The Relationship Between Neuropsychological Functioning and Driving Ability in Dementia: A Meta-Analysis

Learning to drive with neurological conditions: profile of users of an adapted driver training program and cognitive factors associated with success

PURPOSE

To describe the sociodemographic and cognitive profile of participants enrolled in an adapted driving program for individuals with neurological conditions, to explore the association between cognitive functioning and driving program outcome, and to describe driving habits after program completion.

METHODS

This study combined retrospective chart review and cross-sectional data collection.

RESULTS

The sample included 71 participants with neurological disorders (aged 15-56 years, M = 22.2 ± 8.6; 39% women). Driving program was either successful (47%), failed (7%), discontinued (34%), or ongoing (13%). Among 35 participants with complete neuropsychological and driving program outcome data, those who successfully completed the program showed better attention functioning, and better performance relative to global functioning for attention, executive functions, and working memory, compared to those who discontinued/failed the program. Among 21 participants who completed a telephone questionnaire on average 3.7 years after program enrollment, 67% obtained their driver's license and drove regularly. Participants reported high levels of satisfaction with the program.

CONCLUSION

These results suggest that approximately half of the persons enrolled in a driver training program designed for learners with neurological conditions, obtain a driver's license; and that attention, and to a lesser extent executive functioning and working memory, are related to driving program success.IMPLICATIONS FOR REHABILITATIONIn individual with neurological conditions, learning how to drive can be challenging.An adapted driver training program, involving collaboration between driving instructors and healthcare professionals, simplification of theoretical learning, and increasing driving practice opportunities, can be effective, both in terms of licensing success and client satisfaction.Conducting a pre-driving program neuropsychological assessment, with identification of cognitive strengths and weaknesses, can provide valuable information for clinicians and driving instructors for optimizing training and predicting outcome.Better performance in attention, and better relative to global cognitive functioning in attention, executive functions, and working memory, are related to higher success rate of an adapted driving program.

Difficulty resuming driving in acute acquired brain injury: Retrospective observational study using discriminant analysis

OBJECTIVES

We hypothesized that neuropsychological testing and history of falls would be associated with difficulty resume driving after acute acquired brain injury (ABI). This study aimed to analyze ABI facing difficulties in resuming driving in the acute phase.

METHODS

We retrospectively analyzed 63 patients receiving assistance in driving-resumption after ABI. Patients were categorized into two groups: driving-resumption-possible and driving-resumption-difficult. Discriminant analysis delineated characteristics of patients experiencing driving-resumption difficulty. Additionally, significant predictors were analyzed using ROC curves.

RESULTS

42 patients were able to resume driving, and 21 experienced difficulties in driving resumption. Factors predicting difficulty returning to driving were age, history of falls, TMT Part B, and ROCF. Furthermore, cut-off values for each were 72 years, 148 seconds for TMT Part B, and 29.5 points for ROCF.

CONCLUSIONS

Patients with advanced age, history of falls, delayed TMT Part B, and poor ROCF outcomes may face challenges in resuming driving after ABI. These factors may serve as a valuable metric to assess driving resumption difficulties after ABI.

Digital clock drawing test reflects visuospatial ability of older drivers

Objectives

To keep older drivers safe, it is necessary to assess their fitness to drive. We developed a touch screen-based digital Clock Drawing Test (dCDT) and examined the relationship between the dCDT scores and on-road driving performance of older drivers in a community-setting.

Methods

One hundred and forty-one community-dwelling older drivers (range; 64-88 years old) who participated in this study were included in the analysis. Participants completed the dCDT, the Mini-Mental State Examination-Japanese (MMSE-J), and an on-road driving assessment. We examined the relationship between dCDT scores using the method by Rouleau et al. (maximum 10 points) and the on-road driving performance based on a driving assessment system originally developed by Nagoya University.

Results

Multiple regression analyses showed that errors in the driving test were associated with dCDT score for the items "confirmation," "turning left" and "maintains driving lane position".

Discussion

This study confirmed the relationship between the dCDT score and driving errors, such as confirmation, turning left and maintaining driving lane position. The increase in these errors indicates a decline in visuospatial ability while driving. The dCDT score may reflect older drivers' visuospatial abilities while driving.

The Role of Dietary Ingredients in Mental Energy - A Scoping Review of Randomized Controlled Trials

Low mental energy can contribute to decreased productivity, altered life balance, decreased physical performance, and ultimately affect quality of life. As such, there is a great demand for food and beverage products that positively impact mental energy. Numerous products claim to alter mental energy making continued review of the scientific evidence critical. The objective of this study was to conduct a scoping review of randomized controlled trials to evaluate the effect of 18 dietary ingredients on mental energy outcomes in adults without severe disease. Methods: A literature search, completed using PubMed, resulted in the identification of 2261 articles, 190 of which met eligibility from initial abstract review. Full-text review was completed on the 190 studies which resulted in 101 articles that fully met eligibility for inclusion in this study. The search strategy for two ingredients did not yield any eligible studies, leaving studies for 16 ingredients that were extracted and summarized by reported significantly improved outcomes for cognition, mood and perceived feelings, and sleep assessments. The preliminary results for several dietary ingredients directionally suggested a mental energy benefit (≥20% of outcomes), including ashwagandha, chamomile, dark chocolate, ginseng, green tea, lavender, lion's mane mushroom, maca, tart cherries, turmeric, and valerian root. The results of this scoping review suggest that of the 16 dietary ingredients reviewed, 11 may be promising for further exploration on their potential benefits in supporting mental energy. Given consumer demand and market growth for food and beverage products that positively impact mental energy; continued efforts in assessment method alignment and additional evaluation in well-designed trials is warranted.KEY TEACHING POINTSOf the 16 dietary ingredients reviewed, 11 (ashwagandha, chamomile, dark chocolate, ginseng, green tea, lavender, lion's mane mushroom, maca, melatonin foods, turmeric, and valerian root) may be promising for further exploration on their potential mental energy benefits.Dark chocolate, ginseng, ashwagandha, and lion's mane mushroom were the most promising ingredients for further evaluation in the cognition domain of the ingredients evaluated.Turmeric, maca, lavendar, and ashwagandha were the most promising ingredients for further evaluation in the mood and perceived feelings domain of the ingredients evaluated.Ashwagandha, chamomile, green tea, melatonin foods, valerian root were the most promising ingredients for further evaluation in the sleep domain of the ingredients evaluated.Additional, well-designed, consistent, clinical trials and systematic reviews are warranted as the challenge of heterogeneity in mental energy study design remains.

The Subjective Experiences of Driving Cessation and Life Satisfaction

Compared to the driving group, the driving cessation group in this study was found to be a high-risk population in terms of their life satisfaction. This study evaluated data from 315 older adults, aged 55 or older, using the 2018 Korean Older Adults Driving and Mobility Service Trend Survey. These data were collected from 17 representative cities and provinces in South Korea. To minimize the potential for selection bias and the confounding factors inherent in observational studies, this study employed the propensity score matching (PSM) method. Following the matching, multivariate regression analyses were conducted to compare the driving cessation group (n = 65) with the driving group (n = 50) in terms of their life satisfaction. After adjusting for demographic and health-related variables, the older adults who had ceased driving were found to have lower life satisfaction (Coef. = -1.39, p-value = 0.018). Our results highlight the importance of establishing preliminary evidence to guide the development of tailored programs for older adults-especially for those likely to experience diminished life satisfaction and heightened risk-to address the mobility challenges stemming from driving cessation.

