Driving performance in persons with mild senile dementia of the Alzheimer type

Assessment of older drivers: relationships among on-road errors, medical conditions and test outcome

PROBLEM

It is essential that driver licensing authorities have a valid and reliable system for evaluating older drivers' continuing competency; road tests are usually required as part of such a system. This study sought to find information about the nature of driving errors made during license review tests, and about relationships between error type and test outcome for older drivers.

METHOD

Data from licensing authority files from 533 road tests during a 12-month period were analyzed; medical and other referral information was included. Average driver age was 76 years. Performance scores were generated for intersection negotiation, lane changing, low speed manoeuvres, positioning and speed control, safety margin, and car control.

RESULTS

Logistic regression analysis showed that test outcome was well predicted by a subset of driving performance scores; adding driver age to the model explained very little variance. Age alone was strongly associated with outcome. Relationships between referral information and test outcome are also reported.

IMPACT

Results highlight several factors relevant to the development of more valid and reliable road tests for older drivers.

Speed-of-processing and driving simulator training result in improved driving performance

Useful field of view, a measure of processing speed and spatial attention, can be improved with training. We evaluated the effects of this improvement on older adults' driving performance. Elderly adults participated in a speed-of-processing training program (N = 48), a traditional driver training program performed in a driving simulator (N = 22), or a low-risk reference group (N = 25). Before training, immediately after training or an equivalent time delay, and after an 18-month delay each participant was evaluated in a driving simulator and completed a 14-mile (22.5-km) open-road driving evaluation. Speed-of-processing training, but not simulator training, improved a specific measure of useful field of view (UFOV), transferred to some simulator measures, and resulted in fewer dangerous maneuvers during the driving evaluation. The simulator-trained group improved on two driving performance measures: turning into the correct lane and proper signal use. Similar effects were not observed in the speed-of-processing training or low-risk reference groups. The persistence of these effects over an 18-month test interval was also evaluated. Actual or potential applications of this research include driver assessment and/or training programs and cognitive intervention programs for older adults.

Identifying driving impairment in Alzheimer disease: a comparison of self and observer reports versus driving evaluation

This study examined the relationship between driving behaviors and awareness of deficit in patients with Alzheimer's disease (AD). Fifteen mildly impaired AD patients and 15 healthy elderly controls with valid drivers' licenses were administered a series of questionnaires concerning daily functioning and driving performance, and all 30 subjects were evaluated on a standardized road test. Self-report and caregiver/informant responses were compared with determine levels of discrepancy in ratings, while comparisons of AD and healthy elderly controls revealed group differences. Actual driving performance was considered the standard by which to determine accuracy of perceptions. Drivers with AD were rated as significantly worse than healthy elderly drivers on nine of 10 driving behaviors by an independent evaluator. AD patients' self-reports of driving ability were significantly better than the evaluator's ratings on seven of the 10 items, whereas the healthy elderly drivers rated themselves better than did the evaluator on one item. Although caregivers were likely to acknowledge a general concern with their AD patients' driving, they underreported specific driving problems when their ratings were compared with those of an independent evaluator. These findings have implications for the development of caregiver-based modifications of driving behavior.

Effects of cognition on driving involvement among the oldest old: variations by gender and alternative transportation opportunities

PURPOSE

This study explored the impact of cognition and the availability of other drivers on driving restriction and cessation among older adults.

DESIGN AND METHODS

Survey data from the first wave of the Asset and Health Dynamics Among the Oldest Old data were analyzed, using multinomial logistic regressions.

RESULTS

Cognitive impairment is associated with driving restriction and cessation, although a noteworthy minority of mildly and severely cognitively impaired individuals continue to drive. Partner's driving and involvement and presence of other drivers in the household moderated the effect of cognition on driving restriction and cessation.

IMPLICATIONS

The decision processes surrounding an individual's restricting or stopping driving are complex and may include consideration not only of competence, but also of sense of self-worth and relationship with a partner.

Self-reported driving, cognitive status, and physician awareness of cognitive impairment

OBJECTIVES

To assess self-reported driving rates in older people and correlate these data with cognitive status and physician recognition of cognitive impairment.

