40 (0.03), P<0.001]. A worse GRS was associated with poorer performance in δ [-0.08 (0.03), P=0.041] and EM [-0.10 (0.03), P=0.035]., Conclusions: The ANU-ADRI was broadly associated with worse cognitive performance, including general ability and dementia severity, validating its further use in early dementia risk assessment.

Background: The translation of evidence on dementia risk factors into clinical advice requires careful evaluation of the methodology and scope of data from which risk estimates are obtained., Objective: To evaluate the quantity, quality, and representativeness of evidence, we conducted a review of reviews of risk factors for Alzheimer's disease (AD), Vascular dementia (VaD), and Any Dementia., Methods: PubMed, Cochrane library, and the Global Index Medicus were searched to identify meta-analyses of observational studies of risk factors for AD, VaD, and Any Dementia. PROSPERO CRD42017053920., Results: Meta-analysis data were available for 34 risk factors for AD, 26 risk factors for Any Dementia and eight for VaD. Quality of evidence varied greatly in terms of the number of contributing studies, whether data on midlife exposure was available, and consistency of measures. The most evidence was available for cardiovascular risk factors. The most geographically representative evidence (five of six global regions) was available for alcohol, physical activity, diabetes, high midlife BMI, antihypertensives, and motor function. Evidence from Australia/Oceana or Africa was limited. With the exception of diabetes, meta-analysis data were unavailable from Latin America/Caribbean. Midlife specific data were only available for cholesterol and arthritis., Conclusion: There is a lack of midlife specific data, limited data on VaD, and a lack of geographical representation for many risk factors for dementia. The quality, quantity, and representativeness of evidence needs to be considered before recommendations are made about the relevance of risk factors in mid- or late-life or for dementia subtypes.

Aim: We evaluated the effectiveness of individually tailored driving lessons compared with a road rules refresher course for improving older driver safety., Methods: Two arm parallel randomised controlled trial, involving current drivers aged 65 and older (Mean age 72.0, 47.4% male) residing in Canberra, Australia. The intervention group (n = 28) received a two-hour class-based road rules refresher course, and two one-hour driving lessons tailored to improve poor driving skills and habits identified in a baseline on-road assessment. The control group (n = 29) received the road rules refresher course only. Tests of cognitive performance, and on-road driving were conducted at baseline and at 12-weeks. Main outcome measure was the Driver safety rating (DSR) on the on-road driving test. The number of Critical Errors made during the on-road was also recorded., Results: 55 drivers completed the trial (intervention group: 27, control group: 28). Both groups showed reduction in dangerous/hazardous driver errors that required instructor intervention. From baseline to follow-up there was a greater reduction in the number of critical errors made by the intervention group relative to the control group (IRR = 0.53, SE = 0.1, p = .008). The intervention group improved on the DSR more than the control group (intervention mean change = 1.07 SD = 2.00, control group mean change = 0.32 SD = 1.61). The intervention group had 64% remediation of unsafe driving, where drivers who achieved a score of 'fail' at baseline, 'passed' at follow-up. The control group had 25% remediation., Conclusion: Tailored driving lessons reduced the critical driving errors made by older adults. Longer term follow-up and larger trials are required., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: Computerized training for cognitive enhancement is of great public interest, however, there is inconsistent evidence for the transfer of training gains to every day activity. Several large trials have focused on speed of processing (SOP) training with some promising findings for long-term effects on daily activity, but no immediate transfer to other cognitive tests. Here, we examine the transfer of SOP training gains to cognitive measures that are known predictors of driving safety in older adults. Methods: Fifty-three adults aged 65-87 years who were current drivers participated in a two group non-randomized design with repeated measures and a no-contact matched control group. The Intervention group completed an average of 7.9 ( SD = 3.0) hours of self-administered online SOP training at home. Control group was matched on age, gender and test-re-test interval. Measures included the Useful Field of View (UFOV) test, a Hazard Perception test, choice reaction time (Cars RT), Trail Making Test B, a Maze test, visual motion threshold, as well as road craft and road knowledge tests. Results: Speed of processing training resulted in significant improvement in processing speed on the UFOV test relative to controls, with an average change of -45.8 ms ( SE = 14.5), and effect size of ω 2 = 0.21. Performance on the Maze test also improved, but significant slowing on the Hazard Perception test was observed after SOP training. Training effects on the UFOV task was associated with similar effects on the Cars RT, but not the Hazard Perception and Maze tests, suggesting transfer to some but not all driving related measures. There were no effects of training on any of the other measures examined. Conclusion: Speed of processing training effects on the UFOV task can be achieved with self-administered, online training at home, with some transfer to other cognitive tests. However, differential effects of training may be observed for tasks requiring goal-directed search strategies rather than diffuse attention.