Motor-cognitive functions required for driving in post-stroke individuals identified via machine-learning analysis

BACKGROUND

People who were previously hospitalised with stroke may have difficulty operating a motor vehicle, and their driving aptitude needs to be evaluated to prevent traffic accidents in today's car-based society. Although the association between motor-cognitive functions and driving aptitude has been extensively studied, motor-cognitive functions required for driving have not been elucidated.

METHODS

In this paper, we propose a machine-learning algorithm that introduces sparse regularization to automatically select driving aptitude-related indices from 65 input indices obtained from 10 tests of motor-cognitive function conducted on 55 participants with stroke. Indices related to driving aptitude and their required tests can be identified based on the output probability of the presence or absence of driving aptitude to provide evidence for identifying subjects who must undergo the on-road driving test. We also analyzed the importance of the indices of motor-cognitive function tests in evaluating driving aptitude to further clarify the relationship between motor-cognitive function and driving aptitude.

RESULTS

The experimental results showed that the proposed method achieved predictive evaluation of the presence or absence of driving aptitude with high accuracy (area under curve 0.946) and identified a group of indices of motor-cognitive function tests that are strongly related to driving aptitude.

CONCLUSIONS

The proposed method is able to effectively and accurately unravel driving-related motor-cognitive functions from a panoply of test results, allowing for autonomous evaluation of driving aptitude in post-stroke individuals. This has the potential to reduce the number of screening tests required and the corresponding clinical workload, further improving personal and public safety and the quality of life of individuals with stroke.

Return to Driving Is Safe 6 Weeks After Anterior Cervical Surgery for Symptomatic Cervical Degenerative Disc Disease

STUDY DESIGN

Prospective Cohort Study.

OBJECTIVES

This study aims to determine the timing and clinical parameters for a safe return to driving.

SUMMARY OF BACKGROUND DATE

Returning to driving after cervical spine surgery remains a controversial topic, with no clear consensus on how to best assess a patient's fitness to drive. Previous studies using brake reaction time or subjective questionnaires recommend a return to driving 6 weeks after surgery.

METHODS

Patients above 18 years of age who underwent anterior cervical spine surgery for symptomatic cervical degenerative disk disease and possessed a valid motorcar driving license were recruited from 2018 to 2020. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) scores, range of motion, and functional strength of the cervical spine were collected preoperatively and at 2-, 4-, 6- and 12 weeks postsurgery. Patients underwent a standard functional driving assessment protocol at the institution to determine their fitness to drive. This comprised of a clinic-based off-road screening tests and on-road driving test in a real-world environment.

RESULTS

Twenty-one patients were recruited. The mean age was 56.6±8.9 years. Eighty-one percent of the patients passed the on-road driving assessment at 6 weeks. Patients who passed the driving assessment had lower mean NDI scores, 3.4±3.1 versus 10.8±8.0 ( P =0.006), and higher mean mJOA scores 16.1±0.6 versus 15.0±1.8 ( P =0.045). Patients who passed the driving assessment also had higher functional cervical flexor strength, 21.1s±5.8s versus 13.0s±10.2s ( P =0.042) in a supine position but not correlated with a range of motion of the spine in all directions.

CONCLUSION

Most patients undergoing single or dual-level anterior cervical surgery for symptomatic cervical degenerative disk disease demonstrate the ability to pass a standardized driving assessment and are safe to return to driving more than 6 weeks after surgery. Driving ability appears to be correlated with NDI scores ≤3 ( P =0.006), mJOA scores ≥16 ( P =0.045), and cervical flexion endurance of ≥21s ( P =0.042).

LEVEL OF EVIDENCE

Level II.

Driving Assessment for Persons with Dementia: How and when?

Dementia is a progressive neurodegenerative disease leading to deterioration in cognitive and physical skills. Driving is an important instrumental activity of daily living, essential for independence. However, this is a complex skill. A moving vehicle can be a dangerous tool in the hand of someone who cannot maneuver it properly. As a result, the assessment of driving capacity should be part of the management of dementia. Moreover, dementia comprises of different etiologies and stages consisting of different presentations. As a result, this study aims to identify driving behaviors common in dementia and compare different assessment methods. A literature search was conducted using the PRISMA checklist as a framework. A total of forty-four observational studies and four meta-analyses were identified. Study characteristics varied greatly with regards to methodology, population, assessments, and outcome measures used. Drivers with dementia performed generally worse than cognitively normal drivers. Poor speed maintenance, lane maintenance, difficulty managing intersections and poor response to traffic stimuli were the most common behaviors in drivers with dementia. Naturalistic driving, standardized road assessments, neuropsychological tests, participant self-rating and caregiver rating were the most common driving assessment methods used. Naturalistic driving and on-road assessments had the highest predictive accuracy. Results on other forms of assessments varied greatly. Both driving behaviors and assessments were influenced by different stages and etiologies of dementia at varying degrees. Methodology and results in available research are varied and inconsistent. As a result, better quality research is required in this field.

The Benton Visual Form Discrimination Test as a Predictor of Neurocognitive Disorder in Older Veterans

OBJECTIVE

The Benton Visual Form Discrimination Test (VFDT) is a commonly used measure of visual discrimination and visual recognition memory and has shown promise in distinguishing between different levels of cognitive impairment. We assess the predictive diagnostic utility of the VFDT in a sample of older Veterans with cognitive concerns.

METHOD

Subjects included a total of 172 mostly male Veterans over the age of 64 (mean = 76.0; SD = 7.6) recruited from a VA clinic specializing in neuropsychological assessment of older Veterans. The clinical sample included 56 subjects diagnosed with Major Neurocognitive Disorder, 74 diagnosed with Mild Neurocognitive Disorder, and 42 with No Neurocognitive Impairment. Impairment categories were modeled in separate multinomial logistic regressions with two versions of the VFDT as predictors: the Visual Form Discrimination Test-Recognition Subtest (VFDT-Rec) test (visual recognition memory) and the Visual Form Discrimination Test-Matching Subtest VFDT-Mat test (visual form discrimination). Years of education were included as a covariate.

RESULTS

After adjusting for education, higher VFDT-Rec total scores were associated with lower odds of being categorized with a greater degree of cognitive/functional impairment (OR 0.66-0.83, p < .001). VFDT-Mat scores showed a similar pattern, but only reached statistical significance for the Major versus No Neurocognitive Impairment (OR = 0.77, p = .0010) and Major versus Mild comparisons (OR = 0.89, p = .0233).

CONCLUSIONS

The VFDT may enhance the confidence of differential diagnosis of dementia in older adult Veterans. Formal education-adjusted norms need to be established for clinical use.

Visual disorders and driving ability in persons with dementia: A mini review

Background

Impaired driving ability in patients with Alzheimer’s disease (AD) is associated with a decline in cognitive processes and a deterioration of their basic sensory visual functions. Although a variety of ocular abnormalities have been described in patients with AD, little is known about the impact of those visual disorders on their driving performance.

Aim

Aim of this mini-review is to provide an update on the driving ability of patients with dementia and summarize the primary visual disorders affecting their driving behavior.

Methods

Databases were screened for studies investigating dementia, associated visual abnormalities and driving ability.

Results

There is consistent evidence that dementia affects driving ability. Patients with dementia present with a variety of visual disorders, such as visual acuity reduction, visual field defects, impaired contrast sensitivity, decline in color vision and age-related pathological changes, that may have a negative impact on their driving ability. However, there is a paucity in studies describing the impact of oculovisual decline on the driving ability of AD subjects. A bidirectional association between cognitive and visual impairment (VI) has been described.