DESIGN

Cross-sectional study.

SETTING

A multiphysician private practice clinic in a primarily Asian-American community of Honolulu, Hawaii.

PARTICIPANTS

Two hundred ninety-seven ambulatory patients aged 65 and older.

MEASUREMENTS

Cognitive function was assessed by physician interview using the Cognitive Abilities Screening Instrument (CASI) and proxy informant data. Subjects' self-reported driving status. Outpatient medical records were reviewed.

RESULTS

Sixty percent of the studied population reported that they currently drove. This rate decreased from 73.3% (148/202) for subjects with good CASI performance (CASI 282) to 37.5% (21/56) for subjects with intermediate CASI performance (CASI 74-81.9) and further to 23.7% (9/38)for subjects with poor CASI performance (CASI <74). Further analysis of drivers with intermediate and poor CASI performance scores revealed that almost none of their physicians recognized that these drivers had cognitive problems(4.8% (1/21) of drivers with intermediate CASI performance and 11.1% (1/9) of drivers with poor CASI performance).

CONCLUSION

In this convenience sample of older drivers, driving rates dropped precipitously with poorer performance on cognitive tests, yet a significant percentage of individuals with intermediate or poor cognitive test performance reported that they currently drove. This poor performance was often unrecognized by their physicians. Low recognition rates could affect physicians' interventions to curb unsafe driving.

Evaluation and management of the driver with dementia

BACKGROUND

The number of older adult drivers with dementia is expected to increase over the next few decades. This increase raises public and personal safety concerns given the higher crash rates of drivers with a dementing illness. However, the identification of drivers with a dementia who may be at risk for a crash is difficult, particularly for those in the early stages of dementia.

REVIEW SUMMARY

Studies examining the correlation of dementia with driving outcomes such as motor vehicle crashes are reviewed. The strengths and weaknesses of recent consensus statements, published to assist clinicians in evaluating drivers with a dementia, are discussed. The authors also review common practices currently in use by physicians to identify at-risk drivers, including mental status examinations, global dementia rating scales, specialist referral, medical evaluations, and the use of caregiver reports and other proxy measures. Legal issues, based on the role of the physician, are reviewed along with suggestions for driving cessation and education for the caregiver and family.

CONCLUSIONS

In patients with mild to moderate dementia, the literature indicates that physicians would have difficulty in identifying which individuals should not drive. Performance-based measures of driving skills, such as on-road driving tests, are recommended as a means of assessing driving competency.

Driving and dementia: a review of the literature

In North American society driving is closely linked with independence. Unfortunately, the freedom to operate a motor vehicle may be lost when an individual develops a specific medical diagnosis. The complex issue of dementia and driving safety is frequently encountered by health care professionals. Physicians are required, by law, to report any medical diagnosis such as dementia, that may affect driving safety. Physicians often refer to occupational therapists to assist them in determining if an individual's impairment significantly impacts driving safety. Unfortunately many health care professionals are not using reliable, valid and sensitive tests to determine the point at which an individual with dementia will become an unsafe driver. Through a review of the literature, the authors explore the effects of normal aging and cognitive impairment on driving safety. Specific assessment tools used to assess driving ability are examined and the role of health professionals in driver assessment is discussed. Some suggestions to improve the overall approach to evaluating driving safety are offered in the conclusion.