Aim: To describe population-level characteristics of drivers and non-drivers in a cohort of older Australians and identify predictors of driving cessation and expectations., Methods: The sample comprised the oldest cohort of the PATH Through Life project who were assessed 4 times between 2001 and 2013. At waves 3 and 4 questions on driving were included in the study interview. Data were also collected on health, physical and cognitive function and psychosocial wellbeing. Descriptive analyses compared drivers and non-drivers on sociodemographic, health and functional variables and regression models identified predictors of cessation and driving expectations., Results: 92.5% of the sample were current drivers. They reported better physical, mental and cognitive health than non-drivers. Drivers expected to drive for another 12.6 years, the majority drove 6+ days per week. Four percent of the sample ceased driving over the four year follow-up. Predictors of cessation were financial problems, driving expectations and driving fewer kilometres per week. Predictors of expectations were poorer self-rated health, mastery, difficulties reading maps, self-rated visual function, years of driving experience, and fewer kilometres driven per week., Conclusion: Driving is normative for many older Australians in their 70s. Similar factors are associated with actual cessation and expectation of driving suggesting that older adults do have a sense of their expected driving life., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Grading instruments are an important part of evidence-based medicine and are used to inform health policy and the development of clinical practice guidelines. They are extensively used in the development of clinical guidelines and the assessment of research publications, having particular impact on health care and policy sectors. The positive effects of using grading instruments are, however, potentially undermined by their misuse and a number of shortcomings. This review found eight key concerns about grading instruments: (1) lack of information on validity and reliability, (2) poor concurrent validity, (3) may not account for external validity, (4) may not be inherently logical, (5) susceptibility to subjectivity, (6) complex systems with inadequate instructions, (7) may be biased toward randomized controlled trial (RCT) studies, and (8) may not adequately address the variety of non-RCTs. This narrative review concludes that there is a need to take into account these criticisms and domain-specific limitations, to enable the use and development of the most appropriate grading instruments. Grading systems need to be matched to both the research question being asked and the type of evidence being used.

Background: There is little information on the application and impact of revised criteria for diagnosing dementia and mild cognitive impairment (MCI), now termed major and mild neurocognitive disorders (NCDs) in the DSM-5. We evaluate a psychometric algorithm for diagnosing DSM-5 NCDs in a community-dwelling sample, and characterize the neuropsychological and functional profile of expert-diagnosed DSM-5 NCDs relative to DSM-IV dementia and International Working Group criteria for MCI., Methods: A population-based sample of 1644 adults aged 72-78 years was assessed. Algorithmic diagnostic criteria used detailed neuropsychological data, medical history, longitudinal cognitive performance, and informant interview. Those meeting all criteria for at least one diagnosis had data reviewed by a neurologist (expert diagnosis) who achieved consensus with a psychiatrist for complex cases., Results: The algorithm accurately classified DSM-5 major NCD (area under the curve (AUC) = 0.95, 95% confidence interval (CI) 0.92-0.97), DSM-IV dementia (AUC = 0.91, 95% CI 0.85-0.97), DSM-5 mild NCD (AUC = 0.75, 95% CI 0.70-0.80), and MCI (AUC = 0.76, 95% CI 0.72-0.81) when compared to expert diagnosis. Expert diagnosis of dementia using DSM-5 criteria overlapped with 90% of DSM-IV dementia cases, but resulted in a 127% increase in diagnosis relative to DSM-IV. Additional cases had less severe memory, language impairment, and instrumental activities of daily living (IADL) impairments compared to cases meeting DSM-IV criteria for dementia. DSM-5 mild NCD overlapped with 83% of MCI cases and resulted in a 19% increase in diagnosis. These additional cases had a subtly different neurocognitive profile to MCI cases, including poorer social cognition., Conclusion: DSM-5 NCD criteria can be operationalized in a psychometric algorithm in a population setting. Expert diagnosis using DSM-5 NCD criteria captured most cases with DSM-IV dementia and MCI in our sample, but included many additional cases suggesting that DSM-5 criteria are broader in their categorization.

