A systematic review of intervention approaches for driving cessation in older adults

Supporting decision-making for individuals living with dementia and their care partners with knowledge translation: an umbrella review

Living with dementia requires decision-making about numerous topics including daily activities, such as advance care planning (ACP). Both individuals living with dementia and care partners require informed support for decision-making. We conducted an umbrella review to assess knowledge translation (KT) interventions supporting decision-making for individuals living with dementia and their informal care partners. Four databases were searched using 50 different search-terms, identifying 22 reviews presenting 32 KT interventions. The most common KT decision topic was ACP (N=21) which includes advanced care directives, feeding options, and placement in long-term care. The majority of KT interventions targeted care partners only (N=16), or both care partners and individuals living with dementia (N=13), with fewer interventions (N=3) targeting individuals living with dementia. Overall, our umbrella review offers insights into the beneficial impacts of KT interventions, such as increased knowledge and confidence, and decreased decisional conflicts.

A Systematic Review of Effective Interventions and Strategies to Support the Transition of Older Adults From Driving to Driving Retirement/Cessation

Background and Objectives

In most western countries, older adults depend on private cars for transportation and do not proactively plan for driving cessation. The objective of this review was to examine current research studies outlining effective interventions and strategies to assist older adults during their transition from driver to driving retirement or cessation.

Research Design and Methods

A search was completed across 9 databases using key words and MeSH terms for drivers, cessation of driving, and older adult drivers. Eligibility screening of 9,807 titles and abstracts, followed by a detailed screening of 206 papers, was completed using the Covidence platform. Twelve papers were selected for full-text screen and data extraction, comprising 3 papers with evidence-based intervention programs and 9 papers with evidence-informed strategies.

Results

Three papers met the research criteria of a controlled study for programs that support and facilitate driving cessation for older adults. Nine additional studies were exploratory or descriptive, which outlined strategies that could support older drivers, their families, and/or healthcare professionals during this transition. Driving retirement programs/toolkits are also presented.

Discussion and Implications

The driver retirement programs had promising results, but there were methodological weaknesses within the studies. Strategies extracted contributed to 6 themes: Reluctance and avoidance of the topic, multiple stakeholder involvement is important, taking proactive approach is critical, refocus the process away from assessment to proactive planning, collaborative approach to enable "ownership" of the decision is needed, and engage in planning alternative transportation should be the end result. Meeting the transportation needs of older adults will be essential to support aging in place, out-of-home mobility, and participation, particularly in developed countries where there is such a high dependency on private motor vehicles.

[Sondage sur les pratiques des médecins de famille et sur la collaboration interprofessionnelle avec des ergothérapeutes en GMF quant au dépistage des conducteurs à risque]

Cette étude a sondé 46 médecins de famille québécois quant à leurs pratiques pour l'évaluation et le dépistage des conducteurs à risque afin 1) de mieux comprendre leur niveau de compétence perçu; 2) de recenser les difficultés rencontrées dans le processus de prise de décision et 3) de documenter leurs besoins et attitudes quant à une collaboration plus étroite avec les ergothérapeutes. Les participants (femmes : 84,8 %; moyenne d'expérience : 15,7 (±12,1) ans) ont répondu à un sondage en ligne de 30 questions. Les résultats de cette étude démontrent que malgré un certain confort à effectuer l'évaluation et le dépistage des conducteurs à risque, les médecins ne se considèrent pas comme les professionnels les mieux qualifiés pour ce faire. Ils reconnaissent également le rôle que jouent les ergothérapeutes dans le dépistage de cette clientèle et l'intervention auprès d'elle. Ils voient ainsi la pertinence d'avoir accès aux services de ces professionnels en soins de première ligne.

'It is empowering and gives people dignity in a very difficult process': A multistage, multimethod qualitative study to understand the views of end users in the cultural adaptation of a dementia and driving decision aid

BACKGROUND

Decisions about driving for individuals living with dementia (ILWD) can be challenging. There are limited evidence-based person-centred interventions in the United Kingdom that support decisions about transitioning to not driving or guidelines for developing decision aids for ILWD. This study aimed to understand the important features of a decision aid through the cultural adaptation of Australian dementia and driving decision aid (DDDA) for ILWD residing in the United Kingdom.

METHODS

This qualitative study was theoretically underpinned by a person-centred framework and conducted over three stages: (1) Development of a draft UK-specific DDDA; (2) semistructured interviews with ILWD and an online survey with stakeholders to obtain their views on a draft UK DDDA and (3) content analysis and synthesis of qualitative data to inform the final version of the decision aid.