Simulated car crashes at intersections in drivers with Alzheimer disease

Current evidence suggests that car crashes in cognitively impaired older drivers often occur because of failure to notice other drivers at intersections. We tested whether licensed drivers with mild to moderate cognitive impairment due to Alzheimer disease (AD) are at greater risk for intersection crashes. In this experiment, 30 participants drove on a virtual highway in a simulator scenario where the approach to within 3.6 seconds of an intersection triggered an illegal incursion by another vehicle. To avoid collision with the incurring vehicle, the driver had to perceive, attend to, and interpret the roadway situation; formulate an evasive plan; and then exert appropriate action on the accelerator, brake, or steering controls, all under pressure of time. The results showed that 6 of 18 drivers with AD (33%) experienced crashes versus none of 12 nondemented drivers of similar age. Use of a visual tool that plots control over steering wheel position, brake and accelerator pedals, vehicle speed, and vehicle position during the 5 seconds preceding a crash event showed inattention and control responses that were either inappropriate or too slow. The findings were combined with those in another recent study of collision avoidance in drivers with AD that focused on potential rear end collisions. Predictors of crashes in the combined studies included visuospatial impairment, disordered attention, reduced processing of visual motion cues, and overall cognitive decline. The results help to specify the linkage between decline in certain cognitive domains and increased crash risk in AD and also support the use of high-fidelity simulation and neuropsychologic assessment in an effort to standardize the assessment of fitness to drive in persons with medical impairments.

Autofahren im Alter - eine Literaturanalyse

Zusammenfassung: Seit einigen Jahren beschäftigt man sich verstärkt mit alten Menschen nicht nur als als Verkehrsteilnehmer allgemein, sondern besonders als Autofahrer. Daß zukünftig erheblich mehr alte Menschen mit einem Auto unterwegs sein werden als bisher, hat zu kontroversen Beurteilungen insbesondere der zukünftigen Verkehrssicherheitslage geführt. Die vorliegende Literaturanalyse soll angesichts der Kontroverse klären, was Fakt ist. Gesichtet wurden schwerpunktmäßig Beiträge, die in den 90er Jahren erschienen sind. Eingeteilt wurden sie in jene, die die Leistungsfähigkeit des alternden Organismus im Kontext der Straßenverkehrsteilnahme untersuchen, und jene, die das Problem der Persönlichkeit des alternden Autofahrers thematisieren, wobei die zweite Gruppe deutlich weniger stark besetzt ist. Das Teilthema Leistungsfähigkeit wird von der medizinisch-biologischen zur eher psychologischen Seite hin entwickelt. Dabei wird eine Vielzahl von alterstypischen Veränderungen aufgezeigt, die in der Literatur als mögliche Einflußgrößen für die Sicherheit beim Autofahren diskutiert werden. Die tatsächliche Verkehrssicherheit älterer Autofahrer wird durch eine Analyse der aktuellen Unfallstatistiken untersucht. Dabei zeigt sich, daß Defizite und Leistungsverluste durch günstige Einstellungen und richtige Entscheidungen zumindest teilweise kompensiert werden können, so daß die Unfallstatistiken ein eher günstiges Bild zeigen. Selbstverständlich kann auch die sich fortentwickelnde Technik genutzt werden, älteren Menschen die Bedienung eines Fahrzeuges und die Bewältigung der Fahraufgaben zu erleichtern. Verschiedene technische Möglichkeiten werden vorgestellt.

Relation of useful field of view and other screening tests to on-road driving performance

The purpose of this study was to examine the value of a clinical driving assessment battery in predicting performance on an on-road driving test. 43 participants referred to the Bryn Mawr Rehab Adapted Driving Program for evaluation of driving ability underwent an evaluation consisting of a predriver screening and an on road driving test. The predriver screening included a vision screening, a reaction rime task, a split-attention task, the Hooper Visual Organization Test, verbal and symbolic sign recognition, and assessment of Useful Field of View. Logistic regression analyses were applied to identify which predriver screening variables could be used to predict outcome on the on road driving test (pass/fail); UFOV was that best single predictor. The addition of screening tests beyond UFOV alone did not increase predictive validity. These findings suggest that UFOV may serve as an indicator of the need for further driving assessment.

A single-photon emission computed tomography imaging study of driving impairment in patients with Alzheimer's disease

Single-photon emission computed tomography (SPECT) was used in this study to examine the neurophysiologic basis of driving impairment in 79 subjects with dementia. Driving impairment, as measured by caregiver ratings, was significantly related to regional reduction of right hemisphere cortical perfusion on SPECT, particularly in the temporo-occipital area. With increased severity of driving impairment, frontal cortical perfusion was also reduced. Clock drawing was more significantly related to driving impairment than the Mini-Mental State Examination (MMSE). Driving impairment in Alzheimer's disease is related to changes in cortical function which vary according to the severity of the disease. Cognitive tests of visuoperceptual and executive functions may be more useful screening tools for identifying those at greatest risk for driving problems than examinations like the MMSE that are weighted toward left-hemisphere-based verbal tasks.

