Older drivers: On-road and off-road test results

A systematic review of major evaluation metrics for simulator-based automatic assessment of driving after stroke

Background: Simulator-based driving assessments (SA) have recently been used and studied for various purposes, particularly for post-stroke patients. Automating such assessment has potential benefits especially on reducing financial cost and time. Nevertheless, there currently exists no clear guideline on assessment techniques and metrics available for SA for post-stroke patients. Therefore, this systematic review is conducted to explore such techniques and establish guidelines for evaluation metrics. Objective: This review aims to find: (a) major evaluation metrics for automatic SA in post-stroke patients and (b) assessment inputs and techniques for such evaluation metrics. Methods: The study follows the PRISMA guideline. Systematic searches were performed on PubMed, Web of Science, ScienceDirect, ACM Digital Library, and IEEE Xplore Digital Library for articles published from January 1, 2010, to December 31, 2023. This review targeted journal articles written in English about automatic performance assessment of simulator-based driving by post-stroke patients. A narrative synthesis was provided for the included studies. Results: The review included six articles with a total of 239 participants. Across all of the included studies, we discovered 49 distinct assessment inputs. Threshold-based, machine-learning-based, and driving simulator calculation approaches are three primary types of assessment techniques and evaluation metrics identified in the review. Discussion: Most studies incorporated more than one type of input, indicating the importance of a comprehensive evaluation of driving abilities. Threshold-based techniques and metrics were the most commonly used in all studies, likely due to their simplicity. An existing relevant review also highlighted the limited number of studies in this area, underscoring the need for further research to establish the validity and effectiveness of simulator-based automatic assessment of driving (SAAD). Conclusions: More studies should be conducted on various aspects of SAAD to explore and validate this type of assessment.

Different deployments of attentional breadth selectively predict UFOV task performance in older adults

The Useful Field of View task (UFOV) is a strong and reliable predictor of crash risk in older drivers. However, while the functional domain of attention is clearly implicated in UFOV performance, the potential role of one specific attentional process remains unclear: attentional breadth (the spatial extent of the attended region around the point of visual fixation). The goal of the present study was to systematically test the role of two distinct aspects of attentional breadth, maintaining a specific breadth of attention and resizing the attended region, in UFOV performance. To this end, 135 older adults completed the UFOV and modified Navon tasks to measure their efficiency in maintaining, contracting, and expanding the breadth of attention. We then examined individual-difference associations between these aspects of attentional breadth deployment and UFOV performance. We found that performance on UFOV Subtask 2 was associated with efficient contraction of attentional breadth (i.e., resizing the attended region to a smaller area), while Subtask 3 performance was associated with the efficiency of expanding attentional breadth (i.e., resizing the attended region to a larger area). The selectivity of these relationships appears to implicate these specific deployments of attentional breadth in how people complete the task, as it suggests that these relationships are not simply attributable to shared variance in a broader domain of cognitive functioning. The implications of these results for our understanding of UFOV, as well as future research directions that test the relative contributions of different cognitive processes in predicting task performance, are discussed.

Performance Analysis of Driving Ability (P-Drive): Investigating Construct Validity and Concordance of Australasian Data

On-road assessment is optimal for determining medical fitness-to-drive but unreliable if determined by global pass/fail decisions alone. Occupational therapists need standardized, psychometrically sound on-road scoring procedures. Performance Analysis of Driving Ability (P-Drive) is a promising on-road test developed in Sweden, but it has not been standardized for Australasia. We investigated the psychometric properties and concordance with an on-road decision of data gathered with the Australasian version of P-Drive. P-Drive was administered to older and cognitively impaired drivers (N = 134) aged 18 to 91 years (mean age 68) who were referred to 10 driving clinics in Australia and New Zealand to determine driving performance. Rasch analysis provided evidence for construct validity and concordance of the data gathered. An optimal cut-off score of 85 was set, yielding evidence of good sensitivity at 88% and specificity at 88%. The Australasian version of P-Drive produces valid and reliable data regarding on-road driving performance.

Validation of a computerized driving simulator test of cognitive abilities for fitness-to-drive assessments

Background

Driving requires a series of cognitive abilities, many of which are affected by age and medical conditions. The psychosocial importance of continued driving ushers the need for valid measurements in fitness-to-drive assessments. A driving simulator test could prove useful in these assessments, having greater face validity than other off-road tests and being more cost-effective and safer than ordinary on-road testing. The aim of this study was to validate a driving simulator test for assessment of cognitive ability in fitness-to-drive assessments.

Methods

The study included 67 healthy participants. Internal consistency of the simulator subtests was estimated. A correlation analysis between results on the simulator and the cognitive tests Trail Making Test (TMT) A and B and the Useful field of View test (UFOV) and multiple regression analysis were conducted. Finally, a comparison of results between age groups (>65 years) and (<65 years) was done.

Results

Results showed good internal consistency. Significant and moderate correlations were found for all reaction time in the simulator's subtests and UFOV 3, and all but two with TMT A. Lane positioning in the simulator showed significant and low to moderate correlations with UFOV 3 in all subtests. Reaction time and Double reaction time on subtest 3 were significantly correlated with UFOV 2 and UFOV 3 and TMT A, respectively. Test on Centerline (position) in subtest 3 as dependent variable was significantly correlated with UFOV 3. Significant means differences and large effect sizes between the age groups were found for all reaction time and lane positioning tests.

