Bilateral cataract, crash risk, driving performance, and self-regulation practices among older drivers

15-year incidence of driving cessation and associated risk factors: The Blue Mountains Eye Study

OBJECTIVES

To report the 15-year incidence of driving cessation and its associated vision-related risk factors in an older Australian population-based cohort.

STUDY DESIGN

15-year data from a sample of 2379 participants who indicated that they were driving at baseline from The Blue Mountains Eye Study was analysed. Questions about driving cessation was asked at all four visits and was recorded as a binary response (Yes/No). Clinical vision examinations were performed at each visit to determine presenting and best-corrected visual acuity and any incident eye diseases (Yes/No).

MAIN OUTCOME MEASURES

The cumulative 15-year incidence of driving cessation was calculated using interval-censored data progression-free survival analyses. Age- and sex-adjusted and multivariable-adjusted interval-censored Cox proportional hazard models were used to report the hazard ratios (HRs) for associations of baseline and incident vision status with driving cessation.

RESULTS

The 15-year cumulative incidence of driving cessation amongst the 2379 participants was 20.7 %, with women more likely to cease driving than men (p = 0.0005). Cataract (HR 1.98 (95 % confidence interval(Cl) 1.45-2.71)) and age-related macular degeneration (HR 1.85 (95%Cl 1.37-2.50)) were associated with increased risk of driving cessation whilst presenting and best-corrected visual acuity in the better eye were protective against cessation (presenting: HR 0.96 (95%Cl 0.95-0.98); best-corrected: HR 0.93 (95%Cl 0.91-0.95)) in age- and sex-adjusted models, with these factors remaining independently associated in the multivariable-adjusted models.

CONCLUSION

Cumulative incidence of driving cessation increased with older age and was higher in females. Cataract and age-related macular degeneration were independently associated with cessation, whilst better visual acuity at baseline helped prolong driving.

Twenty-Year Follow-Up of Cataract Surgery in Car-Drivers: Associations Between Subjective Visual Difficulties and Objective Visual Function

Background/Aims

Driving especially at night is a visually demanding task. Long-time outcome of cataract surgery in drivers is important to study, as many patients live for decades after surgery. The purpose of this study is to longitudinally investigate visual function in active car drivers, 20 years after cataract surgery.

Methods

From a population-based, prospective, cohort of cataract surgery patients, initiated in 1997-98, 114 of the 133 surviving patients were included. Preoperatively, postoperatively 5, 10, 15 and 20 years after surgery, the patients answered a visual function questionnaire including driving status and difficulty. Habitual visual acuity, best corrected visual acuity (BCVA), and low contrast acuity (LCVA) 10% and 2.5% were measured.

Results

The driving difficulties in daylight were almost absent after surgery and did not change over 20 years. Nighttime driving was more difficult and declined longitudinally after surgery, p=0.013, but were at 20 years still less than before cataract surgery. Patients with better BCVA experienced less difficulties driving in darkness, p=0.005. Self-reported problems with glare were significantly associated with BCVA of the better-seeing eye, LCVA 10% and LCVA 2.5% (p=0.046, p=0.033, and 0.024 respectively). Self-reported difficulties with seeing in low-contrast conditions were also significantly associated with BCVA, p=0.004.

Conclusion

Twenty years after cataract surgery, most active drivers have no or minor visual functional problems during driving in daytime. Difficulties in nighttime driving are more common and increase significantly over time. Twenty years after surgery, all current drivers had still better subjective ability to drive, compared with before surgery.

