Impaired vision and other factors associated with driving cessation in the elderly: the Blue Mountains Eye Study

Hazard Perception in Visually Impaired Drivers Who Use Bioptic Telescopes

Purpose

Bioptic telescopic spectacles can allow individuals with central vision impairment to obtain or maintain driving privileges. The purpose of this study was to (1) compare hazard perception ability among bioptic drivers and traditionally licensed controls, (2) assess the impact of bioptic telescopic spectacles on hazard perception in drivers with vision impairment, and (3) analyze the relationships among vision and hazard detection in bioptic drivers.

Methods

Visual acuity, contrast sensitivity, and visual field were measured for each participant. All drivers completed the Driving Habits Questionnaire. Hazard perception testing was conducted using commercially available first-person video driving clips. Subjects signaled when they could first identify a traffic hazard requiring a change of speed or direction. Bioptic drivers were tested with and without their bioptic telescopes in alternating blocks. Hazard detection times for each clip were converted to z-scores, converted back to seconds using the average response time across all videos, and then compared among conditions.

Results

Twenty-one bioptic drivers and 21 normally sighted controls participated in the study. The hazard response time of bioptic drivers was improved when able to use the telescope (5.4 ± 1.4 seconds vs 6.3 ± 1.8 seconds without telescope); however, it remained significantly longer than for controls (4.0 ± 1.4 seconds). Poorer visual acuity, contrast sensitivity, and superior visual field sensitivity loss were related to longer hazard response times.

Conclusions

Drivers with central vision loss had improved hazard response times with the use of bioptic telescopic spectacles, although their responses were still slower than normally sighted control drivers.

Translational Relevance

The use of a bioptic telescope by licensed, visually impaired drivers improves their hazard detection speed on a video-based task, lending support to their use on the road.

Associations between vision impairment and vision-related interventions on crash risk and driving cessation: systematic review and meta-analysis

OBJECTIVES

To systematically investigate the associations between vision impairment and risk of motor vehicle crash (MVC) involvement, and evaluate vision-related interventions to reduce MVCs.

DESIGN

Medline (Ovid), EMBASE and Global Health electronic databases were systematically searched from inception to March 2022 for observational and interventional English-language studies. Screening, data extraction and appraisals using the Joanna Briggs Institute appraisal tools were completed by two reviewers independently. Where appropriate, measures of association were converted into risk ratios (RRs) or ORs for meta-analysis.

PARTICIPANTS

Drivers of four-wheeled vehicles of all ages with no cognitive declines.

PRIMARY AND SECONDARY OUTCOMES

MVC involvement (primary) and driving cessation (secondary).

RESULTS

101 studies (n=778 052) were included after full-text review. 57 studies only involved older drivers (≥65 years) and 85 were in high-income settings. Heterogeneity in the data meant that most meta-analyses were underpowered as only 25 studies, further split into different groups of eye diseases and measures of vision, could be meta-analysed. The limited evidence from the meta-analyses suggests that visual field defects (four studies; RR 1.51 (95% CI 1.23, 1.85); p<0.001; I2=46.79%), and contrast sensitivity (two studies; RR 1.40 (95% CI 1.08, 1.80); p=0.01, I2=0.11%) and visual acuity loss (five studies; RR 1.21 (95% CI 1.02, 1.43); p=0.03, I2=28.49%) may increase crash risk. The results are more inconclusive for available evidence for associations of glaucoma (five studies, RR 1.27 (95% CI 0.67, 2.42); p=0.47; I2=93.48%) and cataract (two studies RR 1.15 (95% CI 0.97, 1.36); p=0.11; I2=3.96%) with crashes. Driving cessation may also be linked with glaucoma (two studies; RR 1.62 (95% CI 1.20, 2.19); p<0.001, I2=22.45%), age-related macular degeneration (AMD) (three studies; RR 2.21 (95% CI 1.47, 3.31); p<0.001, I2=75.11%) and reduced contrast sensitivity (three studies; RR 1.30 (95% CI 1.05, 1.61); p=0.02; I2=63.19%). Cataract surgery halved MVC risk (three studies; RR 0.55 (95% CI 0.34, 0.92); p=0.02; I2=97.10). Ranibizumab injections (four randomised controlled trials) prolonged driving in persons with AMD.