Conclusion

The findings of concurrent validity, especially with TMT A and UFOV 3 and its sensitivity for age-related differences, indicate potential for the simulator to be used as a complement in fitness-to-drive assessments. However, a clinical study is necessary to further examine its usefulness for patients with cognitive deficits.

Overestimation of on-road driving performance is associated with reduced driving safety in older drivers

OBJECTIVES

Older drivers often show less precise self-ratings with a tendency to overestimate themselves. It is unclear, however, how overestimators differ from underestimators or drivers with adequate self-ratings.

METHODS

59 healthy older drivers participated in this on-road study. Besides standardized on-road driving assessment, the study protocol included the collection of neuropsychological and driving-related data as well as different self-ratings. Statistical analyses involved correlations between different subjective and objective ratings as well as statistical comparisons between drivers who overestimated and drivers who adequately rated their on-road driving performance (no drivers underestimated their performance).

RESULTS

Despite positive correlations between different self- and expert ratings, our results revealed that 25 % of the participants overestimated their on-road driving skills. Among other things, overestimators showed poorer on-road driving performances, more prospective near and minor at-fault accidents, poorer cognitive performances in specific driving-related domains and reduced annual mileage.

DISCUSSION

Our results suggest that older drivers who overestimate their driving skills show poorer performances within a broad range of skills that directly reflect or are closely related to driving safety. Against the background that an adequate self-assessment is required by German traffic regulations, our findings suggest that overestimators represent a risk group among the population of older drivers.

Predicting Fitness to Drive for Medically At-Risk Drivers Using Touchscreen DriveSafe DriveAware

IMPORTANCE

Occupational therapists require valid cognitive fitness-to-drive tools to advise drivers in this high-stakes area.

OBJECTIVE

To examine the psychometric properties and predictive validity of data gathered with the touchscreen DriveSafe DriveAware (DSDA).

DESIGN

Prospective study that compared a screening tool with a criterion standard.

SETTING

Ten community- and hospital-based driver assessment clinics in Australia and New Zealand.

PARTICIPANTS

Older and cognitively impaired drivers (N = 134) ages 18 to 91 years (Mage= 68) who were referred for an assessment to determine the impact of a medical condition on driving. The inclusion criteria were a valid driver's license, vision within license authority guidelines, completion of at least 1 year of high school, and English as a first language.

OUTCOMES AND MEASURES

The results of the touchscreen DSDA, a standardized assessment of awareness of the driving environment and one's own driving abilities, were compared with those of a standardized occupational therapist-administered on-road assessment.

RESULTS

Rasch analysis provided evidence for the construct validity and internal reliability of data gathered with the touchscreen DSDA. Optimal upper and lower cutoff scores were set to trichotomize drivers into three categories: likely to pass an on-road assessment, likely to fail an on-road assessment, and further testing required. Specificity of the touchscreen DSDA was 86%, and sensitivity was 91%; positive predictive value was 83%, negative predictive value was 92%, and overall accuracy of classification was 88%.

CONCLUSIONS AND RELEVANCE

Evidence supports the utility of the touchscreen DSDA for accurately predicting which participants require on-road assessment. What This Article Adds: The touchscreen DSDA is a promising screen for occupational therapists and other health professionals to use in conjunction with other clinical indicators to determine whether drivers require further assessment.

Development of a Web-Based Mini-Driving Scene Screening Test (MDSST) for Clinical Practice in Driving Rehabilitation

(1) Background: For the elderly and disabled, self-driving is very important for social participation. An understanding of changing driving conditions is essential in order to drive safely. This study aimed to develop a web-based Korean Mini-Driving Scene Screening Test (MDSST) and to verify its reliability and validity for clinical application. (2) Methods: We developed a web-based MDSST, and its content validity was verified by an expert group. The tests were conducted with 102 elderly drivers to verify the internal consistency and reliability of items, and the validity of convergence with the existing Korean-Safe Driving Behavior Measure (K-SDBM) and the Korean-Adelaide Driving Self-Efficacy Scale (K-ADSES) driving tests was also verified. The test–retest reliability was verified using 54 individuals who participated in the initial test. (3) Results: The average content validity index of MDSST was 0.90, and the average internal consistency of all items was 0.822, indicating high content validity and internal consistency. The exploratory factor analysis for construct validity, the KOM value of the data, was 0.658, and Bartlett’s sphericity test also showed a strongly significant result. The four factors were road traffic and signal perception, situation understanding, risk factor recognition, and situation prediction. The explanatory power was reliable at 61.27%. For the convergence validation, MDSST and K-SDBM showed r = 0.435 and K-ADSES showed r = 0.346, showing a moderate correlation. In the evaluation–reevaluation reliability verification, the reliability increased to r = 0.952. (4) Conclusions: The web-based MDSST test developed in this study is a useful tool for detecting and understanding real-world driving situations faced by elderly drivers. It is hoped that the MDSST test can be applied more widely as a driving ability test that can be used in the clinical field of driving rehabilitation.