A Systematic Review of the Effects of Second-Eye Cataract Surgery on Motor Function

Cataract removal surgery is one of the most commonly performed surgical procedure in developed countries. The financial and staff resource cost that first-eye cataract surgery incurs, leads to restricted access to second-eye cataract surgery (SES) in some areas, including the United Kingdom. These restrictions have been imposed despite a lack of knowledge about the impact of not performing SES on visuo-motor function. To this end, a systematic literature review was carried out, with the aim of synthesising our present understanding of the effects of SES on motor function. Key terms were searched across four databases, PsycINFO, Medline, Web of Science, and CINAHL. Of the screened studies (K = 499) 13 met the eligibility criteria. The homogeneity between participants, study-design and outcome measures across these studies was not sufficient for meta-analyses and a narrative synthesis was carried out. The evidence from objective sources indicates a positive effect of SES on both mobility and fall rates, however, when considering self-report measures, the reduction in falls associated with SES becomes negligible. The evidence for any positive effect of SES on driving is also mixed, whereby SES was associated with improvements in simulated driving performance but was not associated with changes in driving behaviours measured through in vehicle monitoring. Self-report measures of driving performance also returned inconsistent results. Whilst SES appears to be associated with a general trend towards improved motor function, more evidence is needed to reach any firm conclusions and to best advise policy regarding access to SES in an ageing population. Systematic Review Registration: https://osf.io/7hne6/, identifier INPLASY2020100042.

Association Between Young-Onset Dementia and Risk of Hospitalization for Motor Vehicle Crash Injury in Taiwan

IMPORTANCE

Several studies have suggested that older-onset dementia is associated with an increased risk of motor vehicle crash injury (MVCI). However, evidence of an association between young-onset dementia and the risk of MVCI is insufficient, particularly in Asia.

OBJECTIVE

To investigate the association between young-onset dementia and MVCI-related hospitalization in Taiwan.

DESIGN, SETTING, AND PARTICIPANTS

In this nationwide, population-based cohort study in Taiwan, a cohort of 39 344 patients aged 40 to 64 years with incident dementia diagnosed between 2006 and 2012 was matched 1:1 with a cohort of participants without dementia by age, sex, and index year (initial diagnosis of dementia). Participants were identified from Taiwan's National Health Insurance Research Database (NHIRD). Data were analyzed between March 25 and October 22, 2021.

EXPOSURES

Dementia, defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

Hospitalization for MVCI, determined using linked data from Taiwan's Police-Reported Traffic Accident Registry and the NHIRD from January 1, 2003, to December 31, 2015. Hazard ratios (HRs) for MVCI-related hospitalization were estimated using Cox proportional hazards regression models adjusted for sex, age, salary-based insurance premium, urbanization level, and comorbidities.

RESULTS

Of the 78 688 participants, 47 034 (59.8%) were male; the mean (SD) age was 54.5 (7.4) years. During the 10-year follow-up period, the incidence density of MVCI-related hospitalization was 45.58 per 10 000 person-years (95% CI, 42.77-48.39 per 10 000 person-years) among participants with dementia and 24.10 per 10 000 person-years (95% CI, 22.22-25.99 per 10 000 person-years) among participants without dementia. Compared with participants without dementia, patients with young-onset dementia were at higher risk of MVCI-related hospitalization (adjusted HR [aHR], 1.83; 95% CI, 1.63-2.06), especially those in younger age groups (aged 40-44 years: aHR, 3.54; 95% CI, 2.48-5.07) and within a shorter period (within 1 year of follow-up: aHR, 3.53; 95% CI, 2.50-4.98) after dementia was diagnosed. Patients with young-onset dementia also had a higher risk of being a pedestrian when the crash occurred (aHR, 2.89; 95% CI, 2.04-4.11), having an intracranial or internal injury (aHR, 2.44; 95% CI, 2.02-2.94), and having a severe injury (aHR, 2.90; 95% CI, 2.16-3.89).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, patients in Taiwan with a diagnosis of young-onset dementia had a higher risk of MVCI-related hospitalization than did individuals without dementia and the risk varied by age, disease duration, transport mode, injury type, and injury severity. These findings suggest a need for the planning of strategies to prevent transportation crashes among patients with young-onset dementia.