CONCLUSION

Impaired vision identified through a variety of measures is associated with both increased MVC involvement and cessation. Cataract surgery can reduce MVC risk. Despite literature being highly heterogeneous, this review shows that detection of vision problems and appropriate treatment are critical to road safety.

PROSPERO REGISTRATION NUMBER

CRD42020172153.

Non-cognitive factors associated with driving cessation among older adults: An integrative review

Exploring the factors that affect driving cessation is crucial, because sustained mobility plays an important role in successful aging. This study aimed to collect evidence on the non-cognitive factors associated with driving cessation among older adults. The method used in this study was an integrated review of published research on the factors affecting driving cessation. A comprehensive search was performed using electronic databases including PubMed, Web of Science, Scopus, CINHAL, ProQuest, EBSCO, and Google Scholar. The results revealed six main categories (physical health, psychological health, interpersonal influence, transportation support, policies, and sociodemographic characteristics) and 24 subcategories for driving cessation. Given the potentially serious consequences of driving cessation in the older adult population, exploring the predictors of driving cessation can be used to design interventions for optimizing drivers' health, rehabilitating the functional limitations that affect driving ability, creating a safer driving environment, and optimizing vehicles to meet the needs of older drivers.

Self-Reported Driving Difficulty, Avoidance, and Negative Emotion With On-Road Driving Performance in Older Adults With Glaucoma

PURPOSE

To investigate the relationship between self-perceived driving difficulty, driving avoidance, and negative emotion about driving with glaucoma severity and on-road driving performance.

DESIGN

Cohort study.

METHODS

Glaucoma patients (n = 111), aged 55 to 90 years, with mild, moderate, and advanced glaucoma in the better-eye based on the Glaucoma Staging System, and age-matched controls (n = 47) were recruited from a large tertiary academic center. Self-reported questionnaires were administered by a trained occupational therapist followed by a standardized on-road driving evaluation (pass vs "at-risk" score) with a masked and certified driving rehabilitation specialist.

RESULTS

Compared to controls, glaucoma participants reported greater driving difficulty with as early as mild glaucoma (P = .0391) and negative emotion about driving starting with moderate glaucoma (P = .0042). Glaucoma participants reporting at least 1 driving difficulty and negative emotion had a 3.3-fold (adjusted odds ratio [OR] = 3.3; 95% CI = 1.24-8.52; P = .0163) and 4.2-fold (adjusted OR = 4.2; 95% CI = 1.5-12.2; P = .0078) greater odds, respectively, of an at-risk score on the on-road test. Self-reported driving difficulty in "difficult" conditions (P = .0019), rain (P = .0096), interstates (P = .0378), and high traffic (P = .0076), driving avoidance on sunny (P = .0065) and cloudy (P = .0043) days, and driving fewer days per week (P = .0329) were also associated with at-risk driving.

CONCLUSIONS

Screening tools that assess self-perceived driving difficulty and driving avoidance in specific conditions, negative emotion about driving, and driving exposure may help identify unsafe drivers with glaucoma. Some of these drivers, particularly those with modest glaucoma, may benefit from a driving evaluation and early referral to resources that could enable them to continue driving safely and confidently.

A longitudinal analysis of factors associated with age-related cataract among older Australian women: a cohort study of 7851 older Australian women 79-90 years

BACKGROUND

Age-related cataracts are a significant global health issue due to population ageing. More than 70% of older Australians aged 80 or above have clinically significant age-related cataracts.

AIM

The study aimed to identify factors associated with age-related cataracts among older Australian women 79-90 years.

METHOD

A 6-year longitudinal analysis of the Australian Longitudinal Study on Women's Health (ALSWH) was conducted on 7117 women from surveys four to six. The women were asked whether they had been diagnosed or treated for cataracts 3 years before each survey. We used generalised estimating equation (GEE) modelling to identify factors independently associated with age-related cataracts.