Characteristics of driving self-assessments and factors related to inaccurate self-assessment in Japanese older adults

Older adults are considered to decide their driving behaviors based their own assessment of their driving performance, and thus it is important that these self-assessments be accurate. Therefore, this study aimed to clarify how older drivers assess their driving performance and examine factors related to the level of inaccuracy in their self-assessments. Japanese drivers aged 70 years or older (N = 181) were asked to assess their own driving performance by questionnaire and then to drive on a public road while wearing an electronic device that measured their actual driving behaviors. They were accompanied by a driving instructor who sat in the passenger seat and assessed their driving performance. The results showed that older drivers' self-assessments were significantly higher than the experts' assessments of their driving performance. This tendency applied to all driving competencies, including overall rating, speed, and scanning. In addition, there were greater discrepancies between self-assessments and expert assessments for drivers who were rated poorly by experts compared with those who were highly rated. Drivers with a greater rating discrepancy were likely to drive faster around an intersection with a stop sign. This discrepancy was also related to a low entropy rate (low randomness in head rotation) around a signalized T-junction. These findings based on on-road driving assessments provide credible evidence of performance overestimation by older drivers. Furthermore, the results suggest that making older drivers recognize the evaluative criteria might be effective for reducing the discrepancy between self-assessments and expert assessments. It was also suggested that improving the accuracy of one's self-assessment had the potential to improve driving behaviors such as choice of speed and scanning behavior.

Investigating On-Road Lane Maintenance and Speed Regulation in Post-Stroke Driving: A Pilot Case-Control Study

Stroke can adversely affect the coordination and judgement of drivers due to executive dysfunction, which is relatively common in the post-stroke population but often undetected. Quantitatively examining vehicle control performance in post-stroke driving becomes essential to inspect whether and where post-stroke older drivers are risky. To date, it is unclear as to which indicators, such as lane keeping or speed control, can differentiate the driving performance of post-stroke older drivers from that of normal (neurotypical) older drivers. By employing a case-control design using advanced vehicle movement tracking and analysis technology, this pilot study aimed to compare the variations in driving trajectory, lane keeping and speed control between the two groups of older drivers using spatial and statistical techniques. The results showed that the mean standard deviation of lane deviation (SDLD) in post-stroke participants was higher than that of normal participants in complex driving tasks (U-turn and left turn) but almost the same in simple driving tasks (straight line sections). No statistically significant differences were found in the speed control performance. The findings indicate that, although older drivers can still drive as they need to after a stroke, the decline in cognitive abilities still imposes a higher cognitive workload and more effort for post-stroke older drivers. Future studies can investigate post-stroke adults' driving behaviour at more challenging driving scenarios or design driving intervention programs to improve their executive function in driving.

Enhancing the Clinical Utility of DriveSafe DriveAware for People with Huntington's Disease

DriveSafe DriveAware (DSDA) is a cognitive screening tool assessing driving safety. Previously, we found DSDA categorised some HD participants as 'likely to pass' on-road assessments, despite displaying cognitive impairments in domains known to impact driving. As processing speed is affected early in HD, we examined whether DSDA completion time could provide supplementary cognitive information to support clinical decision-making. The HD group completed subtests significantly slower than controls, and completion times correlated with cognitive functions essential for driving. Considering DSDA completion time may tailor the assessment for people with HD so that it is more reflective of HD-related cognitive functioning.

Off-road assessment of cognitive fitness to drive

Road safety is a major issue in every society. The assessment of driving ability with a real vehicle is a lengthy and costly process; therefore, there is a growing need for the development of a neuropsychological battery that can provide a fast and reliable evaluation of a person's cognitive fitness to drive. In the present study, we examined the relationship of an off-road lab-type test, namely, the Driving Scenes test, with performance on a driving simulator, as well as the influence of cognitive factors on driving ability as evaluated by Driving Scenes. Our results demonstrated a relationship between Driving Scenes and driving simulator performance. They also showed that some cognitive factors (namely, selective attention and verbal memory), were predictive of driving ability (as determined by the Driving Scenes test), but not others (namely visuospatial perception/memory, working memory, and visuospatial recognition). In addition, age strongly predicted performance on this test (younger age was associated with better performance). The conclusions derived from the present study highlight the need to identify off-road tools with high predictive value in assessing driving ability.

Standardized on-road tests assessing fitness-to-drive in people with cognitive impairments: A systematic review

Objective

The on-road assessment is the gold standard because of its ecological validity. Yet existing instruments are heterogeneous and little is known about their psychometric properties. This study identified existing on-road assessment instruments and extracted data on psychometric properties and usability in clinical settings.

Method

A systematic review identified studies evaluating standardized on-road evaluation instruments adapted for people with cognitive impairment. Published articles were searched on PubMed, CINHAL, PsycINFO, Web of Science, and ScienceDirect. Study quality and the level of evidence were assessed using the COSMIN checklist. The collected data were synthetized using a narrative approach. Usability was subjectively assessed for each instrument by extracting information on acceptability, access, cost, and training.

Results

The review identified 18 published studies between 1994 and 2016 that investigated 12 different on-road evaluation instruments: the Performance-Based Driving Evaluation, the Washington University Road Test, the New Haven, the Test Ride for Practical Fitness to Drive, the Rhode Island Road Test, the Sum of Manoeuvres Score, the Performance Analysis of Driving Ability, the Composite Driving Assessment Scale, the Nottingham Neurological Driving Assessment, the Driving Observation Schedule, the Record of Driving Errors, and the Western University’s On-road Assessment. Participants were mainly male (64%), between 48 and 80 years old, and had a broad variety of cognitive disorders. Most instruments showed reasonable psychometric values for internal consistency, criterion validity, and reliability. However, the level of evidence was poor to support any of the instruments given the low number of studies for each.

Conclusion

Despite the social and health consequences of decisions taken using these instruments, little is known about the value of a single evaluation and the ability of instruments to identify expected changes. None of the identified on-road evaluation instruments seem currently adapted for clinical settings targeting rehabilitation and occupational priorities rather than road security alone.

Study registration

PROSPERO registration number CRD42018103276.