Conclusion

Given the bidirectional association between VI and dementia, vision screening and cognitive assessment of the older driver should aim to identify at-risk individuals and employ timely strategies for treatment of both cognitive and ocular problems. Future studies should characterize the basic visual sensory status of AD patients participating in driving studies, and investigate the impact of vision abnormalities on their driving performance.

Egocentric distance perception in older adults: Results from a functional magnetic resonance imaging and driving simulator study

The ability to appropriately perceive distances in activities of daily living, such as driving, is necessary when performing complex maneuvers. With aging, certain driving behaviors and cognitive functions change; however, it remains unknown if egocentric distance perception (EDP) performance is altered and whether its neural activity also changes as we grow older. To that end, 19 young and 17 older healthy adults drove in a driving simulator and performed an functional magnetic resonance imaging (fMRI) experiment where we presented adults with an EDP task. We discovered that (a) EDP task performance was similar between groups, with higher response times in older adults; (b) older adults showed higher prefrontal and parietal activation; and (c) higher functional connectivity within frontal and parietal-occipital-cerebellar networks; and (d) an association between EDP performance and hard braking behaviors in the driving simulator was found. In conclusion, EDP functioning remains largely intact with aging, possibly due to an extended and effective rearrangement in functional brain resources, and may play a role in braking behaviors while driving.

Retention and impairment of neurocognitive functions in mild cognitive impairment and Alzheimer's disease with a comprehensive neuropsychological test

AIM

MATRICS Consensus Cognitive Battery was developed by the National Institute of Mental Health to establish acceptance criteria for measuring cognitive changes in schizophrenia and can be used to assess cognitive functions in other psychiatric disorders. We used a Japanese version of MATRICS Consensus Cognitive Battery to explore the changes in multiple cognitive functions in patients with mild cognitive impairment and mild Alzheimer's disease.

METHODS

We administered the Japanese version of MATRICS Consensus Cognitive Battery to 11 patients with mild cognitive impairment (MCI), 11 patients with Alzheimer's disease, and 27 healthy controls. All Japanese versions of MATRICS Consensus Cognitive Battery domain scores were converted to t-scores using sample means and standard deviations and were compared for significant performance differences among healthy control, MCI, and mild Alzheimer's disease groups.

RESULTS

Compared with healthy controls, patients with MCI and mild Alzheimer's disease demonstrated the same degree of impairment to processing speed, verbal learning, and visual learning. Reasoning and problem-solving showed significant impairments only in mild Alzheimer's disease. Verbal and visual abilities in working memory showed different performances in the MCI and mild Alzheimer's disease groups, with the Alzheimer's disease group demonstrating significantly more deficits in these domains. No significant difference was found among the groups in attention/vigilance and social cognition.

CONCLUSIONS

The Japanese version of MATRICS Consensus Cognitive Battery can be used to elucidate the characteristics of cognitive dysfunction of normal aging, MCI, and mild dementia in clinical practice.

Different brain activation patterns in the prefrontal area between self-paced and high-speed driving tasks

The purpose of this study was to investigate the effects on prefrontal cortex brain activity when participants attempted to stop a car accurately at a stop line when driving at different speeds using functional near-infrared spectroscopy (fNIRS). Twenty healthy subjects with driving experience drove their own cars for a distance of 60 m five times each at their own pace or as fast as possible. The variation in the distance between the stop line and the car was not significantly different between the self-paced and high-speed tasks. However, oxygenated hemoglobin concentration in the prefrontal cortex was significantly higher in the high-speed task than in the self-paced task. These findings suggest that driving at high speed requires more divided attention than driving at self-paced speed, even though the participants were able to stop the car at the same distance from the target. This study shows the advantages and usefulness of fNIRS .

M, Michelle. H, Anna. D, Reuben. R, Greg. K, Andre. JJ, Leslie L, Thomas. M, GF. TK. Impact of HIV on Cognitive Performance in Professional Drivers

BACKGROUND

The intellectually demanding modern workplace is often dependent on good cognitive health, yet there is little understanding of how neurocognitive dysfunction related to HIV presents in employed individuals working in high-risk vocations such as driving. HIV-associated neurocognitive impairment is also associated with poorer long-term cognitive, health, and employment outcomes.

SETTING

This study, set in Cape Town, South Africa, assessed the effects of HIV on neuropsychological test performance in employed male professional drivers.

METHOD

We administered a neuropsychological test battery spanning 7 cognitive domains and obtained behavioral data, anthropometry, and medical biomarkers from 3 groups of professional drivers (68 men with HIV, 55 men with cardiovascular risk factors, and 81 controls). We compared the drivers' cognitive profiles and used multiple regression modeling to investigate whether between-group differences persisted after considering potentially confounding sociodemographic and clinical variables (ie, income, home language, depression, and the Framingham risk score).

RESULTS

Relative to other study participants, professional drivers with HIV performed significantly more poorly on tests assessing processing speed (P < 0.003) and attention and working memory (P = 0.018). Group membership remained a predictor of cognitive performance after controlling for potential confounders. The cognitive deficits observed in men with HIV were, however, largely characterized as being mild or asymptomatic. Consistent with this characterization, their relatively poor performance on neuropsychological testing did not generalize to self-reported impairment on activities of daily living.

CONCLUSION

Drivers with HIV may be at risk of poorer long-term health and employment outcomes. Programs that monitor and support their long-term cognitive health are needed.

Strong evidence for age as the single most dominant predictor of medically supervised driving test-mini mental status test outcomes provide only weak but significant moderate additional predictive value

Background

With age, medical conditions impairing safe driving accumulate. Consequently, the risk of accidents increases. To mitigate this risk, Swiss law requires biannual assessments of the fitness to drive of elderly drivers. Drivers may prove their cognitive and physical capacity for safe driving in a medically supervised driving test (MSDT) when borderline cases, as indicated by low performance in a set of four cognitive tests, including e.g. the mini mental status test (MMST). Any prognostic, rather than indicative, relations for MSDT outcomes have neither been confirmed nor falsified so far. In order to avoid use of unsubstantiated rules of thumb, we here evaluate the predictive value for MSDT outcomes of the outcomes of the standard set of four cognitive tests, used in Swiss traffic medicine examinations.

Methods

We present descriptive information on age, gender and cognitive pretesting results of all MSDTs recorded in our case database from 2017 to 2019. Based on these retrospective cohort data, we used logistic regression to predict the binary outcome MSDT. An exploratory analysis used all available data (model 1). Based on the Akaike Information Criterion (AIC), we then established a model including variables age and MMST (model 2). To evaluate the predictive value of the four cognitive assessments, model 3 included cognitive test outcomes only. Receiver operating characteristics (ROC) and area under the curve (AUC) allowed evaluating discriminative performance of the three different models using independent validation data.

Results

Using N = 188 complete data sets of a total of 225 included cases, AIC identified age (p < 0.0008) and MMST (p = 0.024) as dominating predictors for MSDT outcomes with a median AUC of 0.71 (95%-CI 0.57–0.85) across different training and validation splits, while using the four cognitive test results exclusively yielded a median AUC of 0.55 (95%-CI 0.40–0.71).

Conclusions

Our analysis provided strong evidence for age as the single most dominant predictor of MSDT outcomes. Adding MMST provides only weak additional predictive value for MSDT outcomes. Combining the results of four cognitive test used as standard screen in Swiss traffic medicine alone, proved to be of poor predictive value. This highlights the importance of MSDTs for balancing between the mitigation of risks by and the right to drive for the elderly.