Attention: neuropsychological predictor of competency in Alzheimer's disease

This study was undertaken to examine the relationship between two different competencies, financial and medical decision making, and explore whether neuropsychological testing can identify a common underlying cognitive operation impaired in patients with AD. The objective was to examine the neuropsychological predictors of financial and medical decision-making competencies in patients with Alzheimer's disease (AD). Twenty individuals with mild to moderate AD and 20 control subjects matched for age and education were evaluated at a university medical center. All participants were administered a financial competency questionnaire, a competency test for medical decision making, and a set of standardized neuropsychological tests selected to reflect cognitive processes theoretically related to competency. In addition, an informant provided information regarding banking history for each participant. AD patients performed more poorly on all measures, including both measures of competency, which were highly related (R = .718, P < .001). Two tests, Trails A and Word List Recall, were significantly correlated with both competency measures, with Trails A predicting over 85% of the variance in competency scores. Trails A discriminated competent from not competent participants with an accuracy ranging from 77% to 82%. Measures of financial and medical decision-making competency were significantly correlated among patients with AD. One brief neuropsychological test of attention, Trails A, proved to be highly predictive of performance on both competency measures and useful in the discrimination of competent performance on these measures and by informant report.

Vision impairment and driving

Driving is the primary mode of travel in many countries. It facilitates the performance of routine daily activities and is thus integral with the concept of quality of life. Vision is inarguably a fundamental component of safe driving. Drivers with certain eye conditions reduce their driving exposure and restrict their driving to the safest times, yet there is preliminary evidence that some eye conditions increase the risk of crashes. Visual acuity is only weakly related to crash involvement, whereas peripheral vision appears to play a more critical role. Color vision deficiency by itself is not a threat to safe driving. Based on the current literature, it is unclear whether other types of visual sensory impairment have a significant impact on driving safety and performance. Tests of visual attention and processing speed show great promise as methods of identifying high-risk drivers. There is a serious need for well-designed studies in key practical areas, such as the safety of low-vision drivers who use bioptic telescopes, the impact of monocular vision impairment on safety, and the effectiveness of vision rescreening policies after initial licensure. For ophthalmologists to guide patients about driving fitness, valid and reliable assessment tools must be developed and made widely available.

The driving habits of adults aged 60 years and older

OBJECTIVES

We describe the driving habits of adults aged 60 years and older who were interviewed in the context of a community survey focused on mental disturbances. Our goal was to identify clinical cues that might signal driving difficulty in older adults who might present to the primary care physician for health care.

DESIGN

A population-based survey.

SETTING

Continuing participants in a follow-up study of community-dwelling adults who were living in East Baltimore in 1981.

PARTICIPANTS

Subjects were 1920 continuing participants of the Baltimore sample of the Epidemiologic Catchment Area Program; 589 were aged 60 years and older and provided information on driving habits.

MEASUREMENTS

Respondents were asked about their driving status: had they made adaptations to driving and had they experienced any adverse driving events in the 2 years before the interview. Driving behaviors were assessed in relation to chronic disease, sensory impairment, functional status, and mental status.

RESULTS

Former drivers were more likely to be older, female, and nonwhite. Diabetes, vision impairment, functional impairment, and making an error on the copy design task of the Mini-Mental State Examination (MMSE) were associated with no longer driving. Women were more likely to report having made adaptations to driving, as were persons with heart disease, arthritis, vision impairment, and those who made an error on the copy design task of the MMSE. Heart disease and hearing impairment were associated with report of an adverse driving event. In multivariate models that included terms for potentially influential characteristics such as age, gender, and miles driven, only the copy design task was associated with driving status, and only heart disease was associated with driving adaptation and adverse driving events.