Speed management across road environments of varying complexities and self-regulation behaviors in drivers with cataract

Evidence suggests that drivers with cataract self-regulate their driving, but there is a lack of objective information. This study compared speed behavior in older drivers with and without cataract and how the parameter is influenced by road traffic complexity and driver characteristics. The study included 15 drivers with cataract and a control group of 20 drivers. Visual status was assessed using visual acuity, contrast sensitivity, and intraocular straylight. Speed management was studied using a driving simulator. Driving difficulty and self-regulation patterns were evaluated by means of the Driver Habits Questionnaire (DHQ). The cataract group showed a significant decrease in visual function in all the parameters evaluated (p < 0.05). These drivers tended to drive at lower speeds than the control group. Road characteristics, gender, and intraocular straylight in the better eye were identified as significant predictors of speed management. Drivers with cataract experience greater driving difficulty, particularly when driving at night (p < 0.05). Drivers with cataract reduce their driving speed more than older drivers without visual impairment. The straylight parameter may be a good indicator of each driver's subjective perception of their own visual ability to drive. This work helps shed light on the mechanisms through which age-related visual impairment influences driving behavior.

Determinants of driving among oldest-old Australian women

This study examined predictors of driving among oldest-old Australian women in their late 80s in accordance with the World Health Organization's healthy aging framework. The study used data from the 1921-26 cohort of the Australian Longitudinal Study on Women's Health, wave-6 (n = 4025). The result of the multivariable logistic regression showed providing care, living alone, volunteering, living in rural/outer regional Australia, having higher educational attainment, and social interactions were associated with driving. The findings indicate driving should not be dismissed based on age alone. Policymakers need to also consider social roles, driving environment and context with the goals of healthy aging.

The role of vision-related problems in fatal road accidents in Finland

PURPOSE

To evaluate the significance of vision-related problems in fatal motor vehicle accidents (FMVAs) based on a systematic investigation process by multidisciplinary road accident investigation teams (RAITs).

METHODS

Retrospective registry-based study of all FMVAs during the years 2012-2016 in Finland in which driver causing the accident had a valid Finnish driving licence and the operated motor vehicle required having a driving licence.

RESULTS

There were a total of 968 FMVAs. In only 1.3% of all the accidents, a vision-related problem was considered to have contributed to the FMVA, while an observational failure of 23.6% was the leading cause of all the FMVAs.

CONCLUSIONS

Eye-originating vision problems are rarely a causative risk for FMVAs in Finland. Making current visual standards more stringent would unlikely to be effective in FMVA prevention.

The short-term effects of artificially-impaired binocular vision on driving performance

Appropriate visual function is paramount to ensuring adequate driving performance and road safety. Here, we examined the influence of sudden artificially-impaired binocular vision on driving performance using a car simulator. Twenty-four young drivers (mean age 22.42 ± 3.19 years) drove under three different visual conditions (natural driving, monocular blur, and monocular occlusion) through three different traffic environments with low, medium, and high levels of complexity (highway, rural, and city, respectively). We assessed their driving performance, perceived level of task complexity, and subjectively-experienced road safety. Furthermore, as a manipulation check, we also evaluated the drivers' cardiac vagal responses, as a well-known index of task complexity. The sudden deterioration of binocular vision caused unsafe driving behaviours (distance out of the road and maximum breaking intensity) in the most complex traffic environments. Specific self-regulatory strategies (i.e. increased cardiac vagal responses) and subjective responses corroborated these results. Practitioner summary: This study provides evidence that the sudden deterioration of binocular vision has a detrimental effect on simulated driving performance. Our analysis of cardiovascular functioning shows that drivers adopt self-regulatory strategies when their binocular vision functioning is compromised. Abbreviations: VA: visual acuity; BV: binocular vision; HRV: heart rate variability; NASA: TLX: NASA-Task Load Index; SSS: Stanford Sleepiness scale; RMSSD: root mean square of successive difference; HF: high-frequency.