RESULTS

Eleven ILWD and six of their spouses participated in interviews, and 102 stakeholders responded to an online survey. The four broad features identified as important to include in a decision aid for drivers living with dementia were: a structured and interactive format; positive and supportive messaging and presentation; relevant and concise content and choice-centred. The perceived benefits of the decision aid were identified as supporting conversations, enhancing collaborative decision making and enabling agency with decisions about driving and future mobility options.

CONCLUSIONS

Decision aids that are underpinned by interactive choice-driven questions enhance a person-centred approach to decisions about driving. Positively framing decision aids through the presentation and content can facilitate engagement with the decision-making process about driving. The findings have implications for the development of decision aids designed for ILWD on other important health and social topics.

PATIENT AND PUBLIC INVOLVEMENT

Advocating for the development of a UK DDDA were ILWD. Healthcare professionals contributed to the development of a draft UK DDDA. Former and current drivers living with dementia, family members, healthcare professionals and other support networks of ILWD participated in interviews or an online survey which informed the final version of the UK DDDA.

Driving Cessation and Late-Life Depressive and Anxiety Symptoms: Findings from the National Health and Aging Trends Study

OBJECTIVES

To describe the association between driving cessation and depressive and anxiety symptoms over time by assessing depression and anxiety at 1- and 4-years follow-up.

METHODS

The study examined community-dwelling adults aged 65 years and older from the National Health and Aging Trends Study who were driving at the 2015 interview and completed 1-year (N = 4,182) and 4-year (N = 3,102) follow-up interviews. Outcomes were positive screens for depressive and anxiety symptoms in 2016 or 2019, and the primary independent variable was driving cessation within one year of the baseline interview.

RESULTS

Adjusting for socio-demographic and clinical characteristics, driving cessation was associated with depressive symptoms at 1 year (OR = 2.25, 95% CI: 1.33-3.82) and 4-year follow-up (OR = 3.55, 95% CI: 1.72-7.29). Driving cessation was also associated with anxiety symptoms at 1 year (OR = 1.71, 95% CI: 1.05-2.79) and 4 year follow up (OR = 3.22, 95% CI: 1.04-9.99).

CONCLUSIONS

Driving cessation was associated with an increased risk of developing depressive and anxiety symptoms in later life. However, reasons for this association remain unclear.

CLINICAL IMPLICATIONS

Although the mechanism linking driving cessation with worse mental health symptoms is uncertain, driving facilitates many important activities. Clinicians should monitor the well-being of patients who stop or intend to stop driving.

Development and Initial Validation of the Transportation Support Scale

IMPORTANCE

Driving cessation affects older drivers and, possibly, also care partners (most of whom tend to be women). Although tools exist to assess the effects on family and friends of providing informal care to someone who needs assistance, no tool is available to clinicians that specifically focuses on the effects of driving cessation.

OBJECTIVE

To develop the Transportation Support Scale (TSS) to measure care partners' responses-both negative and positive-to driving cessation and assuming transportation responsibilities.

DESIGN

We developed a list of 98 items to capture the impact on care partners of providing transportation to older adults who have stopped driving. In Phase 1, we pretested the items qualitatively with a small sample of care partners. In Phase 2, we reduced the number of items and examined several psychometric properties of the TSS with a larger sample.

SETTING

Community.

PARTICIPANTS

Two convenience samples of care partners who provide transportation (Phase 1, n = 11; Phase 2, n = 66).

RESULTS

The initial pool of items was reduced from 98 to 22. The final TSS has an internal consistency of .88 (Cronbach's α). Thirty-five percent of care partners' scores fell above the middle possible score; these care partners were likely experiencing a high negative impact related to providing transportation after driving cessation.

CONCLUSIONS AND RELEVANCE

The TSS demonstrated adequate preliminary psychometric properties. We need additional research to further evaluate the psychometric properties of the TSS (e.g., test-retest reliability). A fully validated TSS may be useful to clinicians and researchers. What This Article Adds: The TSS has the potential to help clarify the perspective of care partners as well as inform the development and evaluation of services for care partners who are providing transportation to former drivers.

Driving following a diagnosis of dementia: Exploring the views and experiences of people with dementia-A UK survey

BACKGROUND

Driving cessation can be one of the adjustments made following a diagnosis of dementia. Little is known about the views and opinions of people living with dementia about this. The study aimed to gather a broad idea of the expectations, impacts and the process of driving cessation from the perspective of those living with dementia.