Background: The number of people living with dementia is expected to exceed 130 million by 2050, which will have serious personal, social and economic implications. Employing successful intervention and treatment strategies focused on disease prevention is currently the only available approach that can have an impact on the projected rates of dementia, with risk assessment being a key component of population-based risk reduction for identification of at-risk individuals. We evaluated a risk index comprising lifestyle, medical and demographic factors (the Australian National University Alzheimer's Disease Risk Index [ANU-ADRI]), as well as a genetic risk score (GRS), for assessment of the risk of progression to mild cognitive impairment (MCI)., Methods: The ANU-ADRI was computed for the baseline assessment of 2078 participants in the Personality and Total Health (PATH) Through Life project. GRSs were constructed on the basis of 25 single-nucleotide polymorphisms previously associated with Alzheimer's disease (AD). Participants were assessed for clinically diagnosed MCI and dementia as well as psychometric test-based MCI (MCI-TB) at 12 years of follow-up. Multi-state models were used to estimate the odds of transitioning from cognitively normal (CN) to MCI, dementia and MCI-TB over 12 years according to baseline ANU-ADRI and GRS., Results: A higher ANU-ADRI score was associated with increased risk of progressing from CN to both MCI and MCI-TB (HR 1.07 [95% CI 1.04-1.11]; 1.07 [1.04-1.09]). The GRS was associated with transitions from CN to dementia (HR 4.19 [95% CI 1.72-10.20), but not to MCI or MCI-TB (HR 1.05 [95% CI 0.86-1.29]; 1.03 [0.87-1.21]). Limitations of our study include that the ethnicity of participants in the PATH project is predominately Caucasian, potentially limiting the generalisability of the results of this study to people of other ethnicities. Biomarkers of AD were not available to define MCI attributable to AD. Not all the predictive variables for the ANU-ADRI were available in the PATH project., Conclusions: In the general population, the ANU-ADRI, comprising lifestyle, medical and demographic factors, is associated with the risk of progression from CN to MCI, whereas a GRS comprising the main AD risk genes was not associated with this risk. The ANU-ADRI may be used for population-level risk assessment and screening.

Background: Neuropsychiatric symptoms (NPS) are common in older adults with cognitive impairment, yet little is known about population-based prevalence and clinical implications of co-morbid symptom presentation across the spectrum from normal cognition to dementia., Objective: To characterize the prevalence of NPS and explore the clinical implications of co-morbid symptom presentation., Methods: Cross-sectional study of 1,417 older adults (aged 73-79) with dementia (n = 40); with mild cognitive impairment (MCI; n = 133); who are 'cognitively normal, but-at-risk' (CN-AR; n = 397); and who are cognitively normal (n = 847). NPS were assessed by the Neuropsychiatric Inventory. Cluster analyses were conducted using a latent class analysis (LCA)., Results: NPS are highly prevalent across the cognitive function spectrum (30.8% -80%). NPS were associated with a 3-fold increased risk of dementia, a 2-fold increased risk of MCI, and a 1.5-times increased risk of CN-AR. Each additional co-morbid symptom was associated with an additional 1.5-times increased risk of dementia, but not MCI or CN-AR. LCA revealed four distinctive sub-populations: 1) frontal/low comorbidity; 2) high prevalence/high comorbidity; 3) affective/low comorbidity; and 4) sleep/low comorbidity., Conclusion: Our findings confirm previous reports on the prevalence of NPS in community-based samples and are consistent with the profiles of NPS domain characteristics of MCI and dementia. Number of co-morbid NPS and not symptom clusters are associated with increased risk of dementia. Understanding such patterns will help inform our understanding of mild behavioral disorders and assist with clinical assessment.

Background: With population aging, drivers with mild cognitive impairment (MCI) are increasing; however, there is little evidence available regarding their safety., Objective: We aimed to evaluate risk of unsafe on-road driving performance among older adults with MCI., Method: The study was a cross-sectional observational study, set in Canberra, Australia. Participants were non-demented, current drivers (n = 302) aged 65 to 96 years (M = 75.7, SD = 6.18, 40% female) recruited through the community and primary and tertiary care clinics. Measures included a standardized on-road driving test (ORT), a battery of screening measures designed to evaluate older driver safety (UFOV®, DriveSafe, Multi-D), a neurocognitive test battery, and questionnaires on driving history and behavior., Results: Using Winblad criteria, 57 participants were classified as having MCI and 245 as cognitively normal (CN). While the MCI group had a significantly lower overall safety rating on the ORT (5.61 versus 6.05, p = 0.03), there was a wide range of driving safety scores in the CN and MCI groups. The MCI group performed worse than the CN group on the off-road screening tests. The best fitting model of predictors of ORT performance across the combined sample included age, the Multi-D, and DriveSafe, classifying 90.4% of the sample correctly., Conclusion: Adults with MCI exhibit a similar range of driving ability to CN adults, although on average they scored lower on off-road and on-road assessments. Driving specific tests were more strongly associated with safety ratings than traditional neuropsychological tests.