Big Data analysis of vision screening standards used to evaluate fitness to drive

PURPOSE

Visual acuity assessment is the most commonly performed vision screening method for drivers. The standards and repeat assessment intervals used, however, are arbitrary, lack an evidence base and are highly variable across different countries. This study utilises the power of Big Data to provide evidence-based recommendations for standardised driver vision screening.

METHODS

Anonymised electronic medical record data was gathered from 40 Irish optometry practices comprising 81,184 unique patients. A Kaplan-Meier Survival (KMS) analysis was used to determine the effect of increasing age and time since screening on the likelihood of passing the visual acuity standard for driving. A logistic function was fit to assess the effect of varying the minimum visual acuity standard required to drive on the screening pass rate within the population.

RESULTS

The likelihood of failing repeat screening increased as a function of time since initial screening for all age groups (χ²=1447, df =6, p < 0.001), with older patients most affected. Rescreening intervals for individuals who initially met the vision standard unaided reduced as a function of age. Using an 80% survivability threshold, intervals ranged from every eight years for drivers under 50, reducing to every two years for those aged over 80. Rescreening intervals for drivers requiring optical correction to meet the standard, also decreased with age. Approximately 1% of individuals are excluded from driving using a 0.3 logMAR visual acuity standard with correction.

CONCLUSION

Visual acuity-based screening should take place at regular intervals for all drivers, not just those over 70. Re-screening intervals should be based on age, with shorter intervals for older drivers due to the combined effect of age and time on the likelihood of passing the driving visual acuity standards. The most commonly used standard of 0.3 logMAR results in a minimal number of potential drivers being excluded from driving.

Driving Performance in Older Adults: Current Measures, Findings, and Implications for Roadway Safety

Background and Objectives

Over 10,000 people a day turn 65 in the United States. For many older adults, driving represents an essential component of independence and is one of the most important factors in overall mobility. Recent survey studies in older adults suggest that up to 60% of older adult drivers with mild cognitive impairment, and up to 30% with dementia, continue to drive. The purpose of this review is to provide a comprehensive and detailed resource on the topics of cognition and driving for clinicians, researchers, and policymakers working on efforts related to older adult drivers.

Research Design and Methods

Publications on PubMed and Medline and discussions with experts working in geriatrics, technology, driving policy, psychology, and diverse aspects of driving performance were utilized to inform the current review.

Results

Research indicates that there is a complex and inverse correlation between multiple cognitive measures, driving performance, and risky driving behaviors. The fragmented nature of available peer-reviewed literature, and a reliance on correlative data, do not currently allow for the identification of the temporal and reciprocal nature of the interplay between cognition and driving endpoints.

Discussion and Implications

There are currently no widely accepted definitions, conceptual models, or uniform set of analyses for conducting geriatric research that is focused on driving. Establishing conventions for conducting research that harmonizes the fields of geriatrics, cognition, and driving research is critical for the development of the evidence base that will inform clinical practice and road safety policy.

Driving and Alzheimer's dementia or mild cognitive impairment: a systematic review of the existing guidelines emphasizing on the neurologist's role

BACKGROUND

Driving is a complex task requiring the integrity and the cooperation of cognition, motor, and somatosensory skills, all of which are impacted by neurological diseases.

OBJECTIVE

Identification of neurologist's role when assessing fitness to drive of cognitively impaired individuals.

METHODS

We performed a systematic review of the guidelines/recommendations (G/Rs) regarding the evaluation of driving fitness of patients with mild cognitive impairment (MCI) and/or dementia. Emphasis was put on the neurological and neuropsychological aspects of the evaluation.

RESULTS

Eighteen G/Rs were included in the review (9 national guidelines, 5 recommendation papers, 3 consensus statements, and 1 position paper). All G/Rs referred to drivers with dementia and 9/18 referred to drivers with MCI. A common approach among G/Rs is the initial trichotomization of patients in safe to drive, unsafe to drive, and undetermined cases, which are referred to a second-line evaluator. First-line evaluators are general practitioners in 10/18 G/Rs; second-line evaluators are neurologists in 7/18 G/Rs. Specific neuropsychological tests are proposed in 11/18 G/Rs and relative cut-off values in 7/18. The most commonly used tests are the MMSE, TMT, and CDT. A thorough neurological examination is proposed in only 1/18 G/R.

CONCLUSION

Although extensive multi-disciplinary research has provided useful information for driving behavior of cognitively impaired individuals, we are still far from a widely accepted approach of driving ability evaluation in this increasing population. A comprehensive assessment from a multi-disciplinary team in which the neurologist plays a critical role seems to be required, although this has not yet been implemented in any G/Rs.

Protocol for the conceptualization and evaluation of a screening-tool for fitness-to-drive assessment in older people with cognitive impairment

Introduction

Due to aging and health status people may be subjected to a decrease of cognitive ability and subsequently also a decline of driving safety. On the other hand there is a lack of valid and economically applicable instruments to assess driving performance.

Objective

The study is designed to develop a valid screening-tool for fitness-to-drive assessment in older people with cognitive impairment externally validated on the basis of on-road driving performance.

Methods

In a single-centre, non-randomized cross-sectional trial cognitive functioning and on-road-driving-behavior of older drivers will be assessed. Forty participants with cognitive impairment of different etiology and 40 healthy controls will undergo an extensive neuropsychological assessment. Additionally, an on-road driving assessment for external validation of fitness to drive will be carried out. Primary outcome measures will be performance in attention, executive functions and visuospatial tasks that will be validated with respect to performance on the on-road-driving-test. Secondary outcome measures will be sociodemographic, clinical- and driving characteristics to systematically examine their influence on the prediction of driving behavior.

Discussion

In clinical practice counselling patients with respect to driving safety is of great relevance. Thus, having valid, reliable, time economical and easily interpretable screening-tools on hand to counsel patients is of great relevance for practitioners.

Ethics and dissemination

Ethics approval was obtained from the Ethics Committee at the Ludwig-Maximilians-University Munich. The trial results will be disseminated through peer-reviewed publications and various conferences.

Trial registration

18–640.

Trial registration: German Clinical Trials Register.

Registration number: DRKS00023549.

Civil responsibility in Geriatric Psychiatry

Mental health issues impair decision-making capacity, more so in elderly people. Impaired decision-making capacity can make person unfit to enter into various civil deeds and agreements. Such civil deeds can include guardianship, property transaction, holding a bank account, having voting rights, making a will, donating an organ, etc. This article focuses on importance of mental health in entering into above-mentioned civil agreements, how to do assessments to determine if one is fit to enter into civil agreements, and what are the legal ways in which a person can avail help to execute his/her civil rights even when affected by mental health issues.

On-road driving test performance in veterans: Effects of age, clinical diagnosis and cognitive measures

INTRODUCTION

Veterans are at heightened risk of being in a motor-vehicle crash and many fail on-road driving evaluations, particularly as they age. This may be due in part to the high prevalence of age-associated conditions impacting cognition in this population, including neurodegenerative diseases (e.g., Alzheimer's Disease) and acquired neurological conditions (e.g., cerebrovascular accident). However, understanding of the impact of referral diagnosis, age and cognition on Veterans' on-road driving performance is limited.