CONCLUSION

Simple tests that tap visuospatial ability, such as the copy design task of the MMSE, may warrant additional study for use in driving assessment of older adults in primary care. The results underscore the importance of making an inquiry about driving as a separate and independent component of functional assessment.

On-road assessment of driving competence after brain impairment: review of current practice and recommendations for a standardized examination

OBJECTIVE

To examine the approaches to on-road assessment of driver competence in persons with brain impairment. Items examined were procedures, standardization, scoring methods, equipment requirements, and determination of fitness to drive.

DATA SOURCES

All studies identified through citation or Medline search.

STUDY SELECTION

The studies reviewed were those published from 1971 to the present that examined driving competence after brain impairment, as measured by a driving test.

DATA EXTRACTION

A qualitative review of published studies reporting methodologies and authors' conclusions abstracted from sourced publications.

DATA SYNTHESIS

Off-road driving assessments examine proficiency in operating a motor vehicle, but not ability to drive in traffic or accurate prediction of safe driving. On-road driving assessments have been used to examine the predictive validity of other driving assessment methods or the driving performance of subjects with brain impairment. Determining a subject's competence to drive is frequently a subjective evaluation. With a standardized driving test, a significant correlation between the objective driving score and the rater's global evaluation of fitness has been reported.

CONCLUSION

Closed-course, off-road driving tests are recommended for examining vehicle operation skills and readiness for in-traffic evaluation only. This allows practice with any vehicle adaptations before on-road evaluation and identification of clients who are unsafe to proceed on-road. A practical driving test in traffic, with standardized route and driving maneuvers, is recommended for determining driver competence. Scoring of driving performance should be standardized, reliable, and specific, to identify deficient driving skills that may be amenable to training. Driving performance should be evaluated according to predefined criteria, and the judgment regarding competence should be closely related to this objective measure.

Alzheimer changes are common in aged drivers killed in single car crashes and at intersections

With increasing age, diseases affecting the cognitive functions are more frequent. These diseases may increase the risk for fatal car crashes. We analyzed the frequency of neuropathological alterations characteristic of Alzheimer's disease (i.e. neuritic and diffuse plaques, and neurofibrillary tangles) in two association areas of the brain, parietal and frontal cerebral cortex, from 98 fatally injured aged drivers. In the age groups of 65-75 and over 75 years of age, 50% and 72% of the drivers, respectively, had neuritic plaques in either parietal and/or frontal cortex. In 14% of all killed drivers the number of neuritic plaques reached the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) age-related histologic score C, which indicates the diagnosis of Alzheimer's disease (AD), and an additional 33% had score B, which suggests the diagnosis of AD. Neuropathological AD changes were most common in the brains of drivers killed in single vehicle crashes, followed by multivehicle crashes at intersections and least common in multivehicle crashes elsewhere, but the differences did not reach statistical significance. In a great majority (80-85%) of cases the killed aged driver was the guilty party of the crash. The results imply, that incipient AD may contribute to fatal crashes of aged drivers, and therefore the forensic autopsy of these victims should include neuropathological examination.

A comparative approach to identify unsafe older drivers

The identification of unsafe older drivers is a current and important challenge. In the present research, a comparative approach was used in which the on road driving errors and expert evaluations of older drivers with clinically significant declines in mental abilities (N = 155) were compared to the errors and evaluations of a normal elderly control group (N = 68) and a normal younger control group (N = 30). The results indicate that the conventional criteria used in North America for licensing new drivers is inappropriate for license removal in experienced drivers. The results also indicate that hazardous errors were the single best indicator of membership in the group of older drivers with clinical impairment. This group also differs from the two normal control groups on turn positioning errors, minor positioning errors and overcautiousness. All groups differ from each other on scanning errors. A regression analysis further indicated that the five driving errors listed above accounted for over 57% of the variance associated with global ratings provided by expert driving instructors.

A preliminary assessment of the medical and functional factors associated with vehicle crashes by older adults

OBJECTIVES

To examine associations between medical and functional variables and at-fault car crashes in a cohort of older drivers.

DESIGN

A case-control study.