Planning for Driving Retirement: The Effect of Driving Perceptions, Driving Events, and Assessment of Driving Alternatives

Most older adults will eventually stop driving, but few engage in planning for driving retirement. This study assessed whether driving stress, enjoyment, confidence, concerning driving events, and assessment of driving alternatives influence planning. Demographic factors were also included. Data were collected via a mailed transportation survey, with a final sample of 551 older adults who currently drive. Linear regression analyses revealed that more driving retirement planning was associated with greater driving stress, less driving confidence, and a more positive view of driving alternatives. Driving enjoyment and recent concerning driving events were not significantly related. Among the control variables, race and income were significantly related to planning, suggesting that lower income and identifying as Black race were associated with more planning. Gender only approached significance, suggesting that females may plan more than males. Overall, these findings suggest that more driving retirement planning is warranted. Some of the groups known to be at increased risk for driving reduction and cessation plan more for that eventuality than their counterparts. Implications of the study and suggestions for future research are discussed.

Chronic medical conditions and their association with crash risk and changes in driving habits: a prospective study of the GAZEL cohort

OBJECTIVES

To assess crash risk and driving habits associated with chronic medical conditions among drivers entering old age.

DESIGN

Prospective cohort study.

SETTING

French cohort GAZEL.

PARTICIPANTS

12 460 drivers in the analysis of road traffic crash, among whom 11 670 completed the follow-up period (2007-2014). We assessed driving cessation among 11 633 participants over the same period, and mileage and driving avoidance among the 4973 participants who returned a road safety questionnaire in 2015.

MAIN OUTCOME MEASURES

Yearly occurrence of at least one road crash as a driver; time to driving cessation; mileage; driving avoidance: at night, with bad weather, in heavy traffic, with glare conditions, over long distances.

RESULTS

Several potentially risky conditions (angina, myocardial infarction, coronary disease; stroke; nephritic colic, urinary stones; glaucoma) were associated with lower mileage and/or driving avoidance and did not increase crash risk. Neither driving avoidance nor lower mileage was found for other conditions associated with an increased crash risk: hearing difficulties (adjusted OR 1.19, 95% CI 1.06 to 1.34); joint disorders (1.17, 95% CI 1.06 to 1.30). Depression, anxiety and stress was associated with an increased crash risk (1.23, 95% CI 1.01 to 1.49) despite increased driving avoidance. Parkinson's disease was associated with driving cessation (adjusted HR 32.61, 95% CI 14.21 to 65.17).

CONCLUSIONS

Depending on their condition, and probably on the associated risk perception, drivers entering old age report diverse driving habits. For example, hearing difficulties is a frequent condition, rarely considered a threat to road safety, and nonetheless associated with an increased crash risk.

Kinetic visual acuity is correlated with functional visual acuity at higher speeds

Objective

To measure the kinetic visual acuity (KVA) which is the ability to identify approaching objects and the functional visual acuity (FVA) which is continuous VA during 1 min under binocular and monocular condition (non-dominant eye shielding) for healthy subjects, and related ocular parameters to explore their correlation and implication in aspect of integrated visual function.

Methods

The mean age of the 28 participants was 38.6±8.9 years (range, 23–57 years; 6 women). A KVA metre (AS-4Fα) and FVA metre (AS-28) were used to measure KVA and FVA, respectively. Multiple regression analysis was conducted to explore correlations among the measured visual function and related parameters, including age, binocularity, best-corrected visual acuity, refraction and tear break-up time.

Results

The results of binocular KVA were better than monocular KVA at all speeds. A strong correlation was found between monocular and binocular KVA. The results of binocular FVA were better than monocular FVA (p<0.001) and there was a correlation between monocular and binocular FVA (R=0.638, p<0.001), as well as the maintenance rate for FVA (R=0.228, p=0.003). A linear mixed-effects model revealed that binocularity for KVA prediction was significant at all speeds and FVA was also significant at 60 km/h (p<0.05).