Are interventions effective at improving driving in older drivers?: A systematic review

Background

With the aging of the population, the number of older drivers is on the rise. This poses significant challenges for public health initiatives, as older drivers have a relatively higher risk for collisions. While many studies focus on developing screening tools to identify medically at-risk drivers, little research has been done to develop training programs or interventions to promote, maintain or enhance driving-related abilities among healthy individuals. The purpose of this systematic review is to synopsize the current literature on interventions that are tailored to improve driving in older healthy individuals by working on components of safe driving such as: self-awareness, knowledge, behaviour, skills and/or reducing crash/collision rates in healthy older drivers.

Methods

Relevant databases such as Scopus and PubMed databases were selected and searched for primary articles published in between January 2007 and December 2017. Articles were identified using MeSH search terms: (“safety” OR “education” OR “training” OR “driving” OR “simulator” OR “program” OR “countermeasures”) AND (“older drivers” OR “senior drivers” OR “aged drivers” OR “elderly drivers”). All retrieved abstracts were reviewed, and full texts printed if deemed relevant.

Results

Twenty-five (25) articles were classified according to: 1) Classroom settings; 2) Computer-based training for cognitive or visual processing; 3) Physical training; 4) In-simulator training; 5) On-road training; and 6) Mixed interventions. Results show that different types of approaches have been successful in improving specific driving skills and/or behaviours. However, there are clear discrepancies on how driving performance/behaviours are evaluated between studies, both in terms of methods or dependent variables, it is therefore difficult to make direct comparisons between these studies.

Conclusions

This review identified strong study projects, effective at improving older drivers’ performance and thus allowed to highlight potential interventions that can be used to maintain or improve older drivers’ safety behind the wheel. There is a need to further test these interventions by combining them and determining their effectiveness at improving driving performance.

Reliability and validity of on-road driving tests in vulnerable adults: a systematic review

The on-road driving test is considered a ‘gold standard’ evaluation; however, its validity and reliability have not been sufficiently reviewed. This systematic review aimed to map out and synthesize literature regarding on-road driving tests using the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. Cochrane Library, PubMed, CINAHL, and Web of Science databases were searched from initiation through February 2018. All articles addressing reliability or validity of on-road driving tests involving adult rehabilitation patients were included. The search output identified 513 studies and 36 articles, which were included in the review. The Washington University Road Test/Rhode Island Road Test, performance analysis of driving ability, test ride for investigating practical fitness-to-drive, and K-score demonstrated high reliability and validity in regard to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. The Washington University Road Test/Rhode Island Road Test and test ride for investigating practical fitness-to-drive were analyzed based on Classical Test Theory techniques, and performance analysis of driving ability and K-score were analyzed based on Item Response Theory techniques. The frequency of studies were Washington University Road Test/Rhode Island Road Test (n=9), Test Ride for Investigating Practical fitness-to-drive (n=8), performance analysis of driving ability (n=4), and K-score (n=1). From the viewpoint of accuracy and generalization, the Washington University Road Test/Rhode Island Road Test, test ride for investigating practical fitness-to-drive, and performance analysis of driving ability were identified as highly qualified concerning on-road driving tests. However, the ability to assess real-world driving depends on various environmental conditions.

Personal and Clinical Factors Associated with Older Drivers' Self-Awareness of Driving Performance

Most older adults perceive themselves as good drivers; however, their perception may not be accurate, and could negatively affect their driving safety. This study examined the accuracy of older drivers' self-awareness of driving ability in their everyday driving environment by determining the concordance between the perceived (assessed by the Perceived Driving Ability [PDA] questionnaire) and actual (assessed by electronic Driving Observation Schedule [eDOS]) driving performance. One hundred and eight older drivers (male: 67.6%; age: mean = 80.6 years, standard deviation [SD] = 4.9 years) who participated in the study were classified into three groups: underestimation (19%), accurate estimation (29%), and overestimation (53%). Using the demographic and clinical functioning information collected in the Candrive annual assessments, an ordinal regression showed that two factors were related to the accuracy of self-awareness: older drivers with better visuo-motor processing speed measured by the Trail Making Test (TMT)-A and fewer self-reported comorbid conditions tended to overestimate their driving ability, and vice versa.

Contributory Factors to critically wrong road-crossing judgements among older people: an integrated research study

Introduction

Older people are having higher risk of vehicle-pedestrian collisions. This study examines the relative importance of different environmental, physical and cognitive factors in contributing to critically wrong road-crossing judgements.

Methods

An integrated research design is adopted. Older pedestrians were recruited through Elderly Community Centres in Hong Kong. Data about their physical and cognitive ability were collected through setting up outreach laboratories within the participants' neighbourhood communities. In addition to obtaining two walking speeds, three clinical tests (the visual acuity test, Timed Up and Go test and Mini Mental State Examination [MMSE] test) were conducted. A questionnaire survey collected personal information and activity data. Eighteen different road-crossing scenarios showing the same dual-lane one-way local road with different traffic conditions (a vehicle approaching at different distances, at different speeds, and on different lanes) were captured in videos and presented to the participants. Their decision time and judgement for each scenario were recorded in a computer. Apart from descriptive statistics, a binary logistic generalised estimating equation model was estimated. The dependent variable is whether a road-crossing judgement was critically wrong or not.

Results and Conclusions

A total of 7,182 road-crossing judgements of 399 older people were collected. The most statistically significant factors contributing to critically wrong road-crossing judgements are the road environment variables of the speed and distance of the oncoming vehicle. On physical variables, walking speed is the most important factor. Lastly, the cognitive variable of MMSE score is significant. For the mild and moderate impairment groups, the chances of making a critically wrong judgement are 1.83 and 2.01 times that of the normal group respectively.