RESULTS

At baseline (79-84 years), 44.8% lived in metropolitan Australia, 67.9% had good general health, 26.5% had private health insurance, 30.6% had cataracts, 28.8% had undergone cataract surgery, 12.0% had diabetes, 24.9% had skin cancer, 56.2% had hypertension, 24.0% had a history of falls, 63.0% had visited general practitioner (GP) frequently, and 48.8% were driving themselves as their main means of transport. In the final model, poor general health [adjusted odds ratio (AOR) = 1.23, 95% CI = 1.14, 1.33)], not driving (AOR = 1.09, 95% CI = 1.01, 1.18), having private health insurance (AOR = 1.13, 95% CI = 1.04, 1.23), frequent GP visits (AOR = 1.16, 95% CI = 1.07, 1.25), skin cancer (AOR = 1.26, 95% CI = 1.16, 1.37), hypertension (AOR = 1.13, 95% CI = 1.05, 1.21), and fall (AOR = 1.12, 95% CI = 1.04, 1.22) were significantly associated with the age-related cataracts.

CONCLUSIONS

Systemic diseases, poor quality of life, driving cessation, and health service use were significantly associated with age-related cataracts in older women.

Mesopic conditions optimise the detection of visual function loss in drivers with simulated media opacity

Drivers have different visual demands across varying contrast and luminance conditions. However, vision assessments for driving are typically conducted under photopic conditions. This study investigated the sensitivity of photopic and mesopic conditions to detect contrast sensitivity (CS) loss in drivers with simulated media opacities. CS was measured in forty-seven healthy drivers aged 18–50 years (mean ± SD: 25.5 ± 6.5) under photopic and mesopic-adapted luminance levels with the Pelli-Robson chart and the Mesotest II (without glare). Media opacities were simulated using white-opacity containing Lee Fog filters (1–5) and CS measured in a randomised order. A significant (p < 0.001) reduction in photopic CS (logCS) was measured with the Pelli-Robson chart only when media opacity was simulated with Fog filter 5 (1.53 ± 0.15, 2.8 triplets reduction) compared to baseline (1.95 ± 0.03). Mean mesopic CS demonstrated a significant (all p < 0.001) reduction from baseline (1.67 ± 0.14) for Fog filters 3 (1.4 triplets, 1.45 ± 0.16), 4 (2.4 triplets, 1.31 ± 0.14) and 5 (4.3 triplets, 1.02 ± 0.15). For Mesotest II, only Fog filter 5 produced a significant reduction (0.10 ± 0.09; p < 0.001) in mean mesopic CS from baseline (0.30 ± 0.01). Mesopic CS is more vulnerable to different levels of simulated media opacity, hence should be considered clinically when assessing visual function in older drivers at risk of media opacity.

Application of Andersen-Newman model to assess cataract surgery uptake among older Australian women: findings from the Australian Longitudinal Study on Women's Health (ALSWH)

INTRODUCTION

Although Cataract Surgery Rate is increasing, the availability of surgery is outstripped by the increasing number of cataract cases as populations age.

AIM

The study aimed to identify factors associated with cataract surgery uptake in terms of predisposing, enabling, and need factors in very old Australian women.

METHOD

This study used ALSWH data included 6229 women aged 79-84 to 85-90 years. Women were asked whether they had undergone eye surgery (including cataracts) three years prior to each survey. Generalised estimating equation modelling was used to determine factors associated with these surgeries.

RESULT

At baseline (2005), more than half of the participants either had undergone surgery (43.5%) or had unoperated cataracts (7.6%). Increasing age (AOR = 1.11, 95% CI = 1.07, 1.15) and being current or ex-smokers (AOR = 1.15, 95% CI = 1.03, 1.29) were associated with higher odds of cataract surgery (predisposing factors). Women who had private health insurance had 27% higher odds of having surgery (AOR = 1.27, 95% CI = 1.16, 1.39) (enabling factor). Need factors of more General Practitioner visits (AOR = 1.16, 95% CI = 1.09, 1.25) and skin cancer (AOR = 1.09, 95% CI = 1.01, 1.17) also increased the odds of cataract surgery. Women who had no difficulty seeing newspaper print were more likely to have had cataract surgery (AOR = 1.35, 95% CI = 1.23, 1.48).