Conclusion

The current results suggest that both binocularity and FVA may contribute to KVA.

Trial registration number

UMIN00032385

Should every candidate for cataract extraction be scheduled to the preoperative clinic? The Rabin Medical Center experience

BACKGROUND

Cataract surgery is one of the most common elective surgeries. We present a novel approach of preoperative triage using community-based ophthalmologist referral letters for scheduling surgery, thus reducing both patient and physician time prior to surgery. Since most patients are not routinely examined in a preoperative clinic, day of surgery cancelations are a possibility. The aim of this study is to evaluate the efficiency of our triage system.

METHODS

Historical prospective study in which the end point was day-of-surgery cancelation. The main outcome measure of this study was the rate of cancelations which could have been prevented by a preoperative visit. Patients' records were reviewed for reasons for cancelation and demographics.

RESULTS

During the study period, 1030 patients underwent cataract surgery, 171 patients (16.6%) were examined in the preoperative clinic. Forty-five patients (4.4%) were canceled on the day of surgery due to various reasons. The main reason for cancelation (13 cases, 28.9%) was non-availability of operating theater. In 20 cases (1.9% of total patients, 44.4% of cancelations), the cancelations could have been prevented by a preoperative clinic visit.

CONCLUSION

Our results suggests that most cataract patients do not require preoperative visit prior to the day of surgery. The cooperation of community-based ophthalmologists and the availability of senior surgeons in the operating theater allows for the proper implementation of our system. Direct referral to surgery could shorten both costs and time to surgery and provide timely treatment for cataracts in a cost-aware environment.

Naturalistic driving patterns of older adults before and after cataract surgery

OBJECTIVE

Cataract surgery can have many benefits for older adults, including enabling continued ability to drive. However, it is not known how objectively measured driving patterns change after cataract surgery. The purpose of this study was to examine how participants drove before and after cataract surgery.

DESIGN

Longitudinal study.

PARTICIPANTS

Individuals from the Winnipeg site of Candrive (a longitudinal study of older drivers in Canada).

METHODS

An in-vehicle device monitored all trips taken in 1-second intervals, allowing for the analysis of distances driven, number of trips, time of trips, speeding, excessive braking/accelerating, and types of roadways.

RESULTS

Over the 4 years of data collection, there were 16 cases of participants having cataract surgery, whereby there was also suitable driving data for analyses. Participants drove 28% further after surgery (p = 0.022). They also drove further from home and more on primary roads (p < 0.05) and had fewer episodes of hard braking per distance travelled (p < 0.001). No other variables significantly changed.

CONCLUSIONS

This study suggests that older drivers changed some of their driving patterns after cataract surgery. Future studies could explore the effects of increased driving exposure, in conjunction with potentially safer driving behaviors, on overall driving safety after cataract surgery.

Association of Cataract Surgery With Traffic Crashes

Importance

Cataracts are the most common cause of impaired vision worldwide and may increase a driver's risk of a serious traffic crash. The potential benefits of cataract surgery for reducing a patient's subsequent risk of traffic crash are uncertain.

Objective

To conduct a comprehensive longitudinal analysis testing whether cataract surgery is associated with a reduction in serious traffic crashes where the patient was the driver.

Design, Setting, and Participants

Population-based individual-patient self-matching exposure-crossover design in Ontario, Canada, between April 1, 2006, and March 31, 2016. Consecutive patients 65 years and older undergoing cataract surgery (n = 559 546).

Interventions

First eye cataract extraction surgery (most patients received second eye soon after).

Main Outcomes and Measures

Emergency department visit for a traffic crash as a driver.