Investigating cognitive ability and self-reported driving performance of post-stroke adults in a driving simulator

Background Safe driving is a complex activity that requires calibration. This means the driver can accurately assess the level of task demand required for task completion and can accurately evaluate their driving capability. There is much debate on the calibration ability of post-stroke drivers. Objectives The aim of this study was to assess the cognition, self-rated performance, and estimation of task demand in a driving simulator with post-stroke drivers and controls. Methods A between-groups study design was employed, which included a post-stroke driver group and a group of similarly aged older control drivers. Both groups were observed driving in two simulator-based driving scenarios and asked to complete the NASA Task Load Index (TLX) to assess their perceived task demand and self-rate their driving performance. Participants also completed a battery of psychometric tasks to assess attention and executive function, which was used to determine whether post-stroke cognitive impairment impacted on calibration. Results There was no difference in the amount of perceived task demand required to complete the driving task. Despite impairments in cognition, the post-stroke drivers were not more likely to over-estimate their driving abilities than controls. On average, the post-stroke drivers self-rated themselves more poorly than the controls and this rating was related to cognitive ability. Conclusion This study suggests that post-stroke drivers may be aware of their deficits and adjust their driving behavior. Furthermore, using self-performance measures alongside a driving simulator and cognitive assessments may provide complementary fitness-to-drive assessments, as well as rehabilitation tools during post-stroke recovery.

Predictors of older drivers' involvement in high-range speeding behavior

OBJECTIVE

Even small increases in vehicle speed raise crash risk and resulting injury severity. Older drivers are at increased risk of involvement in casualty crashes and injury compared to younger drivers. However, there is little objective evidence about older drivers' speeding. This study investigates the nature and predictors of high-range speeding among drivers aged 75-94 years.

METHODS

Speed per second was estimated using Global Positioning System devices installed in participants' vehicles. High-range speeding events were defined as traveling an average 10+km/h above the speed limit over 30 seconds. Descriptive analysis examined speeding events by participant characteristics and mileage driven. Regression analyses were used to examine the association between involvement in high-range speeding events and possible predictive factors.

RESULTS

Most (96%, 182/190) participants agreed to have their vehicle instrumented, and speeding events were accurately recorded for 97% (177/182) of participants. While 77% (136/177) of participants were involved in one or more high-range events, 42% (75/177) were involved in greater than five events during 12-months of data collection. Participants involved in high-range events drove approximately twice as many kilometres as those not involved. High-range events tended to be infrequent (median = 6 per 10,000 km; IQR = 2-18). The rate of high-range speeding was associated with better cognitive function and attention to the driving environment.

CONCLUSION

This suggests those older drivers with poorer cognition and visual attention may drive more cautiously, thereby reducing their high-range speeding behavior.

Experiences of facilitators or barriers in driving education from learner and novice drivers with ADHD or ASD and their driving instructors

BACKGROUND

Little is known about whether individuals with autism spectrum disorder (ASD) or attention deficit hyperactive disorder (ADHD) experience any specific facilitators or barriers to driving education.

OBJECTIVE

To explore the facilitators or barriers to driving education experienced by individuals with ASD or ADHD who obtained a learner's permit, from the perspective of the learner drivers and their driving instructors.

METHODS

Data were collected from 33 participants with ASD or ADHD, and nine of their driving instructors.

RESULTS

Participants with ASD required twice as many driving lessons and more on-road tests than those with ADHD. Participants with ADHD repeated the written tests more than those with ASD. Driving license theory was more challenging for individuals with ADHD, whilst individuals with ASD found translating theory into practice and adjusting to "unfamiliar" driving situations to be the greatest challenges.

CONCLUSION

Obtaining a driving license was associated with stressful training experience.

Supporting Safety in the Older Adult Driver: A Public Health Nursing Opportunity

The effective operation of a motor vehicle encompasses a wide range of cognitive processes that can decline due to age-related changes in neuroanatomical structures and cognitive functionality. The increasing number of older adult drivers in our rapidly aging population heightens the public safety concern of unsafe driving associated with these changes. Nurses caring for older adults in public health settings are well positioned to make a difference in the management of older patients who may be at risk of endangering themselves or others on the roadways. In this article, information is provided for increasing nurses' awareness of the cognitive factors inhibiting effective driving, recognizing older adults who may be at risk for unsafe driving, and facilitating a patient/family to seek a driving evaluation.

P-Drive: Implementing an Assessment of On-Road Driving in Clinical Settings and Investigating Its Internal and Predictive Validity

We investigated (1) the psychometric properties of data gathered with the Performance Analysis of Driving Ability (P-Drive), an on-road assessment; (2) P-Drive's predictive validity in relation to a summed decision of passing or failing a medical driving evaluation; and (3) the success of implementing P-Drive. Drivers (N=99) with neurological impairment referred for a driving evaluation were observed on road and scored using P-Drive. Results showed evidence of person response validity and internal validity. P-Drive separated the drivers into four different strata (reliability coefficient=.92). A cutoff raw score of 81 was optimal, with sensitivity of 93% and specificity of 92%. Although only 9 occupational therapists (of 19 initially trained) contributed data for analysis, 17 reported using the assessment. Data gathered with P-Drive yielded evidence of excellent psychometric properties. Moreover, P-Drive was implemented successfully in clinical settings, although initial training to full implementation took longer than 1 yr.