CONCLUSION

Need factors are the major drivers of cataract surgery; however, predisposing and enabling factors also play a role, including access to private health insurance. This finding indicates some inequity regarding access to cataract surgery in the Australian setting.

Clinical, Morphological, and Optical Correlates of Visual Function in Patients With Fuchs Endothelial Corneal Dystrophy

PURPOSE

The purpose of this article was to study the clinical, optical, and morphological correlates of visual function in patients with Fuchs endothelial corneal dystrophy (FECD).

METHODS

The case records were analyzed for patients diagnosed with FECD between September 2019 and March 2020. The best-corrected visual acuity (BCVA) was recorded as decimal visual acuity and converted to the logarithm of the minimum angle of resolution units. Contrast sensitivity was measured with the Pelli-Robson contrast sensitivity test. Corneal alterations, including central corneal thickness, depression of the posterior cornea, and corneal densitometry values, were evaluated using Scheimpflug images. Corneal epithelial thickness was measured by spectral-domain optical coherence tomography.

RESULTS

A total of 107 eyes of 61 patients (18 male and 43 female) with FECD were retrospectively investigated. The Spearman rank correlation coefficient showed moderate correlation between BCVA and contrast sensitivity (ρ = -0.66, P < 0.001), with some patients maintaining relatively good BCVA but having reduced contrast sensitivity. Logistic regression analysis demonstrated that age, central corneal thickness, depression of the posterior cornea, and epithelial thickening were negatively associated with contrast sensitivity but not with BCVA.

CONCLUSIONS

Contrast sensitivity is a useful tool for assessing visual dysfunction and should be incorporated into the assessment protocol of patients with FECD. Alterations in the cornea, including central corneal thickness, depression of the posterior cornea, and epithelial thickening, might be objective parameters that can help the clinician in grading the severity of the disease and tracking its progression.

A Data Science Approach to Estimating the Frequency of Driving Cessation Associated Suicide in the US: Evidence From the National Violent Death Reporting System

Driving cessation is a common transition experienced by aging adults that confers both a symbolic and literal loss of independence due to the central role of automobiles for mobility in the US. Prior research has shown that driving cessation has negative implications for mental health, social participation, and access to healthcare. Given these sequelae of driving cessation and prior work showing that late-life transitions related to independence (e.g., transitioning into residential care) are associated with suicide, we sought to estimate the frequency of driving cessation associated suicide. Data include suicide (n = 59,080) and undetermined (n = 6,862) deaths aged ≥55 from the National Violent Death Reporting System (NVDRS, 2003-2017). Each case in the NVDRS has both quantitative data (e.g., demographic characteristics) and qualitative text narratives, derived from coroner/medical examiner reports, which describe the most salient circumstances and features of each death. To identify cases associated with driving cessation, we employed a supervised random forest algorithm to develop a Natural Language Processing (NLP) classifier. Identified driving cessation associated cases were then categorized and characterized using descriptive statistics and qualitative content analysis. From 2003 to 2017, there were an estimated 305 cases of suicide/undetermined deaths associated with driving cessation in the NVDRS, representing 0.04% of all cases. Cases associated with driving cessation were older, more likely to be male, more likely to have a physical health problem, more likely to have experienced a recent crisis, and more likely to have lived in a rural county than other decedents. Qualitative analysis identified functional impairment, alcohol-related driving limitations, loss of employment, and recent car accidents as common themes among cases associated with driving cessation. This analysis illustrates the utility of NLP in identifying novel correlates of suicide in later life. Although driving cessation associated suicide is a rare outcome, further research is warranted on understanding the conditions under which driving cessation is associated with suicidal behavior, and how to support the well-being of aging adults during these types of major life transitions.

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.