Background: The relationship between cannabis use and cognitive function in mid-life has rarely been examined despite verbal learning deficits in young adults., Method: A longitudinal cohort study of 1,897 Australians recruited at 40-46 years of age and followed up 4 years (94%) and 8 years (87%) later. Random effects regression was used to assess within- and between-person associations between cannabis use and cognitive function across waves of data, and examine whether age-related changes in cognitive performance were modified by cannabis use. The first list of the California Verbal Learning Test (immediate and delayed recall), Symbol Digit Modality Test, Digit Backwards, simple and choice reaction time tasks, were administered at each wave. The Spot-the-Word test was used to assess premorbid verbal ability. Self-reported cannabis use in the past year (no use, < weekly use,≥weekly use) was assessed at each wave., Findings: Participants who used cannabis≥weekly had worse immediate recall (b=-0.68, p=0.014) and showed a trend toward worse delayed recall (b=-0.55, p=0.062) compared to non-users after adjusting for correlates of cannabis use and premorbid verbal ability. These effects were due to between-person differences. There were no significant within-person associations between cannabis use and recall, nor was there evidence of greater cognitive decline in cannabis users with age., Conclusions: Mid-life cannabis users had poorer verbal recall than non-users, but this was not related to their current level of cannabis use, and cannabis use was not associated with accelerated cognitive decline., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To design a low-cost simulator-based driving assessment for older adults and to compare its validity with that of an on-road driving assessment and other measures of older driver risk., Design: Cross-sectional observational study., Setting: Canberra, Australia., Participants: Older adult drivers (N = 47; aged 65-88, mean age 75.2)., Measurements: Error rate on a simulated drive with environment and scoring procedure matched to those of an on-road test. Other measures included participant age, simulator sickness severity, neuropsychological measures, and driver screening measures. Outcome variables included occupational therapist (OT)-rated on-road errors, on-road safety rating, and safety category., Results: Participants' error rate on the simulated drive was significantly correlated with their OT-rated driving safety (correlation coefficient (r) = -0.398, P = .006), even after adjustment for age and simulator sickness (P = .009). The simulator error rate was a significant predictor of categorization as unsafe on the road (P = .02, sensitivity 69.2%, specificity 100%), with 13 (27%) drivers assessed as unsafe. Simulator error was also associated with other older driver safety screening measures such as useful field of view (r = 0.341, P = .02), DriveSafe (r = -0.455, P < .01), and visual motion sensitivity (r = 0.368, P = .01) but was not associated with memory (delayed word recall) or global cognition (Mini-Mental State Examination). Drivers made twice as many errors on the simulated assessment as during the on-road assessment (P < .001), with significant differences in the rate and type of errors between the two mediums., Conclusion: A low-cost simulator-based assessment is valid as a screening instrument for identifying at-risk older drivers but not as an alternative to on-road evaluation when accurate data on competence or pattern of impairment is required for licensing decisions and training programs., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Background: A physically active lifestyle has the potential to prevent cognitive decline and dementia, yet the optimal type of physical activity/exercise remains unclear. Dance is of special interest as it complex sensorimotor rhythmic activity with additional cognitive, social, and affective dimensions., Objectives: To determine whether dance benefits executive function more than walking, an activity that is simple and functional., Methods: Two-arm randomized controlled trial among community-dwelling older adults. The intervention group received 1 h of ballroom dancing twice weekly over 8 months (~69 sessions) in local community dance studios. The control group received a combination of a home walking program with a pedometer and optional biweekly group-based walking in local community park to facilitate socialization., Main Outcomes: Executive function tests: processing speed and task shift by the Trail Making Tests, response inhibition by the Stroop Color-Word Test, working memory by the Digit Span Backwards test, immediate and delayed verbal recall by the Rey Auditory Verbal Learning Test, and visuospatial recall by the Brief Visuospatial Memory Test (BVST)., Results: One hundred and fifteen adults (mean 69.5 years, SD 6.4) completed baseline and delayed baseline (3 weeks apart) before being randomized to either dance (n = 60) or walking (n = 55). Of those randomized, 79 (68%) completed the follow-up measurements (32 weeks from baseline). In the dance group only, "non-completers" had significantly lower baseline scores on all executive function tests than those who completed the full program. Intention-to-treat analyses showed no group effect. In a random effects model including participants who completed all measurements, adjusted for baseline score and covariates (age, education, estimated verbal intelligence, and community), a between-group effect in favor of dance was noted only for BVST total learning (Cohen's D Effect size 0.29, p = 0.07) and delayed recall (Cohen's D Effect size = 0.34, p = 0.06)., Conclusion: The superior potential of dance over walking on executive functions of cognitively healthy and active older adults was not supported. Dance improved one of the cognitive domains (spatial memory) important for learning dance. Controlled trials targeting inactive older adults and of a higher dose may produce stronger effects, particularly for novice dancers., Trial Registration: Australian and New Zealand Clinical Trials Register (ACTRN12613000782730).