METHODS

109 Veterans were referred for a driving evaluation (mean age = 72.0, SD = 11.5) at a driving assessment clinic at the Minneapolis Veterans Affairs Healthcare System. Of the 109 Veterans enrolled, 44 were referred due to a neurodegenerative disease, 37 due to an acquired neurological condition, and 28 due to a non-neurological condition (e.g., vision loss). Veterans completed collection of health history information and administration of cognitive tests assessing visual attention, processing speed, and executive functioning, as well as a standardized, on-road driving evaluation.

RESULTS

A total of 17.9% of Veterans failed the on-road evaluation. Clinical diagnostic group was not associated with failure rate. Age was not associated with failure rates in the full sample or within diagnostic groups. After controlling for age, poorer processing speed and selective/divided attention were associated with higher failure rates in the full sample. No cognitive tests were associated with failure rates within diagnostic groups.

CONCLUSION

Referral diagnosis and age alone are not reliable predictors of Veterans' driving performance. Cognitive performance, specifically speed of processing and attention, may be helpful in screening Veterans' driving safety. Practical Applications: Clinicians tasked with assessing Veterans' driving safety should take into account cognitive performance, particularly processing speed and attention, when making decisions regarding driving safety. Age and referral diagnosis, while helpful information, are insufficient to predict outcomes on driving evaluations.

Driving Skills of Individuals With and Without Developmental Coordination Disorder (DCD/Dyspraxia)

Learning to drive is a significant event for the transition to adulthood and delay or avoidance may have social, practical, and psychological implications. For those with Developmental Coordination Disorder (DCD/Dyspraxia), driving presents a considerable challenge, and the literature shows that there are differences in driving ability between individuals with and without DCD. The aim of the current research is to further our understanding of the mechanisms underlying the driving experiences of individuals with DCD. Nineteen participants with DCD (10 drivers and 9 non-drivers) and 36 controls (17 drivers and 19 non-drivers) aged 18-57 years took part in this study. Participants completed standardized tests, questionnaires and a driving simulation task designed to measure speed, road positioning, and rate of change of steering in three conditions with increasing perceptual complexity. Results indicate that behaviors for all participants changed as the perceptual demands of the task increased. However, drivers with DCD were more affected than all other groups, driving more slowly, and driving further to the right. These findings illustrate how the impact of both internal and external constraints negatively affect the success of the driving task for individuals with DCD compared to their TD peers.

The Impact of HIV-Associated Neurocognitive Impairment on Driving Performance in Commercial Truck Drivers

Driving ability can be diminished amongst people with HIV with associated neurocognitive impairment (NCI). We explore the relationship between HIV status, NCI and driving ability in professional truck drivers. Forty male professional drivers (20 HIV-positive; mean age = 39.20 ± 7.05) completed a neuropsychological test battery, two driving simulator tasks that assessed driving ability, and a driving history and habits questionnaire. A higher proportion of HIV-positive drivers exhibited impaired overall cognitive performance (p ≤ 0.001). Overall, drivers with NCI (defined as z ≤ 1.00) were more likely than those without NCI to crash (p = 0.002). There were no significant between-group (HIV-positive versus HIV-negative) differences with regard to self-reported on-road driving events. Professional drivers with NCI, as measured on a driving simulator, are at increased risk of making driving errors under high-risk conditions compared to their neurocognitively normal counterparts. These data should inform driver health management with regard to annual medical screening and surveillance.

Spatial Mental Transformation Skills Discriminate Fitness to Drive in Young and Old Adults

Literature on driving research suggests a relationship between cognition and driving performance in older and younger drivers. There is little research on adults and driving, despite them being the largest age cohort behind the wheel. Among the cognitive domains, visuospatial abilities are expected to be highly predictive of driving skills and driving fitness. The relationship between specific spatial mental transformation skills (i.e., object and self-based ones) and driving performance has not yet been examined. The present study aimed to investigate the relationship between overall cognitive functioning, self and object-based spatial mental transformation skills, and driving performance in a sample of younger and older adult drivers. Participants were comprised of one hundred younger and 83 older adult Italian drivers. Participants completed a computerized driving test assessing traffic stress resilience, visual and motor reaction time, and the ability to obtain an overview of the traffic scenario (DT, vRT, mRT, and ATAV respectively in the Shufried®-Vienna Test System-DRIVESC). The Mental Rotation Test (MRT) and the Object Perspective Taking Test (OPT) were administered in order to assess object-based and self-based spatial mental transformation skills. The Montreal Cognitive Assessment Test (MoCA) was administered control for global cognitive functioning. The effects of education and gender were also controlled in the analysis. The results of the present study suggested that: (1) The effect of age, favoring younger participants, was found in DT, vRT, mRT, and ATAVT tests. (2) The effect of global cognitive functioning was found in DT and ATAV tests. (3) The effect of the spatial mental transformation tests was found in DT, vRT (MRT only), and ATAVT (OPT only) tests. Taken together, these results suggest the specific contribution of spatial mental transformation skills in the execution of complex behaviors connected to the fitness to drive. Prospectively, the results of the present study relating spatial mental transformation skills and driving processes may be a valuable source of knowledge for researchers dealing with the relationship between cognitive resources and navigation aids.

Using Serial Trichotomization with Neuropsychological Measures to Inform Clinical Decisions on Fitness-to-Drive among Older Adults with Cognitive Impairment

Decisions related to driving safety and when to cease driving are complex and costly. There is an interest in developing an off-road driving test utilizing neuropsychological tests that could help assess fitness-to-drive. Serial trichotomization has demonstrated potential as it yields 100% sensitivity and specificity in retrospective test samples. The purpose of this study was to test serial trichotomization using four common neuropsychological tests (Trail Making Test Part A and B, Clock Drawing Test, and Modified Mini-Mental State Examination). Test scores from 105 patients who were seen in a memory clinic were abstracted. After applying the model, participants were classified as unfit, fit, or requiring further testing, 38.1%, 25.8%, and 36.1%, respectively. This study provides further evidence that trichotomization can facilitate the assessment of fitness-to-drive.

Avoidance Behavior Is an Independent Indicator of Poorer On-road Driving Skills in Older Adults

OBJECTIVES

The aim of the current work was to investigate the relationship between avoidance of specific driving situations and on-road driving skills in older drivers considering factors found to be related to both avoidance behavior and driving skills.

METHOD

Seventy-two older drivers (M = 76 years) from the general population were included in this study. Self-reported avoidance behavior, driving practice, perceived driving difficulties, driving-related cognitive functions, as well as medical conditions were assessed within two sessions. Standardized on-road assessments served for assessing on-road driving skills in a third session.

RESULTS

Self-reported avoidance behavior was associated with reduced driving skills (r = -.41), and this relationship remained significant beyond the influence of cognitive skills, self-reported health, driving practice, and perceived driving difficulties. Specifically, avoidance of driving in bad weather, poor visibility and complicated parking was found to be associated with reduced driving skills.

DISCUSSION

This study suggest that avoidance behavior is an independent indicator of impaired driving skills in older drivers. Our results argue against the assumption that avoidance behavior may be a reasonable strategy for safe traffic participation. Longitudinal studies are urgently needed to get more evidence on safety aspects of avoidance behavior.