Driving Cessation in Old Age: Gender Influences on Mortality

Objective: This study examined health and social support as mediators of the association between driving cessation and 10-year mortality among older men and older women. Method: Data were drawn from a prospective panel survey of 1000 community-dwelling older adults with follow-ups over a 10-year period. Extended Cox proportional hazard regression models were used to estimate the relative risk of driving cessation on mortality. Results: Mortality risk was 1.36 (CI = [1.06, 1.73]) times higher for nondrivers than drivers. This relationship was significantly mediated by health status in the overall sample. Physical health and cognitive health fully mediated the association between driving cessation and mortality among older men, whereas the mediation effects were partial among older women. Discussion: Gender differences in driving patterns may account for the differential mediation effects in the association between driving cessation and mortality.

Older drivers' self-reported vision-related night-driving difficulties and night-driving performance

PURPOSE

To investigate associations between older drivers' perceived vision-related night-driving difficulties and night-time driving performance measured on a closed-road circuit.

METHODS

Participants included 26 older drivers (71.8 ± 6.3 years) who reported vision-related night-driving difficulties assessed with the vision and night driving questionnaire (VND-Q). High-contrast, photopic visual acuity (VA) and ratings of discomfort glare (de Boer scale) were also assessed. Night-time driving performance was measured on a closed-road circuit that involved recognition, hazard avoidance and lane-keeping tasks in the absence and presence of intermittent glare. Generalized linear mixed models investigated the relationship between VND-Q scores and overall driving performance scores, as well as with discomfort glare ratings and VA.

RESULTS

Greater levels of vision-related night-driving difficulties (VND-Q scores) were significantly associated with poorer night-driving performance (p = 0.003); the association was even stronger for driving performance in the presence of intermittent glare (p = 0.001). Reduced VA was associated with poorer night-driving performance (p = 0.022) but the association was weaker than for the VND-Q scores. In contrast, ratings of discomfort glare were not significantly associated with driving performance (p = 0.14).

CONCLUSION

The VND-Q was significantly associated with night-time driving performance and provides a useful instrument for assessing vision-related night-driving difficulties which can be incorporated into clinical vision assessments.

Advanced glaucoma at diagnosis: current perspectives

Presentation with advanced glaucoma is a significant risk factor for lifetime blindness. The asymptomatic nature of glaucoma, particularly in early disease, means that substantial vision loss in one eye does not always translate into a perceptible loss of visual function. This, along with the lack of an effective screening strategy, contributes to late presentation. Those most at risk of presenting with advanced glaucoma have asymptomatic high intraocular pressure (IOP), no family history of glaucoma, are socially disadvantaged, and do not attend sight testing. Patients with glaucoma may have impaired functionality for daily activities, such as reading, walking and driving. Quality of life measures have shown this to be significantly worse in patients with more severe visual field loss, particularly if bilateral. In addition, quality of life decreases faster with further bilateral visual field loss when advanced visual field damage is present. Management of these patients requires disproportionally more resources than those with earlier disease. Both medical and surgical options are used as the initial approach to treat patients presenting with advanced glaucoma. The most recently published National Institute for Health and Care Excellence (NICE) guidelines suggest that patients presenting with advanced disease should be offered trabeculectomy as a primary intervention. However, more evidence is required to determine the best initial management. The Treatment of Advanced Glaucoma Study (TAGS) is being conducted, comparing primary medical management with primary mitomycin C-augmented trabeculectomy for people presenting with advanced open-angle glaucoma. The results of TAGS will provide robust evidence for the most appropriate initial intervention.

Measuring Disability in Glaucoma

BACKGROUND

Glaucomatous visual field loss can have far-reaching and debilitating consequences on an individual, affecting one's ability to perform many important tasks. Although assessment of glaucoma-related disability constitutes an important part of clinical care, there remains a lack of organized, detailed information on the most suitable methods to capture disability in glaucoma.

PURPOSE

This review details the available methods to measure glaucoma-related disability and highlights important findings from studies utilizing these various methods.

METHODS

The literature was reviewed to identify papers evaluating disability in glaucoma and findings were summarized by research methodology used and area of impairment.