Objective. To examine the effect of diabetes treatment on change of measures of specific cognitive domains over 4 years. Research Design and Methods. The sample was drawn from a population-based cohort study in Australia (the PATH Through Life Study) and comprised 1814 individuals aged 65-69 years at first measurement, of whom 211 were diagnosed with diabetes. Cognitive function was measured using 10 neuropsychological tests. The effect of type of diabetes treatment (diet, oral hypoglycemic agents, and insulin) on measures of specific cognitive domains was assessed using Generalized Linear Models adjusted for age, sex, education, smoking, physical activity level, BMI, and hypertension. Results. Comparison of cognitive function between diabetes treatment groups showed no significant effect of type of pharmacological treatment on cognitive function compared to diet only group or no diabetes group. Of those on oral hypoglycaemic treatment only, participants who used metformin alone had better cognitive function at baseline for the domains of verbal learning, working memory, and executive function compared to participants on other forms of diabetic treatment. Conclusion. This study did not observe significant effect from type of pharmacological treatment for diabetes on cognitive function except that participants who only used metformin showed significant protective effect from metformin on domain of verbal learning, working memory, and executive function.

Introduction: We investigated the association between glucose tolerance status and trajectories of change in blood glucose, and cognitive function in adults aged 25 to 85., Methods: The sample (n = 4547) was drawn from a national, population-based cohort study in Australia (AusDiab). Fasting plasma glucose (FPG), glycated haemoglobin (HbA1c) and general health were assessed at 0, 5 and 12 years. Covariates included age, education, body mass index, blood pressure and physical activity. At 12 years, participants completed assessments of memory, processing speed and verbal ability., Results: Known diabetes at baseline was associated with slower processing speed at 12 years in both younger (25-59 years) and older (>60 years) age-groups. After 12 years of follow-up, adults aged < 60 with diabetes at baseline had a mean speed score of 49.17 (SE = 1.09) compared with 52.39 (SE = 0.20) in normals. Among younger males without diagnosed diabetes, reduced memory at 12 years was associated with higher HbA1c at 5 years (β = -0.91, SE = 0.26, p < 0.001). No effects were apparent for females or older males. Adjusting for insulin sensitivity (HOMA-%S) and hs-C reactive protein attenuated these associations, but depression and CVD risk did not. Latent class analysis was used to analyse the associations between trajectories of HbA1C and glucose over 12 years, and cognition. Identified classes were described as 1) normal and stable blood glucose over time (reference), 2) high intercept but stable blood glucose over time, and 3) increasing blood glucose over time. In both young males and females, high stable glucose measures were associated with poorer cognitive function after 12 years., Conclusion: Those with type 2 diabetes, younger males with high non-diabetic HbA1c, and adults with high stable blood glucose are at increased risk of poorer cognition. The findings reinforce the need for management of diabetes risk factors in midlife.

Atypical asymmetries of spatial attention have been reported in children with attention deficit hyperactivity disorder (ADHD) and may be exacerbated by non-spatial factors such as attentional capacity. Although preliminary evidence suggests that asymmetries of attention in ADHD may be modifiable by the psychostimulant, methylphenidate, further placebo-controlled studies are required. This study first aimed to confirm recent evidence that increasing non-spatial processing load at fixation can unmask a spatial gradient of target detection in children with ADHD but not Controls. Second, we used placebo-controlled randomised trial methodology to ask whether 20mg of methylphenidate (MPH) could remediate any load-dependent asymmetry of spatial attention in adolescents with ADHD. Twelve male adolescents with ADHD were assessed twice in a double-blind, randomized design, under either placebo or an acute dose of methylphenidate. Thirteen typically developing adolescent Controls completed a single session under placebo. Participants completed a computer-based task in which they monitored a centrally presented rapid serial visual presentation stream for a probe stimulus, while also responding to brief peripheral events. The attentional load of the central task was manipulated by varying the target instructions but not the physical stimuli or the frequency of targets. Between-group analyses under placebo conditions indicated that increased attentional load induced a spatial gradient for target detection in the ADHD but not Controls, such that load slowed response times for left, but not, right hemi-field targets. This load-dependent spatial asymmetry in the adolescents with ADHD was abolished by administration of methylphenidate. Methylphenidate may "normalise" target detection between the hemi-fields in ADHD via enhancement of the right-lateralised ventral attention networks that support non-spatial attention., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