Neurophysiological correlates of age differences in driving behavior during concurrent subtask performance

Driving is a complex cognitive-motor task that requires the continuous integration of multisensory information, cognitive processes, and motor actions. With higher age, driving becomes increasingly challenging as a result of naturally declining neurophysiological resources. Performing additional subtasks, such as conversations with passengers or interactions with in-vehicle devices (e.g., adjusting the radio), may further challenge neurocognitive resources that are required to maintain driving performance. Based on declining brain physiological resources and inferior neurocognitive functioning, older adults (OA) may show higher brain activation and larger performance decrements than younger adults (YA) when engaging in additional subtasks during driving. Age differences, however, may further vary for different neurocognitive task demands, such that driving performance of OA might be particularly affected by certain subtasks. In this study, we hence investigated the brain functional correlates of age differences in driving behavior during concurrent subtask performance in YA and OA. Our final sample consisted of thirty younger (21.80 ± 1.73y, 15 female) and thirty older (69.43 ± 3.30y, 12 female) regular drivers that drove along a typical rural road (25 - 30 min) in a driving simulator and performed three different concurrent subtasks that were presented auditorily or visually: typing a 3-digit number (TYPE), comparing traffic news and gas station prices (working memory, WM), and stating arguments (ARG). We measured variability in lateral car position, velocity, and following distance to a frontal lead car as the standard deviation from 0 to 15 s after subtask onset. Brain activity was continuously recorded using functional near-infrared spectroscopy over the dorsolateral prefrontal cortex. Both YA and OA particularly varied in their lateral position during TYPE with a more pronounced effect in OA. For YA, in contrast, ARG led to higher variability in velocity compared to TYPE and WM, whereas OA showed no task-specific differences. Substantiating our behavioral findings, OA revealed the largest brain functional response to TYPE, while YA demonstrated a very distinct activation during ARG and smaller hemodynamic responses to TYPE and WM. Brain activity in the DLPFC was, overall, not significantly, but small to moderately related to certain behavioral performance parameters (mainly lateral position). We conclude that both OA and YA are vulnerable to distractive subtasks while driving. Age differences, however, seem to largely depend on neurocognitive task demands. OA may be at higher risk for accidents when performing visuo-motor subtasks (e.g., interacting with navigational systems) during driving while YA may be more (cognitively) distracted when talking to passengers.

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.

Machine-learning approach to predict on-road driving ability in healthy older people

AIM

In Japan, fatal traffic accidents due to older drivers are on the rise. Considering that approximately half the older drivers who have caused fatal accidents are cognitively normal healthy people, it has been required to detect older drivers who are cognitively normal but at high risk of having fatal traffic accidents. However, a standardized method for assessing the driving ability of older drivers has not yet been established. We thus aimed to identify a new sensing method for the evaluation of the on-road driving ability of healthy older people on the basis of vehicle behaviors.

METHODS

We enrolled 33 healthy older individuals aged over 65 years and utilized a machine-learning approach to dissociate unsafe drivers from safe drivers based on cognitive assessments and a functional visual acuity test.

RESULTS

The linear support vector machine classifier successfully dissociated unsafe drivers from safe drivers with accuracy of 84.8% (sensitivity of 66.7% and specificity of 95.2%). Five clinical parameters, namely age, the first trial of the Rey Auditory Verbal Learning Test immediate recall, the delayed recall of the Rey-Osterrieth Complex Figure Test, the result of the free-drawn Clock Drawing Test, and maximal visual acuity, were consistently selected as essential features for the best classification model.

CONCLUSION

Our findings improve our understanding of clinical risk factors leading to unsafe driving and may provide insight into a new intervention that prevents fatal traffic accidents caused by healthy older people.

Predicting Alzheimer's Disease Using Driving Simulator Data

Early detection of Alzheimer's Disease (AD) is critical in creating better outcomes for patients. Performance in complex tasks such as vehicular driving may be a sensitive tool for early detection of AD and serve as a good indicator of functional status. In this study, we investigate the classification of AD patients and controls using driving simulator data. Our results show that machine learning algorithms, especially random forest classifier, can accurately discriminate AD patients and controls (AUC = 0.96, Sensitivity = 87%, and Specificity = 93%). The model-identified most important features include Pothole Avoidance, Road Signs Recalled, Inattention Measurements, Reaction Time, and Detection Times, among others, all of which closely align with previous studies about cognitive functions that are affected by AD.

The Drives for Driving Simulation: A Scientometric Analysis and a Selective Review of Reviews on Simulated Driving Research

Driving behaviors and fitness to drive have been assessed over time using different tools: standardized neuropsychological, on-road and driving simulation testing. Nowadays, the great variability of topics related to driving simulation has elicited a high number of reviews. The present work aims to perform a scientometric analysis on driving simulation reviews and to propose a selective review of reviews focusing on relevant aspects related to validity and fidelity. A scientometric analysis of driving simulation reviews published from 1988 to 2019 was conducted. Bibliographic data from 298 reviews were extracted from Scopus and WoS. Performance analysis was conducted to investigate most prolific Countries, Journals, Institutes and Authors. A cluster analysis on authors' keywords was performed to identify relevant associations between different research topics. Based on the reviews extracted from cluster analysis, a selective review of reviews was conducted to answer questions regarding validity, fidelity and critical issues. United States and Germany are the first two Countries for number of driving simulation reviews. United States is the leading Country with 5 Institutes in the top-ten. Top Authors wrote from 3 to 7 reviews each and belong to Institutes located in North America and Europe. Cluster analysis identified three clusters and eight keywords. The selective review of reviews showed a substantial agreement for supporting validity of driving simulation with respect to neuropsychological and on-road testing, while for fidelity with respect to real-world driving experience a blurred representation emerged. The most relevant critical issues were the a) lack of a common set of standards, b) phenomenon of simulation sickness, c) need for psychometric properties, lack of studies investigating d) predictive validity with respect to collision rates and e) ecological validity. Driving simulation represents a cross-cutting topic in scientific literature on driving, and there are several evidences for considering it as a valid alternative to neuropsychological and on-road testing. Further research efforts could be aimed at establishing a consensus statement for protocols assessing fitness to drive, in order to (a) use standardized systems, (b) compare systematically driving simulators with regard to their validity and fidelity, and (c) employ shared criteria for conducting studies in a given sub-topic.

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.

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.

A Study on the Gaze Range Calculation Method During an Actual Car Driving Using Eyeball Angle and Head Angle Information

Car operation requires advanced brain function. Currently, evaluation of the motor vehicle driving ability of people with higher brain dysfunction is medically unknown and there are few evaluation criteria. The increase in accidents by elderly drivers is a social problem in Japan, and a method to evaluate whether elderly people can drive a car is needed. Under these circumstances, a system to evaluate brain dysfunction and driving ability of elderly people is needed. Gaze estimation research is a rapidly developing field. In this paper, we propose the gaze calculation method by eye and head angles. We used the eye tracking device (TalkEyeLite) made by Takei Scientific Instruments Cooperation. For our image processing technique, we estimated the head angle using the template matching method. By using the eye tracking device and the head angle estimate, we built a system that can be used during actual on-road car operation. In order to evaluate our proposed method, we tested the system on Japanese drivers during on-road driving evaluations at a driving school. The subjects were one instructor of the car driving school and eight general drivers (three 40–50 years old and five people over 60 years old). We compared the gaze range of the eight general subjects and the instructor. As a result, we confirmed that one male in his 40s and one elderly driver had narrower gaze ranges.

Assessing driving fitness in dementia: a challenge for old age psychiatrists

OBJECTIVE

To investigate how old age psychiatrists consider the fitness of dementia patients to drive safely and the challenges they face.

METHOD

Participants were interviewed using a semi-structured approach that explored topics including their approach to driving fitness and cessation, challenges experienced and previous training. Thematic analysis was used to generate main themes.