SETTING

A tertiary care medical center.

PARTICIPANTS

Older drivers (ages 55-90 years) residing in Jefferson County, Alabama (n = 174). Cases were drivers who had at least one at-fault crash in the previous 6 years; controls were crash-free during the same period.

MEASUREMENTS

Self-reported medical conditions, reported and observed functional measures, and urinary drug screens. The occurrence of one or more at-fault car crashes in the 6 years preceding the 1991 assessment date represented the outcome measure.

RESULTS

Ninety-nine older drivers experienced between one and seven at-fault vehicle crashes during the period 1985 through 1991, whereas 75 drivers did not. Logistic regression models indicated that the following variables were independently associated with crash involvement: A 40% or greater reduction in the useful field of view (OR = 6.1; 95% CI, 2.9 to 12.7; P < 0.001), black race (OR = 6.6; 95% CI, 1.7 to 26.2; P = .007), a history of falling in the previous 2 years (OR = 2.6; CI, 1.1 to 6.1; P = .025), and not taking a beta-blocking drug (OR = 4.3; CI, 1.2 to 15.0; P = .023).

CONCLUSIONS

Functional assessments, such as a comprehensive test of visual processing, a falls history, and a review of current medications may be of greater relevance than specific medical conditions in the identification of older at-risk drivers. If prospective studies determine that falling and crashing share risk factors, a unified approach to the prevention of these mobility disorders could result. The finding of an independent association of black race with at-fault crashing is in need of further clarification because of the low representation of black drivers in this sample.

Driving avoidance and functional impairment in older drivers

The purpose of this study was to examine the association between visual and cognitive impairment in older drivers and their avoidance of potentially challenging, driving situation. A group of 257 older drivers participated in assessments of visual sensory function, eye health and cognitive function including the useful field of view test, and completed a structured questionnaire on driving exposure and how frequently they avoided challenging driving situations. Results replicated earlier studies showing that many older drivers limit their exposure to driving situations which are generally believed to be more difficult (e.g. rain, night, heavy traffic, rush hour). Furthermore, older drivers with objectively determined visual and/or attentional impairments reported more avoidance than those free of impairments; those with the most impairment reported avoiding more types of situations than other less impaired or non-impaired drivers. Older drivers with a history of at-fault crashes in the prior five years reported more avoidance than those who had crash-free records. Future research should evaluate the potentially beneficial role of self-regulation in enhancing older driver safety, particularly in those older drivers with visual and attentional processing impairments who have elevated crash risk.

Neuropsychological predictors of adaptive kitchen behavior in geriatric psychiatry inpatients

This study examined the degree to which demographic variables, psychiatric diagnosis, depression rating, and neuropsychological test performance predict adaptive kitchen behavior in geriatric psychiatry patients and normal elderly volunteers. Amixed group of 27 participants including 8 normal volunteers and 19 geriatric psychiatry inpatients underwent psychiatric evaluation, neuropsychological testing, and a kitchen skills assessment conducted in a natural setting. Both depression and dementia were prevalent among patients. The kitchen skills assessment was abnormal in 69% of patients, compared to none of the normal volunteers. Estimated premorbid IQs, psychiatric diagnosis, and neuropsychological test scores significantly predicted the pass/fail status on the kitchen skills assessment, but there was no effect for age, education, gender, or depression. The discriminant function analysis classified 92% of cases, and the canonical correlation coefficient was .84. Of the neuropsychological tests employed in the study, two tests involving visuospatial processing and attention were retained in the discriminant function analysis. The results are consistent with previous studies that suggest that visuospatial tasks are more predictive of instrumental activities of daily living than are cognitive tasks emphasizing verbal and memory abilities. In addition, we conclude that neuropsychological test data are useful and valid for the purpose of guiding clinical judgments regarding activities of daily living in geriatric psychiatry patients.

Alzheimer's disease and driving: prediction and assessment of driving performance

OBJECTIVES

To examine driving competence in a group of drivers diagnosed with probable Alzheimer's Disease (AD) in terms of a standardized open road evaluation and expert judgments. To examine the validity of a standardized medical examination, including administration of the Mini-Mental Status Exam (MMSE), and a standardized neuropsychological assessment as predictors of open road driving performance.