Does attention capacity moderate the effect of driver distraction in older drivers?

With age, a decline in attention capacity may occur and this may impact driving performance especially while distracted. Although the effect of distraction on driving performance of older drivers has been investigated, the moderating effect of attention capacity on driving performance during distraction has not been investigated yet. Therefore, the aim was to investigate whether attention capacity has a moderating effect on older drivers' driving performance during visual distraction (experiment 1) and cognitive distraction (experiment 2). In a fixed-based driving simulator, older drivers completed a driving task without and with visual distraction (experiment 1, N=17, mean age 78 years) or cognitive distraction (experiment 2, N=35, mean age 76 years). Several specific driving measures of varying complexity (i.e., speed, lane keeping, following distance, braking behavior, and crashes) were investigated. In addition to these objective driving measures, subjective measures of workload and driving performance were also included. In experiment 1, crash occurrence increased with visual distraction and was negatively related to attention capacity. In experiment 2, complete stops at stop signs decreased, initiation of braking at pedestrian crossings was later, and crash occurrence increased with cognitive distraction. Interestingly, for a measure of lane keeping (i.e., standard deviation of lateral lane position (SDLP)), effects of both types of distraction were moderated by attention capacity. Despite the decrease of driving performance with distraction, participants estimated their driving performance during distraction as good. These results imply that attention capacity is important for driving. Driver assessment and training programs might therefore focus on attention capacity. Nonetheless, it is crucial to eliminate driver distraction as much as possible given the deterioration of performance on several driving measures in those with low and high attention capacity.

Reliability of P-drive in occupational therapy following a short training session: A promising instrument measuring seniors’ on-road driving competencies

Introduction

Occupational therapists could play an important role in facilitating driving cessation for ageing drivers. This, however, requires an easy-to-learn, standardised on-road evaluation method. This study therefore investigates whether use of ‘P-drive’ could be reliably taught to occupational therapists via a short half-day training session.

Method

Using the English 26-item version of P-drive, two occupational therapists evaluated the driving ability of 24 home-dwelling drivers aged 70 years or over on a standardised on-road route. Experienced driving instructors’ on-road, subjective evaluations were then compared with P-drive scores.

Results

Following a short half-day training session, P-drive was shown to have almost perfect between-rater reliability (ICC2,1 = 0.950, 95% CI 0.889 to 0.978). Reliability was stable across sessions including the training phase even if occupational therapists seemed to become slightly less severe in their ratings with experience. P-drive’s score was related to the driving instructors’ subjective evaluations of driving skills in a non-linear manner ( R2 = 0.445, p = 0.021).

Conclusion

P-drive is a reliable instrument that can easily be taught to occupational therapists and implemented as a way of standardising the on-road driving test.

Viewpoints on driving of individuals with and without autism spectrum disorder

OBJECTIVE

Understanding the viewpoints of drivers with autism spectrum disorder (ASD) is crucial in the development of mobility support and driver training that is responsive to their needs.

METHODS

Fifty young adults with ASD and fifty seven typically developed adults participated in the study to form a contrasting group. Q-methodology was used to understand viewpoints on driving as a main mode of transportation. Data were analysed using a PQ by-person varimax rotation factor analysis.

RESULTS

Although some ASD participants perceived themselves as confident and independent drivers, others preferred other modes of transportation such as public transport and walking. Anxiety was also found to be a barrier to driving. The contrast group revealed consistent viewpoints on their driving ability. They preferred driving as their main mode of transportation and believed that they were competent, safe and independent drivers.

CONCLUSION

These results are important in the planning of transport policies and driver training for individuals with ASD. Driver training manuals can be developed to address anxiety issues, hazard perception and navigation problems in the ASD population. Their use of public transport could be further facilitated through more inclusive transport policies.

Post-stroke driving: examining the effect of executive dysfunction

INTRODUCTION

Executive dysfunction can refer to both neurocognitive deficits and behavioral symptoms that include impaired judgment, slow decision making, disorganization, impulsiveness, and risk-taking behaviors. Executive dysfunction is relatively common in the post-stroke population but is often undetected. The impact of executive dysfunction on post-stroke driving is unclear but it may pose a risk to affected drivers and other road users.

AIM

The aim of this study was to investigate the relationship between executive functioning following stroke and driving performance.

METHODOLOGY

A case-control study design was used. Purposive sampling was used to recruit stroke participants (n=19) and healthy controls (n=22). Participants were screened using a battery of psychometric assessments including the Montreal Cognitive Assessment and the Benton Judgment of Line Orientation. Driving performance was assessed using the STISIM driving simulator. Executive function was assessed using the Behavioural Assessment of the Dysexecutive Syndrome (BADS) and the Trail Making Test Part B.

RESULTS

The control participants performed better than the stroke participants on the driving assessment and psychometric assessments. There was an association between the scores of the Trail Making Test Part B (Rho=0.34, p=0.034) and the Key Search Test of the BADS (Rho=-0.61, p=0.005), and the driving assessment scores. However, there was no association between the overall BADS scores and the driving assessment scores of the stroke participants.

CONCLUSIONS

The stroke participants underperformed in the driving assessment and the psychometric assessments that detected neurocognitive deficits, which included executive function. The Trail Making Test Part B and Key Search Test of the BADS were related to identify participants' deterioration in driving performance. Practical Applications: In clinical practice, the latter could be used as an indication of a post-stroke driver's performance.