RESULTS

Thirteen participants were recruited. Most felt they were not experts in driving fitness. Many found these assessments challenging for both themselves and their patients, with a negative impact on therapeutic alliance. There was a lack of formal training and variability both in the approach when considering fitness to drive as well as raising the issue of driving with patients.

CONCLUSIONS

These results highlight the need to increase the availability of training for driving fitness, and to develop a standardised approach to help improve consistency amongst clinicians.

Comparing executive functioning and clinical and sociodemographic characteristics of people with schizophrenia who hold a driver's license to those who do not

BACKGROUND.

Community engagement requires driving. However, there is paucity of research focusing on the potential to drive for people with schizophrenia.

PURPOSE.

This study aimed to characterize people with schizophrenia by comparing clinical signs, executive functions (EF), and sociodemographic aspects of those holding a driver's license to those without one.

METHOD.

This cross-sectional study used convenience sampling to select 60 ambulatory individuals to participate: 31 with a driver's license and 29 without one. They completed the Wisconsin Card Sorting Test (WCST) for evaluation of EF and the Positive and Negative Syndrome Scale (PANSS) for symptoms severity evaluation. Data were analyzed using multivariate analyses of covariance and logistic regression models.

FINDINGS.

Participants with a license had less severe negative symptoms and general psychopathology and better EF and sociodemographic aspects compared to those without a license. Logistic regression revealed significant odds ratios (OR) in general psychopathology (PANSS; OR = 0.963, p = .011) and in the WCST (OR = 0.504, p = .027).

IMPLICATIONS.

This study offers occupational therapists a data-driven perspective on evaluating potential fitness to drive to enable participation in daily life and well-being of people with schizophrenia.

Comparison of traffic collision victims between older and younger drivers in South Korea: Epidemiologic characteristics, risk factors and types of collisions

Objective

This study aimed to show the epidemiological characteristics and the difference in the risk factors and types of collision between older and younger drivers in Korea.

Methods

We collected data from the Emergency Department-based Injury In-depth Surveillance retrieved by the Korea Centers for Disease Control and Prevention from 2011 to 2015. We included injured drivers aged ≥ 18 years who were registered in the database, who were limited to drivers of four-wheeled vehicles. The enrolled patients were divided according to age into older (≥ 65 years) and younger (< 65 years) drivers. The total number of enrolled drivers was 37,511; 2,361 (6.3%) of them were older drivers. The epidemiological characteristics (e.g., age, sex, fatality rate) of traffic collision victims for 5 years were determined, and the risk factors (e.g., seat belt use) and types of collision (single- vs. multi-vehicle) between the two groups were compared.

Results

The median age and interquartile range (IQR; 25^th and 75^th percentiles) of all drivers were 41.0 (IQR, 32.0–52.0), and 24,544 (65.4%) of them were men. The median age increased from 40.0 (IQR, 31.0–50.0) to 43.0 (IQR, 33.0–54.0) between 2010 and 2015 (P < 0.001). The proportion of older drivers increased from 5.0% to 8.4% annually during the study period (P < 0.001). Between 2010 and 2015, the fatality rate decreased from 3.1% to 1.2% (P = 0.287) for older drivers and from 0.9% to 0.5% (P = 0.009) for younger drivers. The proportion of single-vehicle collision (25.9% vs. 20.3%) was higher in older than in younger drivers (P < 0.001). Older drivers had a lower rate of seat-belt use than younger drivers (79.0% vs. 83.0%, P < 0.001).

Conclusions

The proportion of older drivers increased annually during the study period, and older drivers experienced more single-vehicle collision and used seat belt less frequently than younger drivers. A national policy support to reduce traffic collision in older drivers and public relation activities to enhance their seat belt use should be strengthened in the future.

The neuropsychological aspects of performance-based Internet navigation skills: A brief review of an emerging literature

OBJECTIVE

Over the last 20 years, the Internet has become a fundamental means by which many people with neurocognitive disorders manage their activities of daily living (e.g. shopping) and engage in health behaviors (e.g. appointment scheduling). The aim of this review is to summarize the emerging literature on the neuropsychology of performance-based tasks of Internet navigation skills (INS) as measures of everyday functioning.

METHOD

We performed a structured, qualitative review of the extant literature on INS using PRISMA guidelines.

RESULTS

Seventeen peer-reviewed studies met inclusion criteria and their results suggest that performance-based tests of INS: (1) discriminate healthy adults from some neuropsychological populations [e.g. human immunodeficiency virus (HIV), multiple sclerosis (MS), traumatic brain injury (TBI)]; (2) are associated with performance-based tests of everyday functioning capacity, domain-specific declines in manifest everyday functioning, and self-reported Internet behavior, but not global manifest functional status; (3) correlate with standard clinical neuropsychological tests, particularly executive functions and episodic memory; (4) may relate to demographic factors, most notably age; and (5) have largely unknown psychometric properties (e.g. reliability).

CONCLUSION

This review provided early support for the construct validity of performance-based tasks of INS as modern measures of everyday functioning in neuropsychological populations. Future work is needed to refine these tasks, establish their psychometrics, and evaluate their construct validity in diverse populations, as well as to develop effective remediation and compensatory strategies to improve Internet functionality among persons with neurocognitive disorders.

EEG-Based Neurocognitive Metrics May Predict Simulated and On-Road Driving Performance in Older Drivers

The number of older drivers is steadily increasing, and advancing age is associated with a high rate of automobile crashes and fatalities. This can be attributed to a combination of factors including decline in sensory, motor, and cognitive functions due to natural aging or neurodegenerative diseases such as HIV-Associated Neurocognitive Disorder (HAND). Current clinical assessment methods only modestly predict impaired driving. Thus, there is a need for inexpensive and scalable tools to predict on-road driving performance. In this study EEG was acquired from 39 HIV+ patients and 63 healthy participants (HP) during: 3-Choice-Vigilance Task (3CVT), a 30-min driving simulator session, and a 12-mile on-road driving evaluation. Based on driving performance, a designation of Good/Poor (simulator) and Safe/Unsafe (on-road drive) was assigned to each participant. Event-related potentials (ERPs) obtained during 3CVT showed increased amplitude of the P200 component was associated with bad driving performance both during the on-road and simulated drive. This P200 effect was consistent across the HP and HIV+ groups, particularly over the left frontal-central region. Decreased amplitude of the late positive potential (LPP) during 3CVT, particularly over the left frontal regions, was associated with bad driving performance in the simulator. These EEG ERP metrics were shown to be associated with driving performance across participants independent of HIV status. During the on-road evaluation, Unsafe drivers exhibited higher EEG alpha power compared to Safe drivers. The results of this study are 2-fold. First, they demonstrate that high-quality EEG can be inexpensively and easily acquired during simulated and on-road driving assessments. Secondly, EEG metrics acquired during a sustained attention task (3CVT) are associated with driving performance, and these metrics could potentially be used to assess whether an individual has the cognitive skills necessary for safe driving.

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.