METHODS

138 people with dementia and 91 relatives/friends (on behalf of an individual with dementia) took part in an online questionnaire.

RESULTS

People living with dementia reported stopping driving following diagnosis can have negative psychological impacts particularly in relation to; feelings of isolation, depression, loss of freedom and feeling life isn't worth living. Age, gender and choice in the driving cessation process were related to the degree of negative experiences.

CONCLUSIONS

The difficulties reported by people with dementia suggest a need to provide more structured post diagnostic support to aid decision making of driving continuation or cessation; with the view to reducing associated distress and enabling people with dementia to continue to live a meaningful life.

Developing the Driving and Dementia Roadmap: a knowledge-to-action process

OBJECTIVES

Despite three decades of research, gaps remain in meeting the needs of people with dementia and their family/friend carers as they navigate the often-tumultuous process of driving cessation. This paper describes the process of using a knowledge-to-action (KTA) approach to develop an educational web-based resource (i.e. toolkit), called the Driving and Dementia Roadmap (DDR), aimed at addressing some of these gaps.

DESIGN

Aligned with the KTA framework, knowledge creation and action cycle activities informed the development of the DDR. These activities included systematic reviews; meta-synthesis of qualitative studies; interviews and focus groups with key stakeholders; development of a Driving and Dementia Intervention Framework (DD-IF); and a review and curation of publicly available resources and tools. An Advisory Group comprised of people with dementia and family carers provided ongoing feedback on the DDR's content and design.

RESULTS

The DDR is a multi-component online toolkit that contains separate portals for current and former drivers with dementia and their family/friend carers. Based on the DD-IF, various topics of driving cessation are presented to accommodate users' diverse stages and needs in their experiences of decision-making and transitioning to non-driving.

CONCLUSION

Guided by the KTA framework that involved a systematic and iterative process of knowledge creation and translation, the resulting person-centered, individualized and flexible DDR can bring much-needed support to help people with dementia and their families maintain their mobility, community access, and social and emotional wellbeing during and post-driving cessation.

Navigating the pathway to ceasing driving-A voyage of discovery

BACKGROUND

Ceasing driving for older people is a life transition and can be associated with a sense of loss and decreased wellbeing. Nurses can play a key role in supporting the older person to manage the transitions, especially as the work involved in ceasing driving is often hidden. For example, finding alternative and accessible means of travel and maintaining mobility. Travel itself can be viewed as essential, for example attending health appointments and shopping. Discretionary travel may not be viewed as essential, but provides an important means of maintaining activity and social connection.

METHOD

A case study is presented of Mike's journey in ceasing driving. The concept of transition helps in co-creating with Mike his journey of discovery. Semi-structured interviews took place with Mike over a six-month period and a journey pathway created, which was subject to further iterations during subsequent interviews.

RESULTS

Ceasing driving involves a number of transitions encompassing a series of losses, managing uncertainty, problem-solving and learning new skills. Being able to access and adapt to maintain mobility and travel are influenced by structural and environmental barriers.

CONCLUSION

The World Health Organization's strategy to create age-friendly cities and communities is admirable. Like any other strategy this is a long-term plan, and in meantime action needs to happen to support older people in ceasing driving and creating a non-driving life and limit a decrease in well-being. Starting conversations on transitional travel planning is proposed, with nurses playing a central role in making this process happen.

An innovative therapeutic educational program to support older drivers with cognitive disorders: Description of a randomized controlled trial study protocol

Older drivers face the prospect of having to adjust their driving habits because of health problems, which can include neurocognitive disorders. Self-awareness of driving difficulties and the interaction between individual with neurocognitive disorders and natural caregiver seem to be important levers for the implementation of adaptation strategies and for the subsequent voluntary cessation of driving when the cognitive disorders become too severe. This study aims to evaluate an educational program for patient/natural caregiver dyads who wish to implement self-regulation strategies in driving activity, and to improve self-awareness of driving ability. The ACCOMPAGNE program is based on seven group workshops, which target the dyad. The workshops deal with the impact of cognitive, sensory and iatrogenic disorders on driving. They tackle questions about responsibility, and about autonomy and social life. They also provide alternative solutions aimed at maintaining outward-looking activities even if driving is reduced or stopped. A randomized controlled trial is planned to evaluate the effectiveness of the program 2 months and 6 months after inclusion, and to compare this to the effectiveness of conventional approaches. The main outcome of this trial (i.e., the implementation of self-regulated driving strategies), will be measured based on scores on the “Current Self-Regulatory Practices” subscale of the Driver Perception and Practices Questionnaire. The Driving Habits Questionnaire will be used to measure secondary outcomes (indicators of driving changes; indicators of changes in mood, quality of life and caregiver burden; and self-awareness of driving abilities). Indicators will be collected for both patients and natural caregivers. This cognitive, social and psychological program should allow older individuals with cognitive disorders to drive more safely, and help to maintain the quality of life and mood of both patient and natural caregiver despite driving limitations. The patient's care path would be optimized, as he/she would become an actor in the process of giving up driving, which will, most certainly, be needed at some point in the progress of neurocognitive disorders. This process ranges from becoming aware of driving difficulties, to implementing self-regulation strategies, through to complete cessation of driving when necessary.