The drive-wise project: driving simulator training increases real driving performance in healthy older drivers

Background: Age-related cognitive decline is often associated with unsafe driving behavior. We hypothesized that 10 active training sessions in a driving simulator increase cognitive and on-road driving performance. In addition, driving simulator training should outperform cognitive training.

Methods: Ninety-one healthy active drivers (62–87 years) were randomly assigned to one of three groups: (1) a driving simulator training group, (2) an attention training group (vigilance and selective attention), or (3) a control group. The main outcome variables were on-road driving and cognitive performance. Seventy-seven participants (85%) completed the training and were included in the analyses. Training gains were analyzed using a multiple regression analysis with planned orthogonal comparisons.

Results: The driving simulator-training group showed an improvement in on-road driving performance compared to the attention-training group. In addition, both training groups increased cognitive performance compared to the control group.

Conclusion: Driving simulator training offers the potential to enhance driving skills in older drivers. Compared to the attention training, the simulator training seems to be a more powerful program for increasing older drivers' safety on the road.

Safe mobility for elderly drivers--considerations based on expert and self-assessment

To further understand the needs of the growing population of elderly drivers and create solutions for safe mobility it is important to understand the driving scenarios and aspects in day to day traffic that may be of challenge for this group. More so, individual differences in how drivers perceive their own driving ability may have an effect on how individuals limit their mobility and/or increase their exposure to risk situations, with a potential negative effect on safety. In this study two sets of assessments have been used in order to identify scenarios and aspects needing consideration in creating safe mobility for elderly drivers; an expert assessment using on-road driving together with assessments through semi structured in-depth interviews. This combination also enables categorisation of the drivers, comparing their own perception of their driving performance with the expert assessment based on actual on-road driving. Four different categories of drivers were identified: adequate (positive), over, under and adequate (negative) estimators. A number of important aspects were identified in the study. Adapting speed to the situation and driving too fast, especially on straight roads in the city, is one aspect. Seeking the attention of other road users at intersections and roundabouts is another important consideration identified. Awareness of difficulties related to speed adaptation and attention was low amongst all the driver categories. However, a difference in attitude was seen in the categories with a more humble and acceptant attitude amongst the adequate and under estimator groups, as compared to the over estimators suggesting that the aspect of attitudes is another important factor for consideration.

Using the community health assessment to screen for continued driving

This project used the interRAI based, community health assessment (CHA) to develop a model for identifying current elder drivers whose driving behavior should be reviewed. The assessments were completed by independent housing sites in COLLAGE, a non-profit, national senior housing consortium. Secondary analysis of data drawn from older adults in COLLAGE sites in the United States was conducted using a baseline assessment with 8042 subjects and an annual follow-up assessment with 3840 subjects. Logistic regression was used to develop a Driving Review Index (DRI) based on the most useful items from among the many measures available in the CHA assessment. Thirteen items were identified by the logistic regression to predict drivers whose driving behavior was questioned by others. In particular, three variables reference compromised decision-making abilities: general daily decisions, a recent decline in ability to make daily decisions, and ability to manage medications. Two additional measures assess cognitive status: short-term memory problem and a diagnosis of non-Alzheimers dementia. Functional measures reflect restrictions and general frailty, including receiving help in transportation, use of a locomotion appliance, having an unsteady gait, fatigue, and not going out on most days. The final three clinical measures reflect compromised vision, little interest or pleasure in things normally enjoyed, and diarrhea. The DRI focuses the review process on drivers with multiple cognitive and functional problems, including a significant segment of potentially troubled drivers who had not yet been publicly identified by others. There is a need for simple and quickly identified screening tools to identify those older adults whose driving should be reviewed. The DRI, based on the interRAI CHA, fills this void. Assessment at the individual level needs to be part of the backdrop of science as society seeks to target policy to identify high risk drivers instead of simply age-based testing.

Systematic review of the evidence for Trails B cut-off scores in assessing fitness-to-drive

Background

Fitness-to-drive guidelines recommend employing the Trail Making B Test (a.k.a. Trails B), but do not provide guidance regarding cut-off scores. There is ongoing debate regarding the optimal cut-off score on the Trails B test.

The objective of this study was to address this controversy by systematically reviewing the evidence for specific Trails B cut-off scores (e.g., cut-offs in both time to completion and number of errors) with respect to fitness-to-drive.

Methods

Systematic review of all prospective cohort, retrospective cohort, case-control, correlation, and cross-sectional studies reporting the ability of the Trails B to predict driving safety that were published in English-language, peer-reviewed journals.

Results

Forty-seven articles were reviewed. None of the articles justified sample sizes via formal calculations. Cut-off scores reported based on research include: 90 seconds, 133 seconds, 147 seconds, 180 seconds, and < 3 errors.

Conclusions

There is support for the previously published Trails B cut-offs of 3 minutes or 3 errors (the ‘3 or 3 rule’). Major methodological limitations of this body of research were uncovered including (1) lack of justification of sample size leaving studies open to Type II error (i.e., false negative findings), and (2) excessive focus on associations rather than clinically useful cut-off scores.