There is continuing debate about long-term effects of brain injury. We examined a range of traumatic brain injury (TBI) variables (TBI history, severity, frequency, and age of injury) as predictors of cognitive outcome over 8 years in an adult population, and interactions with apolipoprotein E (APOE) genotype, sex, and age cohorts. Three randomly sampled age cohorts (20-24, 40-44, 60-64 years at baseline; N = 6333) were each evaluated three times over 8 years. TBI variables, based on self-report, were separately modeled as predictors of cognitive performance using linear mixed effects models. TBI predicted longitudinal cognitive decline in all three age groups. APOE ε4 + genotypes in the young and middle-aged groups predicted lower baseline cognitive performance in the context of TBI. Baseline cognitive performance was better for young females than males but this pattern reversed in middle age and old age. The findings suggest TBI history is associated with long-term cognitive impairment and decline across the adult lifespan. A role for APOE genotype was apparent in the younger cohorts but there was no evidence that it is associated with impairment in early old age. The effect of sex and TBI on cognition varied with age cohort, consistent with a proposed neuroprotective role for estrogen.

The development and integration of risk assessment and clinical risk management for Alzheimer's disease (AD) and dementia is a rapidly emerging field of research and practice. At present, risk management is the only available approach with potential for a large impact on the projected rates of dementia, given population aging. This review describes six available risk assessment tools, including those developed specifically for AD and those for dementia. These tools differ along several important dimensions, including whether they (a) include clinical measures, (b) require a clinician's ratings, (c) are predominantly self-report, (d) are independently validated, and (e) are available online. A narrative review of recently identified risk factors not included in these instruments is included, indicating future directions for risk assessment. Finally, consideration is given to the prioritization of risk advice according to the ease of risk modification and the potential for synergies among risk factors.

Objectives: Few studies report incidence of mild cognitive impairment (MCI) and other mild cognitive disorders (MCD) in cohorts in their 60s, at an age when diagnoses are less stable. The authors' goal was to estimate the incidence and prevalence of MCI and MCD, characterize subgroups with stable vs nonstable diagnoses, and evaluate the impact of diagnosis on daily life in a young-old cohort., Methods: A community-based cohort age 60 to 64 years in 1999 (n = 2551) was monitored for 8 years and assessed every 4 years. A two-stage sampling design was used to identify MCI and MCD through a neuropsychological and neurological assessment. A panel of physicians blind to previous diagnoses reviewed each case using published criteria., Results: The prevalence of MCDs in the cohort aged 68 to 72 years at the last follow-up was approximately 10%. An estimated 141 subjects (7.7%) progressed to MCI and 183 subjects (10.0%) progressed to MCD between years 4 and 8. Only eight participants received a dementia diagnosis at any wave, five of whom progressed from MCDs. More than 45% of diagnoses were unstable during the 8 years of follow-up. Stable diagnoses were associated with lower Mini-Mental State Examination scores, history of neurological disorder, higher cardiovascular risk, and depression at baseline. MCDs were associated with impairments in instrumental activities of daily living and higher rates of reporting memory problems prior to diagnosis., Conclusions: MCDs in individuals in their 60s occur in at least 10% of the population and are likely to be heterogeneous in terms of their etiology and long-term prognosis, but may cause a significant impact in everyday life., (Copyright © 2013 The Alzheimer's Association. Published by Elsevier Inc. All rights reserved.)