RESULTS

Identified methods for capturing glaucoma-related disability included qualitative descriptions, glaucoma-specific quality of life questionnaires, vision-specific questionnaires, general health questionnaires, functional domain-specific questionnaires, evaluation of task performance, event assessment (ie, falls and motor vehicle accidents), and real-world behavior (ie, daily physical activity). Findings using these methods show a strong relationship between glaucoma and/or glaucoma severity and difficulties with reading, driving, mobility, and other tasks such as prehension and facial recognition. In addition, glaucoma has financial and psychological implications on the patient, and can affect caregivers in some cases as well.

CONCLUSIONS

A wide variety of research tools have been used to characterize the disability resulting from glaucoma. Together, these tools show that glaucoma affects many abilities which are important for independent living. Strengths and limitations of the various research techniques are discussed so that future studies may use the method(s) most suitable for answering the research question posed.

Vision-related quality of life and symptom perception change over time in newly-diagnosed primary open angle glaucoma patients

To evaluate the change over time of vision-related quality of life (QoL) and glaucoma symptoms in a population of newly-diagnosed primary open angle glaucoma (POAG) patients. Multicenter, prospective study. Consecutive newly-diagnosed POAG patients were enrolled and followed-up for one year. Follow-up visits were scheduled at 6 and 12 months from baseline. At each visit, vision-related QoL and glaucoma-related symptoms were assessed by the means of the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) and the Glaucoma Symptom Scale (GSS), respectively. Trends over time for NEI-VFQ-25 and GSS scores were evaluated with longitudinal linear mixed models. One-hundred seventy-eight patients were included in the analysis. At baseline, early to moderate glaucoma stages were associated with higher scores for most GSS and NEI-VFQ-25 items, while lower best-corrected visual acuity was associated with lower scores for 4 of the 12 NEI-VFQ-25 items. During the follow-up, all the GSS scores, the NEI-VFQ-25 total score, and 7 of the 12 NEI-VFQ-25 scores significantly improved (p < 0.05). In multivariate model, higher increases of most GSS and NEI-VFQ-25 scores were modeled in patients with low scores at baseline. Vision-related QoL and glaucoma-related symptom perception significantly improved during the one-year follow-up in this population of newly diagnosed POAG patients.

Self-perceived Impact of Glaucomatous Visual Field Loss and Visual Disabilities on Driving Difficulty and Cessation

PURPOSE

To investigate if glaucoma severity and the presence of self-reported glare and difficulty with dark adaptation are associated with driving difficulty or cessation.

PATIENTS AND METHODS

Individuals with glaucoma, age 50+ and visual acuity in the better eye ≥20/50 were included. Glaucoma severity was defined by the visual field mean deviation (MD) in the better eye and was classified into 2 groups: mild (MD>-6 dB) and moderate/severe (MD≤-6 dB). Patient responses to the glare and dark adaptation subscales in Glaucoma Quality of Life-15 questionnaire were used to measure relevant visual disability. Associations were assessed utilizing prevalence ratios (PR).

RESULTS

A total of 99 participants (57% female) were included with 19% (19/99) reporting driving cessation. Patients with moderate/severe glaucoma when compared with mild glaucoma reported a significantly higher percentage of driving cessation (33% vs. 8%; P=0.002), presence of glare (27% vs. 6%; P=0.012), and difficulty with dark adaptation (31% vs. 10%; P=0.011).Individuals with self-perceived difficulty with dark adaptation were about 4 times more likely than those without to have difficulty driving at night (adjusted PR=3.94; P<0.0001) or in poor driving conditions (adjusted PR=4.09; P=0.0002). Self-reported glare was associated with an increased risk of driving difficulty in poor driving conditions (PR=4.17; P=0.05).

CONCLUSIONS

Patients with moderate/severe glaucomatous visual field loss reported significantly higher percentage of driving cessation, presence of glare and difficulty with dark adaptation. Difficulty with dark adaptation was significantly associated with difficulty driving at night or in poor driving conditions. Further studies are needed to confirm these findings.

Association between glaucoma severity and driving cessation in subjects with primary open-angle glaucoma

Background

The aim of this study, which included a baseline cross-sectional study and a 3-year follow-up prospective study, was to investigate the association between glaucomatous visual field damage and driving cessation in subjects with primary open-angle glaucoma (POAG).