Clinical trial registration number

NCT04493957.

Effect of Memantine on Prolonging Safe Driving in Early AD: a Pilot Study

BACKGROUND

To determine the feasibility of conducting an RCT on the potential effectiveness of memantine hydrochloride in prolonging safe driving in mild AD.

METHODS

A placebo-controlled, double blind randomized trial was conducted. Forty-three individuals ≥60 with mild AD met screening criteria and were randomized. Driving ability was measured by a standardized on-road driving test. Outcomes were driving capacity at 6 and 12 months and completion of the 12-month intervention.

RESULTS

Of 43 participants randomized, 59% of the memantine group and 52% of the placebo group completed the on-road test at 12 months (p = .66). All 13 memantine group participants maintained their driving status at 12 months, whereas only 8 of the 11 placebo group participants did (p = .040, OR = 4.45).

CONCLUSIONS

Results provide the framework for designing a rigorous multisite clinical trial of memantine effect on maintaining driving capacity in mild AD.

Return-to-driving following acquired brain injury: A neuropsychological perspective

BACKGROUND

Return to driving after an acquired brain injury (ABI) has been positively associated with return to employment, maintenance of social relationships, and engagement in recreational and other community activities. Safe driving involves multiple cognitive abilities in a dynamic environment, and cognitive dysfunction resulting from ABI can negatively impact driving performance.

OBJECTIVE

This manuscript examines the post-injury return-to-driving process, including performances on the in-office and on-road assessments, and the role of a rehabilitation neuropsychologist in helping patients resume driving.

METHOD

In this study, 39 of 200 individuals (approximately 20%) treated at an outpatient neurorehabilitation facility, who performed satisfactorily on a pre-driving cognitive screening, completed a behind-the-wheel driving test.

RESULTS

Of the 200 individuals, 34 (87%) passed the road test. Among the remaining five individuals who did not pass the road test, primary reasons for their failure included inability to follow or retain examiner directions primarily about lane position, speed, and vehicle control. The errors were attributable to cognitive difficulties with information processing, memory, attention regulation, and dual tasking.CONCLUSIONThe rehabilitation neuropsychologist contributed to the process by assessing cognition, facilitating self-awareness and error minimization, providing education about driving regulations and safety standards, and preparing for the road test and its outcomes.

Canadian Older Adults' Perceptions of Transitioning from Driver to Non-Driver

Ceasing driving is associated with many negative outcomes. We examined the perceived impact of driving cessation among current older drivers. Transcripts from 92 interviews with participants from several locations across Canada were analyzed using inductive thematic analysis. We identified five themes: planning for mobility change, mobility supports and neighborhoods, financial security, fearing loss of control and independence, and coping and acceptance as a part of aging. Findings highlight diverse attitudes toward driving cessation, ranging from avoidance to acceptance, and emphasize the importance of tailored resources for drivers at various stages of behavior change.

Using Video Replay of Simulated Driving to Estimate Driving Safety and Cognitive Status

Cognitive decline resulting from Dementia of Alzheimer’s Type (DAT) can lead to reduced ability to perform complex daily tasks required for independent living, including driving an automobile. This study explores the ability of untrained observers to classify driving safety using short video clips of simulated driving through intersections; it also examined whether untrained observers could predict whether the driver was cognitively healthy or cognitively impaired. Participants (n = 54) were shown a series of 30 video clips arranged in an online survey and asked to answer questions following each clip regarding the safety of the maneuver and the cognitive status of the driver. Results showed that participants’ subjectively rated DAT drivers as significantly less safe in comparison to control drivers, F (1, 52) = 228.44, p < 0.001. Participant’s classification of DAT drivers and controls was also significantly higher than chance (i.e., >50% correct). Findings provide preliminary support for the development of a clinical decision-making aid using video replay of driving simulator performance in fitness-to-drive assessments for individuals with cognitive impairment.