This study examined the prevalence of co-morbid age-related eye disease and symptoms of depression and anxiety in late life, and the relative roles of visual function and disease in explaining symptoms of depression and anxiety. A community-based sample of 662 individuals aged over 70 years was recruited through the electoral roll. Vision was measured using a battery of tests including high and low contrast visual acuity, contrast sensitivity, motion sensitivity, stereoacuity, Useful Field of View, and visual fields. Depression and anxiety symptoms were measured using the Goldberg scales. The prevalence of self-reported eye disease [cataract, glaucoma, or age-related macular degeneration (AMD)] in the sample was 43.4%, with 7.7% reporting more than one form of ocular pathology. Of those with no eye disease, 3.7% had clinically significant depressive symptoms. This rate was 6.7% among cataract patients, 4.3% among those with glaucoma, and 10.5% for AMD. Generalized linear models adjusting for demographics, general health, treatment, and disability examined self-reported eye disease and visual function as correlates of depression and anxiety. Depressive symptoms were associated with cataract only, AMD, comorbid eye diseases and reduced low contrast visual acuity. Anxiety was significantly associated with self-reported cataract, and reduced low contrast visual acuity, motion sensitivity and contrast sensitivity. We found no evidence for elevated rates of depressive or anxiety symptoms associated with self-reported glaucoma. The results support previous findings of high rates of depression and anxiety in cataract and AMD, and in addition show that mood and anxiety are associated with objective measures of visual function independently of self-reported eye disease. The findings have implications for the assessment and treatment of mental health in the context of late-life visual impairment.

Converging evidence suggests that right-hemisphere dominant spatial attention systems can be modulated by non-spatial processes such as attentional capacity. The severity of neglect in right-hemisphere stroke patients for example, is correlated with impairments in non-lateralized attention. Evidence also suggests the coexistence of lateralized inattention and reduced capacity in developmental disorders of attention, such as attention deficit hyperactivity disorder (ADHD), which is marked by cognitive impairments suggestive of right hemisphere dysfunction. These lines of evidence argue against a coincident damage hypothesis and suggest instead a direct modulation of spatial attention by non-spatial processes. Here we sought experimental evidence for this relationship in both acquired and developmental disorders of attention. Six adult stroke patients with focal right brain injury and 19 children with ADHD were studied in comparison to control groups of both healthy older adults and typically developing children. The participants were required to detect transient, unilateral visual targets while simultaneously monitoring a stream of alphanumeric characters at fixation. Load at fixation was manipulated by asking participants either to ignore the central stream and focus on the peripheral detection task (no report condition), or to monitor the central stream for a probe item that was defined by either a unique feature (low load condition) or a conjunction of features (high load condition). As expected, in all participants greater load at fixation slowed responses to peripheral targets. Crucially, in right brain injured patients but not older healthy adults left target detection was slowed significantly more than central and right target detection. A qualitatively similar pattern was seen in children with ADHD, but not in typically developing children. The imposition of load at fixation slowed responses to left compared with right targets, and this response time asymmetry was correlated with the severity of ADHD symptoms. These results suggest that a direct manipulation of non-spatial attention can reveal lateralised attention deficits in both acquired and developmental forms of inattention. Our findings support the view that spatial attention networks are tightly integrated with non-lateralized aspects of attention., (Copyright © 2013. Published by Elsevier Ltd.)

Background/aim: A subjective history of cognitive decline is integral to dementia screening, yet there are few data on the accuracy of retrospective self-reports. We prospectively examined the longitudinal predictors of self-reported decline, including rate of cognitive change, clinical diagnosis, depressive symptoms and personality., Methods: We used a large (n = 2,551) community-dwelling sample of older adults (60-64 years at baseline) and tracked their cognitive functioning over 3 waves across a period of 8 years. Individual rates of change in multiple domains of cognition, incident dementia and mild cognitive disorders, apolipoprotein E (APOE) ε4 genotype, level of education, depressive symptoms and personality were examined as predictors of wave 3 retrospective self-reported decline as measured by the Informant Questionnaire on Cognitive Decline in the Elderly., Results: The rate of cognitive decline did not predict subjective decline. Significant predictors of self-reported decline included dementia diagnosis, problems with instrumental activities of daily living, depression and neuroticism at the time of self-report, as well as the presence of an APOE ε4 allele., Conclusions: In this relatively young cohort, retrospective self-report of cognitive decline does not reflect objective deterioration in cognition over the time period in question, but it may identify individuals in the initial stages of dementia and those with elevated psychological and genotypic risk factors for the development of dementia., (Copyright © 2012 S. Karger AG, Basel.)