The Addenbrooke's Cognitive Examination Revised as a potential screening test for elderly drivers

Considerable research has shown that neuropsychological tests are predictive of real-world driving ability. The Mini-Mental State Examination (MMSE) is a brief cognitive test that has been commonly used in the assessment of older drivers. However, this test has inherent problems that limit its validity to evaluate cognitive abilities related to driving and to screen for driving impairments in non-demented people. Therefore, it is useful to test new screening instruments that may predict potential unsafe drivers who require an in-depth neuropsychological assessment in a specialised centre. To date, the utility of the Addenbrooke's Cognitive Examination Revised (ACE-R) as an indicator of driving ability has not been established. In the current study, fifty older drivers (mean age=73.1 years) who were referred for a psychological assessment, the protocol of which included the ACE-R, underwent an on-road driving test. Using linear discriminant analyses, the results highlighted the higher classification accuracy of the ACE-R compared to the MMSE score, particularly for detecting unsafe drivers. Measures of visuospatial and executive functions, which are not incorporated in the MMSE score, had an incremental value in the prediction of driving ability. This emerging brief cognitive test may warrant additional study for use in the fitness to drive assessment of older adults.

Self-rated driving and driving safety in older adults

Many U.S. states rely on older adults to self-regulate their driving and determine when driving is no longer a safe option. However, the relationship of older adults' self-rated driving in terms of actual driving competency outcomes is unclear. The current study investigates self-rated driving in terms of (1) systematic differences between older adults with high (good/excellent) versus low (poor/fair/average) self-ratings, and (2) the predictive nature of self-rated driving to adverse driving outcomes in older adults (n=350; mean age 73.9, SD=5.25, range 65-91). Adverse driving outcomes included self-reported incidences of (1) being pulled over by the police, (2) receiving a citation, (3) receiving a recommendation to cease or limit driving, (4) crashes, and (5) state-reported crashes. Results found that older drivers with low self-ratings reported more medical conditions, less driving frequency, and had been given more suggestions to stop/limit their driving; there were no other significant differences between low and high self-raters. Logistic regression revealed older drivers were more likely to have a state-reported crash and receive a suggestion to stop or limit driving. Men were more likely to report all adverse driving outcomes except for receiving a suggestion to stop or limit driving. Regarding self-rated driving, older adults with high ratings were 66% less likely (OR=0.34, 95% CI=0.14-0.85) to have received suggestions to limit or stop driving after accounting for demographics, health and driving frequency. Self-ratings were not predictive of other driving outcomes (being pulled over by the police, receiving a citation, self-reported crashes, or state-reported crashes, ps>0.05). Most older drivers (85.14%) rated themselves as either good or excellent drivers regardless of their actual previous citation or crash rates. Self-rated driving is likely not related to actual driving proficiency as indicated by previous crash involvement in older adults. Suggestions from other individuals to limit or cease driving may be more influential on self-ratings.

Is it reliable to assess visual attention of drivers affected by Parkinson's disease from the backseat?-a simulator study

BACKGROUND

Current methods of determining licence retainment or cancellation is through on-road driving tests. Previous research has shown that occupational therapists frequently assess drivers' visual attention while sitting in the back seat on the opposite side of the driver. Since the eyes of the driver are not always visible, assessment by eye contact becomes problematic. Such procedural drawbacks may challenge validity and reliability of the visual attention assessments. In terms of correctly classified attention, the aim of the study was to establish the accuracy and the inter-rater reliability of driving assessments of visual attention from the back seat. Furthermore, by establishing eye contact between the assessor and the driver through an additional mirror on the wind screen, the present study aimed to establish how much such an intervention would enhance the accuracy of the visual attention assessment.

METHODS

Two drivers with Parkinson's disease (PD) and six control drivers drove a fixed route in a driving simulator while wearing a head mounted eye tracker. The eye tracker data showed where the foveal visual attention actually was directed. These data were time stamped and compared with the simultaneous manual scoring of the visual attention of the drivers. In four of the drivers, one with Parkinson's disease, a mirror on the windscreen was set up to arrange for eye contact between the driver and the assessor. Inter-rater reliability was performed with one of the Parkinson drivers driving, but without the mirror.

RESULTS

Without mirror, the overall accuracy was 56% when assessing the three control drivers and with mirror 83%. However, for the PD driver without mirror the accuracy was 94%, whereas for the PD driver with a mirror the accuracy was 90%. With respect to the inter-rater reliability, a 73% agreement was found.

CONCLUSION

If the final outcome of a driving assessment is dependent on the subcategory of a protocol assessing visual attention, we suggest the use of an additional mirror to establish eye contact between the assessor and the driver. The clinicians' observations on-road should not be a standalone assessment in driving assessments. Instead, eye trackers should be employed for further analyses and correlation in cases where there is doubt about a driver's attention.

Does automatic transmission improve driving behavior in older drivers?

BACKGROUND

Most older drivers continue to drive as they age. To maintain safe and independent transport, mobility is important for all individuals, but especially for older drivers.

OBJECTIVE

The objective of this study was to investigate whether automatic transmission, compared with manual transmission, may improve the driving behavior of older drivers.

METHOD

In total, 31 older drivers (mean age 75.2 years) and 32 younger drivers - used as a control group (mean age 39.2 years) - were assessed twice on the same fixed route; once in a car with manual transmission and once in a car with automatic transmission. The cars were otherwise identical. The driving behavior was assessed with the Ryd On-Road Assessment driving protocol. Time to completion of left turns (right-hand side driving) and the impact of a distraction task were measured.

RESULTS

The older group had more driving errors than the younger group, in both the manual and the automatic transmission car. However, and contrary to the younger drivers, automatic transmission improved the older participants' driving behavior as demonstrated by safer speed adjustment in urban areas, greater maneuvering skills, safer lane position and driving in accordance with the speed regulations.

CONCLUSION

Switching to automatic transmission may be recommended for older drivers as a means to maintain safe driving and thereby the quality of their transport mobility.