Results

Of the 559 546 patients, mean (SD) age was 76 (6) years, 58% were women (n = 326 065), and 86% lived in a city (n = 481 847). A total of 4680 traffic crashes (2.36 per 1000 patient-years) accrued during the 3.5-year baseline interval and 1200 traffic crashes (2.14 per 1000 patient-years) during the 1-year subsequent interval, representing 0.22 fewer crashes per 1000 patient-years following cataract surgery (odds ratio [OR], 0.91; 95% CI, 0.84-0.97; P = .004). The relative reduction included patients with diverse characteristics. No significant reduction was observed in other outcomes, such as traffic crashes where the patient was a passenger (OR, 1.03; 95% CI, 0.96-1.12) or pedestrian (OR, 1.02; 95% CI, 0.88-1.17), nor in other unrelated serious medical emergencies. Patients with younger age (OR, 1.27; 95% CI, 1.13-1.14), male sex (OR, 1.64; 95% CI, 1.46-1.85), a history of crash (baseline OR, 2.79; 95% CI, 1.94-4.02; induction OR, 4.26; 95% CI, 2.01-9.03), more emergency visits (OR, 1.34; 95% CI, 1.19-1.52), and frequent outpatient physician visits (OR, 1.17; 95% CI, 1.01-1.36) had higher risk of subsequent traffic crashes (multivariable model).

Conclusions and Relevance

This study suggests that cataract surgery is associated with a modest decrease in a patient's subsequent risk of a serious traffic crash as a driver, which has potential implications for mortality, morbidity, and costs to society.

First and second eye cataract surgery and driver self-regulation among older drivers with bilateral cataract: a prospective cohort study

Background

Driving a car is the most common form of transport among the older population. Common medical conditions such as cataract, increase with age and impact on the ability to drive. To compensate for visual decline, some cataract patients may self-regulate their driving while waiting for cataract surgery. However, little is known about the self-regulation practices of older drivers throughout the cataract surgery process. The aim of this study is to assess the impact of first and second eye cataract surgery on driver self-regulation practices, and to determine which objective measures of vision are associated with driver self-regulation.

Methods

Fifty-five older drivers with bilateral cataract aged 55+ years were assessed using the self-reported Driving Habits Questionnaire, the Mini-Mental State Examination and three objective visual measures in the month before cataract surgery, at least one to three months after first eye cataract surgery and at least one month after second eye cataract surgery. Participants’ natural driving behaviour in four driving situations was also examined for one week using an in-vehicle monitoring device. Two separate Generalised Estimating Equation logistic models were undertaken to assess the impact of first and second eye cataract surgery on driver-self-regulation status and which changes in visual measures were associated with driver self-regulation status.

Results

The odds of being a self-regulator in at least one driving situation significantly decreased by 70% after first eye cataract surgery (OR: 0.3, 95% CI: 0.1–0.7) and by 90% after second eye surgery (OR: 0.1, 95% CI: 0.1–0.4), compared to before first eye surgery. Improvement in contrast sensitivity after cataract surgery was significantly associated with decreased odds of self-regulation (OR: 0.02, 95% CI: 0.01–0.4).

Conclusions

The findings provide a strong rationale for providing timely first and second eye cataract surgery for older drivers with bilateral cataract, in order to improve their mobility and independence.

The Social Context of Driving Cessation: Understanding the Effects of Cessation on the Life Satisfaction of Older Drivers and Their Social Partners

Older adults with vision loss and a friend or family member were interviewed over a 2-year period. We examined the effects of driving cessation on life satisfaction among older adults and a social contact. Drivers' use of public transportation was examined as a moderator. Driving cessation was associated with a decline in life satisfaction among social partners but not for the drivers. Drivers' use of public transportation at baseline moderated the effects of cessation on changes in well-being among social partners, but had little effect on the life satisfaction of the drivers. Life satisfaction was greater among the social partners of ex-drivers who used public transportation more frequently. The association between driving cessation and well-being should be studied in the context of older drivers' social networks. Infrastructure (e.g., subways and buses) that supports transportation needs plays an important role in mitigating the effects of cessation on older adults' social networks.