The Paradox of Dementia and Driving Cessation: "It's a Hot Topic," "Always on the Back Burner"

BACKGROUND AND OBJECTIVES

Despite the well-recognized difficulty that persons with dementia and family carers experience in the decision making and transition to nondriving, there are few interventions and resources to support them. As part of our ongoing research to develop a driving cessation toolkit that addresses this gap, we sought to examine the context-specific factors relevant to its effective implementation in settings that support older adults with dementia.

RESEARCH DESIGN AND METHODS

A qualitative descriptive approach was used to explore the perspectives of Alzheimer Society (AS) staff in their work of supporting people with dementia and family carers within the context of driving cessation. Individual in-depth interviews were conducted with 15 AS staff members in 4 Canadian provinces. Data were examined using interpretative thematic analysis.

RESULTS

The study results revealed an overarching paradox that despite the importance of driving cessation in people with dementia, it continues to be largely avoided at the individual and system levels. This is explored via the themes of (a) paradox of importance and avoidance identified in AS settings; (b) lack of awareness and understanding about dementia and driving among people with dementia and family carers; (c) distress and avoidance rooted in ongoing system issues; and (d) moving driving cessation to the "front burner."

DISCUSSION AND IMPLICATIONS

Viewed through the emerging social health paradigm, which focuses on the social and emotional consequences of dementia, our results highlight the urgent need to mobilize our communities, medical education systems, and transportation authorities to finally resolve the dementia and driving cessation paradox.

Video feedback intervention for cognitively impaired older drivers: A randomized clinical trial

INTRODUCTION

This clinical trial aimed to determine whether in-car video feedback about unsafe driving events (UDE) to cognitively impaired older drivers and family members leads to a reduction in such driving behaviors.

METHODS

We randomized 51 cognitively impaired older drivers to receive either (1) a weekly progress report with recommendations and access to their videos, or (2) video monitoring alone without feedback over 3 months.

RESULTS

UDE frequency/1000 miles was reduced by 12% in feedback (rate ratio [RR] = 0.88, 95% confidence interval [CI] = .58-1.34), while remaining constant with only monitoring (RR = 1.01, 95% CI = .68-1.51). UDE severity/1000 miles was reduced by 37% in feedback (RR = 0.63, 95% CI = .31-1.27), but increased by 40% in monitoring (RR = 1.40, 95% CI = .68-2.90). Cognitive impairment moderated intervention effects (P = .03) on UDE frequency.

DISCUSSION

Results suggest the potential to improve driving safety among mild cognitively impaired older drivers using a behavior modification approach aimed at problem behaviors detected in their natural driving environment.

Vivre sans ma voiture : une intervention pour soutenir les Canadiens-francophones âgés

The cessation of driving is a difficult transition for the elderly, but it can be facilitated through interventions. The purpose of this study was to explore the satisfaction, usefulness and applicability of the CarFreeMe intervention in the French-Canadian context. A qualitative clinical research device was used on ten older adults aged between 61 and 90 years. The participants had stopped driving within the last twelve months or were planning to stop driving in the near future and did not have cognitive impairments. After the intervention, the participants were generally satisfied and reported on its usefulness and applicability in a French-Canadian context. In addition, they identified the positive impacts related to their social involvement as they re-engaged in or pursued their significant activities. Further research is required to assess the intervention's effects and the practicability of implementing it in Canada.

A virtual second opinion: Acceptability of a computer-based decision tool to assess older drivers with dementia

Clinicians face challenges in deciding which older patients with dementia to report to transportation administrators. This study used a qualitative thematic analysis to understand the utility and limitations of implementing a computer-based Driving in Dementia Decision Tool in clinical practice. Thirteen physicians and eight nurse practitioners participated in an interview to discuss their experience using the tool. While many participants felt the tool provided a useful 'virtual second opinion', specialist physicians felt that the tool did not add value to their clinical practice. Barriers to using the Driving in Dementia Decision Tool included lack of integration with electronic medical records and inability to capture certain contextual nuances. Opinions varied about the impact of the tool on the relationship of clinicians with patients and their families. The Driving in Dementia Decision Tool was judged most useful by nurse practitioners and least useful by specialist physicians. This work highlights the importance of tailoring knowledge translation interventions to particular practices.