Risks and advantages of detecting individuals unfit to drive: a Markov decision analysis

Driving in the elderly in health and disease

Driving is a complex, multifaceted instrumental activity of daily living that has an independent influence on multiple health and well-being outcomes among older adults. Therefore, the benefits of driving to the individual must be balanced, through careful assessment and diagnosis, with the potential risk to self and others posed by a medically impaired driver. The influence of dementia changes substantially during the disease progression from very mild to mild, and driving is not advised for those who have progressed to the moderate stage of Alzheimer disease. Fortunately, validated high-quality screening instruments, including modern simulators and other technology aids, can help clinicians trichotomize risk (i.e., high, moderate, or low) and determine which patients need further evaluation by a driving specialist (e.g., those in the moderate range). Moreover, a body of evidence is building regarding the efficacy of certain intervention pathways to maintain current levels of driving performance among individuals with dementia, or at least slow its decline. Even with the progression of advanced driving technologies, understanding driving ability of patients with dementia will remain a critical challenge to clinicians for the foreseeable future.

Mobility and safety issues in drivers with dementia

Although automobiles remain the mobility method of choice for older adults, late-life cognitive impairment and progressive dementia will eventually impair the ability to meet transport needs of many. There is, however, no commonly utilized method of assessing dementia severity in relation to driving, no consensus on the specific types of assessments that should be applied to older drivers with cognitive impairment, and no gold standard for determining driving fitness or approaching loss of mobility and subsequent counseling. Yet, clinicians are often called upon by patients, their families, health professionals, and driver licensing authorities to assess their patients' fitness-to-drive and to make recommendations about driving privileges. We summarize the literature on dementia and driving, discuss evidenced-based assessments of fitness-to-drive, and outline the important ethical and legal concerns. We address the role of physician assessment, referral to neuropsychology, functional screens, dementia severity tools, driving evaluation clinics, and driver licensing authority referrals that may assist clinicians with an evaluation. Finally, we discuss mobility counseling (e.g. exploration of transportation alternatives) since health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance our patients' social connectedness and quality of life, while meeting their psychological and medical needs and maintaining personal and public safety.

Crash avoidance in response to challenging driving events: The roles of age, serialization, and driving simulator platform

We examined the crash avoidance behaviors of older and middle-aged drivers in reaction to six simulated challenging road events using two different driving simulator platforms. Thirty-five healthy adults aged 21-36 years old (M=28.9±3.96) and 35 healthy adults aged 65-83 years old (M=72.1±4.34) were tested using a mid-level simulator, and 27 adults aged 21-38 years old (M=28.6±6.63) and 27 healthy adults aged 65-83 years old (M=72.7±5.39) were tested on a low-cost desktop simulator. Participants completed a set of six challenging events varying in terms of the maneuvers required, avoiding space given, directional avoidance cues, and time pressure. Results indicated that older drivers showed higher crash risk when events required multiple synchronized reactions. In situations that required simultaneous use of steering and braking, older adults tended to crash significantly more frequently. As for middle-aged drivers, their crashes were attributable to faster driving speed. The same age-related driving patterns were observed across simulator platforms. Our findings support the hypothesis that older adults tend to react serially while engaging in cognitively challenging road maneuvers.

Driving assessment for maintaining mobility and safety in drivers with dementia

BACKGROUND

Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance; extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 years of age screened, but at the price of stopping the driving of 121 people who would not have had a crash.

OBJECTIVES

PRIMARY OBJECTIVES

1. to assess whether driving assessment facilitates continued driving in people with dementia;2. to assess whether driving assessment reduces accidents in people with dementia.

SECONDARY OBJECTIVE

1. to assess the quality of research on assessment of drivers with dementia.

SEARCH METHODS

ALOIS, the Cochrane Dementia Group's Specialized Register was searched on 13 September 2012 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly.

SELECTION CRITERIA

We sought randomised controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment.

DATA COLLECTION AND ANALYSIS

Each review author retrieved studies and assessed for primary and secondary outcomes, study design and study quality.

MAIN RESULTS

No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented.

AUTHORS' CONCLUSIONS

In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.

Driving assessment for maintaining mobility and safety in drivers with dementia

BACKGROUND

Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance; extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 years of age screened, but at the price of stopping the driving of 121 people who would not have had a crash.

PRIMARY OBJECTIVES

1. to assess whether driving assessment facilitates continued driving in people with dementia; 2. to assess whether driving assessment reduces accidents in people with dementia.

SECONDARY OBJECTIVE

1. to assess the quality of research on assessment of drivers with dementia.

SEARCH METHODS

ALOIS, the Cochrane Dementia Group's Specialized Register was searched on 13 September 2012 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly.

SELECTION CRITERIA

We sought randomised controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment.

DATA COLLECTION AND ANALYSIS

Each review author retrieved studies and assessed for primary and secondary outcomes, study design and study quality.

MAIN RESULTS

No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented.

AUTHORS' CONCLUSIONS

In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.

A randomized trial to evaluate the effectiveness of an individual, education-based safe transport program for drivers aged 75 years and older

BACKGROUND

There are concerns over safety of older drivers due to increased crash involvement and vulnerability to injury. However, loss of driving privileges can dramatically reduce independence and quality of life for older members of the community. The aim of this trial is to examine the effectiveness of a safe transport program for drivers aged 75 years and older at reducing driving exposure but maintaining mobility.

METHODS AND DESIGN

A randomised trial will be conducted, involving 380 drivers aged 75 years and older, resident in urban and semi-rural areas of North-West Sydney. The intervention is an education program based on the Knowledge Enhances Your Safety (KEYS) program, adapted for the Australian context. Driving experience will be measured objectively using an in-vehicle monitoring device which includes a global positioning system (GPS) to assess driving exposure and an accelerometer to detect rapid deceleration events. Participation will be assessed using the Keele Assessment of Participation (KAP). Data will be analysed on an intention-to-treat basis; the primary outcomes include driving exposure, rapid deceleration events and scores for KAP. Secondary outcomes include self-reported measures of driving, socialisation, uptake of alternative forms of transport, depressive symptoms and mood. A detailed process evaluation will be conducted, including examination of the delivery of the program and uptake of alternative forms of transport. A subgroup analysis is planned for drivers with reduced function as characterized by established cut-off scores on the Drivesafe assessment tool.

DISCUSSION

This randomised trial is powered to provide an objective assessment of the efficacy of an individually tailored education and alternative transportation program to promote safety of older drivers but maintain mobility.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000543886.

The older adult driver with cognitive impairment: "It's a very frustrating life"

Although automobiles remain the transportation of choice for many older adults, late-life cognitive impairment and dementia often impair the ability to drive safely. However, there is no commonly used method of assessing dementia severity in relation to driving, no consensus on the assessment of older drivers with cognitive impairment, and no gold standard for determining driving fitness. Yet clinicians are called on by patients, their families, other health professionals, and often their state's Department of Motor Vehicles to assess their patients' fitness to drive and to make recommendations about driving privileges. This article describes the challenges of driving with cognitive impairment for both the patient and caregiver, summarizes the literature on dementia and driving, discusses evidence-based assessment of fitness to drive, and addresses important ethical and legal issues. It also describes the role of physician assessment, referral for neuropsychological testing, screening for functional ability, tools to assess dementia severity, driving evaluation clinics, and Department of Motor Vehicles referrals that may assist with evaluation. Lastly, it discusses mobility counseling (eg, exploration of transportation alternatives), because health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance patients' social connectedness and quality of life while meeting their psychological and medical needs and maintaining personal and public safety.