A period of exposure to trains of simultaneous but spatially offset auditory and visual stimuli can induce a temporary shift in the perception of sound location. This phenomenon, known as the 'ventriloquist aftereffect', reflects a realignment of auditory and visual spatial representations such that they approach perceptual alignment despite their physical spatial discordance. Such dynamic changes to sensory representations are likely to underlie the brain's ability to accommodate inter-sensory discordance produced by sensory errors (particularly in sound localization) and variability in sensory transduction. It is currently unknown, however, whether these plastic changes induced by adaptation to spatially disparate inputs occurs automatically or whether they are dependent on selectively attending to the visual or auditory stimuli. Here, we demonstrate that robust auditory spatial aftereffects can be induced even in the presence of a competing visual stimulus. Importantly, we found that when attention is directed to the competing stimuli, the pattern of aftereffects is altered. These results indicate that attention can modulate the ventriloquist aftereffect., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Unilateral spatial neglect is a disorder of attention and spatial representation, in which early visual processes such as figure-ground segmentation have been assumed to be largely intact. There is evidence, however, that the spatial attention bias underlying neglect can bias the segmentation of a figural region from its background. Relatively few studies have explicitly examined the effect of spatial neglect on processing the figures that result from such scene segmentation. Here, we show that a neglect patient's bias in figure-ground segmentation directly influences his conscious recognition of these figures. By varying the relative salience of figural and background regions in static, two-dimensional displays, we show that competition between elements in such displays can modulate a neglect patient's ability to recognise parsed figures in a scene. The findings provide insight into the interaction between scene segmentation, explicit object recognition, and attention.

Listeners can be "deaf" to a substantial change in a scene comprising multiple auditory objects unless their attention has been directed to the changed object. It is unclear whether auditory change detection relies on identification of the objects in pre- and post-change scenes. We compared the rates at which listeners correctly identify changed objects with those predicted by change-detection models based on signal detection theory (SDT) and high-threshold theory (HTT). Detected changes were not identified as accurately as predicted by models based on either theory, suggesting that some changes are detected by a process that does not support change identification. Undetected changes were identified as accurately as predicted by the HTT model but much less accurately than predicted by the SDT models. The process underlying change detection was investigated further by determining receiver-operating characteristics (ROCs). ROCs did not conform to those predicted by either a SDT or a HTT model but were well modeled by a dual-process that incorporated HTT and SDT components. The dual-process model also accurately predicted the rates at which detected and undetected changes were correctly identified.

Prismatic adaptation is increasingly recognised as an effective procedure for rehabilitating symptoms of unilateral spatial neglect--producing relatively long-lasting improvements on a variety of spatial attention tasks. The mechanisms by which the aftereffects of adaptation change neglect patients' performance on these tasks remain controversial. It is not clear, for example, whether adaptation directly influences the pathological ipsilesional attention bias that underlies neglect, or whether it simply changes exploratory motor behaviour. Here we used visual and auditory versions of a target detection task with a secondary task at fixation. Under these conditions, patients with neglect demonstrated a spatial gradient in their ability to orient to the brief, peripheral visual or auditory targets. Following prism adaptation, we found that overall performance on both the auditory and visual task improved, however, most patients in our sample did not show changes in their visual or auditory spatial gradient of attention, despite adequate aftereffects of adaptation and significant improvement in neglect on visual cancellation. Although there were individual cases that suggested prism-induced changes in visual target detection, and even reversal of the visual spatial gradient, such cases were not evident for the auditory modality. The findings indicate that spatial gradients in stimulus-driven attention may be less responsive to the effects of prism adaptation than neglect symptoms in voluntary orienting and exploratory behaviour. Individual factors such as lesion site and symptom severity may also determine the expression of prism effects on spatial neglect., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Visuomotor adaptation to a shift in visual input produced by prismatic lenses is an example of dynamic sensory-motor plasticity within the brain. Prism adaptation is readily induced in healthy individuals, and is thought to reflect the brain's ability to compensate for drifts in spatial calibration between different sensory systems. The neural correlate of this form of functional plasticity is largely unknown, although current models predict the involvement of parieto-cerebellar circuits. Recent studies that have employed event-related functional magnetic resonance imaging (fMRI) to identify brain regions associated with prism adaptation have discovered patterns of parietal and cerebellar modulation as participants corrected their visuomotor errors during the early part of adaptation. However, the role of these regions in the later stage of adaptation, when 'spatial realignment' or true adaptation is predicted to occur, remains unclear. Here, we used fMRI to quantify the distinctive patterns of parieto-cerebellar activity as visuomotor adaptation develops. We directly contrasted activation patterns during the initial error correction phase of visuomotor adaptation with that during the later spatial realignment phase, and found significant recruitment of the parieto-cerebellar network--with activations in the right inferior parietal lobe and the right posterior cerebellum. These findings provide the first evidence of both cerebellar and parietal involvement during the spatial realignment phase of prism adaptation., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)