DESIGN

A prospective investigation with consecutively referred subjects.

SETTING

Coorabel Driver Assessment Centre, Royal Rehabilitation Centre Sydney, Australia.

PARTICIPANTS

Nineteen subjects with a diagnosis of probable AD.

MEASUREMENTS

A standardized clinical medical examination, a standardized neuropsychological assessment, and a standardized open road driving evaluation. The driving evaluation provided a correct driving actions score. The outcome measure was the expert judges' rating of overall driving competence, which was termed the final on-road result.

RESULTS

Seven subjects passed the on-road driving evaluation, and 12 failed. MMSE was found to be a significant predictor of final on-road result. The physician's prediction, the neuropsychology test scores, and the neuropsychologist's prediction were not found to be significantly associated with the final on-road result. The on-road driving evaluation was a reliable test.

CONCLUSION

Inasmuch as all subjects except one were still driving and all wished to continue to drive, it is important to note that 63.2% of subjects failed the on-road evaluation. Conversely, 36.8% were judged safe to drive, suggesting that AD diagnosis alone may be insufficient criteria for cessation of driving. A standardized road test may be the only appropriate means of determining driving competence in people diagnosed with AD.

Mental impairment and driving licences for elderly people--a survey among Norwegian general practitioners

OBJECTIVE

Study how GPs assess mental function when a health certificate for elderly drivers has to be issued.

DESIGN

Postal questionnaire survey.

SETTING

Nationwide survey.

SUBJECTS

Random sample of 532 Norwegian general practitioners, response rate 54%.

MAIN OUTCOME MEASURES

Open and closed questions.

RESULTS

Various types of examinations and assessments are carried out in this context. More than 50% always assess mental function. Only 22% use formal mental tests, mostly when in doubt. The assessment of elderly patients for a health certificate for driving is regarded by many as a difficult problem.

CONCLUSION

There is a lack of uniformity in issuing a health certificate to elderly drivers, a low use of formal cognitive testing, and problems facing GPs in this context. More concrete guidelines and a formal second-line system would facilitate an objective assessment and could also alleviate the burden on the doctor.

The Driver With Dementia: A Review of the Literature

The authors review 10 studies of driving and dementia. They found poor agreement among the researchers with regard to the stage at which a patient with dementia should discontinue driving and the appropriate tools to be used for an assessment of driving skills. They make recommendations for a comprehensive driving assessment and for the clinical management of drivers with dementia. Because the impaired driver is a medical as well as a public safety concern, clinicians and policymakers must work together to address the many problems associated with this issue.

Fairhill guidelines on ethics of the care of people with Alzheimer's disease: a clinical summary. Center for Biomedical Ethics, Case Western Reserve University and the Alzheimer's Association

These guidelines summarize the content of meetings of family caregivers and individuals with dementia of the Alzheimer's type who identified and spoke on ethical issues in dementia care and who engaged in dialogue with an interdisciplinary and interprofessional group of individuals working in the field of Alzheimer's disease. This inductive method begins with attentive listening to the voices of the affected population and family members, in contrast with a theoretical and deductive approach to ethics.

Automobile driving in Huntington's disease

We assessed the influence of the neurological and cognitive impairments of Huntington's disease (HD) on automobile driving. In a group of 73 HD outpatients, 53 (72%) continued to drive after illness onset. Those no longer driving had more severe symptoms than those still driving. Twenty-nine HD patients who were still driving and 16 healthy control subjects underwent a clinical examination, a cognitive examination, a driving-simulator assessment, and completed questionnaires about driving history and habits. HD patients performed significantly worse than control subjects on the driving-simulator tasks and were more likely to have been involved in a collision in the preceding 2 years (58% of HD vs. 11% of control subjects). Patients with collisions were less functionally impaired but had slower simple reaction time scores than did those without collisions. HD patients are at increased risk for accidents, but patients who have accidents are not easily distinguished from those who do not.