Driving Cessation and Cognitive Dysfunction in Patients with Mild Cognitive Impairment

Although driving by adults with cognitive impairment is an important public health concern, little is known about the indicators of driving cessation in patients with mild cognitive impairment (MCI). We aimed to investigate the prevalence of driving cessation in patients with MCI and the predictive value of cognitive performances for driving cessation. Patients with MCI were recruited in the Seoul National University Bundang Hospital; they met following inclusion criteria. Age range of 51–80 years, Clinical Dementia Rating scale score of 0.5, and ever car drivers including former and current drivers. All participants underwent comprehensive standardized cognitive assessments and information on driving status was obtained via an interview using a systematic questionnaire. The median age of the 135 participants was 72 years, and 54 participants (40%) were women; 93 patients (68.9%) were current drivers and 42 (31.1%) were former drivers. In univariate analysis, former drivers showed poorer performances in digit span backward and categorical fluency tests than current drivers. In multivariate logistic regression analysis, a poor digit span backward test score was significantly related with driving cessation (odds ratio: 0.493, 95% confidence interval: 0.258–0.939). In patients with MCI, poor performance in the digit span backward test, which represents impaired working memory capacity, was associated with a higher probability of driving cessation.

Behind the wheel safety in palliative care: a literature review

BACKGROUND

Driving is a complex activity that requires physical abilities and adequate executive and cognitive functioning. There is concern among specialist palliative care services about patients continuing to drive despite having progressive incurable illnesses, comorbidities and medications to manage their symptoms.

OBJECTIVES

To determine the quality of literature available about driving that would apply to palliative care patients, specifically in relation to road test or simulated driving scores and neurocognitive testing.

METHOD

A literature search based on systematic principles was conducted on the Ovid Medline, PsycINFO, Embase and CINAHL database up to 14 October 2018. Patient populations with life-limiting illness such as cancer, cardiorespiratory and neurological diagnoses were included.

RESULTS

37,546 articles were screened. 14 articles satisfied the search criteria. Six studies focused on patients with multiple sclerosis (MS). Four studies investigated driving ability in patients with Huntington's disease. The remaining four articles studied heart failure, chronic obstructive pulmonary disease (COPD), interstitial lung disease and patients with cancer. In the road test studies, 19%-47% of patients with MS and Huntington's failed the behind-the-wheel assessment. The simulated driving scores in seven studies demonstrated statistically significant differences in errors made between study participants and controls. Divided attention was found in seven studies to be associated with poorer road-test or simulated driving ability.

CONCLUSIONS

This review highlights the scarcity of studies available for patients who would be known to palliative care services. For most patient groups, a battery of neurocognitive tests combined with a road-test or simulated driving assessment is still considered the best practice in determining driving safety.

Subcortical Ischemic Change as a Predictor of Driving Cessation in the Elderly

OBJECTIVE

Motor, perceptual, and cognitive functions are known to affect driving competence. Subcortical ischemic changes on brain magnetic resonance imaging (MRI) can reflect reduction in cognitive and motor performance. However, few studies have reported the relationship between subcortical ischemic changes and driving competence of the elderly. Thus, the objective of this study was to investigate the association between subcortical ischemic changes on MRI and driving abilities of the elderly.

METHODS

Participants (n=540) were drawn from a nationwide, multicenter, hospital-based, longitudinal cohort. Each participant underwent MRI scan and interview for driving capacity categorized into 'now driving' and 'driving cessation (driven before, not driving now)'. Participants were divided into three groups (mild, n=389; moderate, n=116; and severe, n=35) depending on the degree of white matter hyperintensity (WMH) on MRI at baseline. Driving status was evaluated at follow-up. Statistical analyses were conducted using χ2 test, analysis of variance (ANOVA), structured equation model (SEM), and generalized estimating equation (GEE).

RESULTS

In SEM, greater baseline degree of WMH was directly associated with driving cessation regardless of cognitive or motor dysfunction (β=-0.110, p<0.001). In GEE models after controlling for age, sex, education, cognitive, and motor dysfunction, more severe change in the degree of WMH was associated with faster change from 'now driving' state to 'driving cessation' state over time in the elderly (β=-0.508, p<0.001).

CONCLUSION

In both cross-sectional and longitudinal results, the degree of subcortical ischemic change on MRI might predict driving cessation in the elderly.

Effect of single caffeine intake on neuropsychological functions in healthy volunteers: A double-blind placebo-controlled study

Objective

We investigated the effects of a single instance of caffeine intake on neurocognitive functions and driving performance in healthy subjects using an established cognitive battery and a driving simulator system.

Methods

This study was conducted in a double-blind, randomized, placebo-controlled manner from February 19, 2016 to August 6, 2016. Caffeine intake was discontinued 3 days prior to the study. Participants were randomly assigned to receive 200-mg doses of caffeine or a placebo. Thirty minutes after administration, cognitive functions were evaluated via the Symbol Digit Coding Test (SDC), the Stroop Test (ST), the Shifting Attention Test (SAT) and the Four Part Continuous Performance Test (FPCPT). After the cognitive function tests were conducted, driving performance was evaluated using a driving simulator. We measured the brake reaction time (BRT) in the Harsh-braking test and the standard deviation of the lateral position (SDLP) in the Road-tracking test.

Results

Of 100 randomized subjects, 50 (50%) of 100 in the caffeine group and 50 (50%) of 100 in the placebo group completed the study. Participants in the caffeine group had more correct responses than participants in the placebo group on the SAT (P = 0.03) and made fewer errors (P = 0.02). Participants in the caffeine group exhibited shorter times in the Harsh-braking test than participants in the placebo group (P = 0.048).

Conclusions

A single instance of caffeine intake changed some neurocognitive functions and driving performance in healthy volunteers.

Trial registration

UMIN000023576.

Neurocognitive Disorder Diagnoses Matter: A Brief Report on Caregiver Appraisal of Driving Ability

Background: Age-associated neurocognitive disorders (NCDs) are associated with progressive loss of abilities for instrumental activities of daily living, including driving. This study assesses the impact of NCD diagnosis, while controlling for reported level of cognitive impairment, on family caregiver judgment of driving safety. Method: An intervention sample of 152 intergenerational caregivers who assist an older adult with medical tasks was used. Caregiver's pre-intervention response to a single item of confidence in the older adult driving was used to determine judgment of driving ability. Cognitive impairment was assessed using caregivers' report for Clinical Dementia Rating (CDR) Sum of Boxes score. Results: Older adults with a diagnosis were rated as less capable of driving safely than those without a diagnosis, while controlling for reported level of cognitive impairment. Conclusion: Results of this study highlight the importance of NCD diagnosis on caregiver judgments. Results of this study have implications for health care and driving safety.

A pilot investigation on the effects of combination transcranial direct current stimulation and speed of processing cognitive remediation therapy on simulated driving behavior in older adults with HIV

Cognitive impairments seen in people living with HIV (PLWH) are associated with difficulties in everyday functioning, specifically driving. This study utilized speed of processing cognitive remediation therapy (SOP-CRT) with transcranial direct current stimulation (tDCS) to gauge the feasibility and impact on simulated driving. Thirty PLWH (M _age = 54.53, SD = 3.33) were randomly assigned to either: sham tDCS SOP-CRT or active tDCS SOP-CRT. Seven indicators of simulated driving performance and safety were obtained. Repeated measures ANOVAs controlling for driver's license status (valid and current license or expired/no license) revealed a large training effect on average driving speed. Participants who received active tDCS SOP-CRT showed a slower average driving speed (p = 0.020, d = 0.972) than those who received sham tDCS SOP-CRT. Non-significant small-to-medium effects were seen for driving violations, collisions, variability in lane positioning, and lane deviations. Combination tDCS SOP-CRT was found to increase indices of cautionary simulated driving behavior. Findings reveal a potential avenue of intervention and rehabilitation for improving driving safety among vulnerable at-risk populations, such as those aging with chronic disease.