Methods

A total of 211 POAG subjects divided into 3 groups according to POAG severity (mild, moderate, or severe) in the better eye were enrolled along with 148 control subjects; subjects were asked about changes in their driving status. In the 3-year follow-up study, 185 of the POAG subjects and 80 of the controls annually reported their driving status. Adjusted odds ratios and 95% confidence intervals for the prevalence and incidence of driving cessation were estimated with a multiple logistic regression model.

Results

In the original cross-sectional study, 11/148 (7%) members of the control group reported having given up driving over the previous 5 years; the corresponding figures for the mild POAG, moderate POAG, and severe POAG groups were 9/173 (5%), 0/22 (0%), and 5/16 (31%), respectively (p = 0.001, Fisher’s exact test), with severe POAG found to be associated with driving cessation after adjustment for age, gender, systemic hypertension, and diabetes mellitus (odds ratio 11.52 [95% CI 2.87-46.35], ref. control, p = 0.001). In the follow-up study, the proportions of subjects who ceased driving were 1/80 (1.3%) in the control group, 8/152 (5.3%) in the mild POAG group, 5/22 (22.7%) in the moderate POAG group, and 2/11 (18.2%) in the severe POAG group (p = 0.001, Fisher’s exact test). Moderate POAG and severe POAG in the better eye were found to be associated with driving cessation after adjustment for age, gender, systemic hypertension, and diabetes mellitus (moderate POAG in the better eye: odds ratio 37.7 [95% CI 3.7-383.8], ref. control, p = 0.002, and severe POAG in the better eye: odds ratio 52.8 [95% CI 3.5-797.0], ref. control, p = 0.004).

Conclusion

Moderate and Severe POAG in the better eye is associated with driving cessation.

Predicting Visual Disability in Glaucoma With Combinations of Vision Measures

Purpose

We characterized vision in glaucoma using seven visual measures, with the goals of determining the dimensionality of vision, and how many and which visual measures best model activity limitation.

Methods

We analyzed cross-sectional data from 150 older adults with glaucoma, collecting seven visual measures: integrated visual field (VF) sensitivity, visual acuity, contrast sensitivity (CS), area under the log CS function, color vision, stereoacuity, and visual acuity with noise. Principal component analysis was used to examine the dimensionality of vision. Multivariable regression models using one, two, or three vision tests (and nonvisual predictors) were compared to determine which was best associated with Rasch-analyzed Glaucoma Quality of Life-15 (GQL-15) person measure scores.

Results

The participants had a mean age of 70.2 and IVF sensitivity of 26.6 dB, suggesting mild-to-moderate glaucoma. All seven vision measures loaded similarly onto the first principal component (eigenvectors, 0.220–0.442), which explained 56.9% of the variance in vision scores. In models for GQL scores, the maximum adjusted-R² values obtained were 0.263, 0.296, and 0.301 when using one, two, and three vision tests in the models, respectively, though several models in each category had similar adjusted-R² values. All three of the best-performing models contained CS.

Conclusions

Vision in glaucoma is a multidimensional construct that can be described by several variably-correlated vision measures. Measuring more than two vision tests does not substantially improve models for activity limitation.

Translational Relevance

A sufficient description of disability in glaucoma can be obtained using one to two vision tests, especially VF and CS.

Challenges for Older Drivers in Urban, Suburban, and Rural Settings

Along with age-related factors, geographical settings—urban, suburban, and rural areas—also contribute to the differences in fatal crashes among older drivers. These differences in crash outcomes might be attributed to the various driving challenges faced by older drivers residing in different locations. To understand these challenges from the perspective of the older driver, a focus group study was conducted with drivers 65 and older from urban, suburban, and rural settings. Guided-group interviews were used to assess driving challenges, mobility options, opportunities for driver support systems (DSS), and alternate transportation needs. Content analysis of the interview responses resulted in four categories representing common challenges faced by older drivers across the settings: behavior of other drivers on the road, placement of road signs, reduced visibility of road signs due to age-related decline, and difficulties using in-vehicle technologies. Six categories involved location-specific challenges such as heavy traffic situations for urban and suburban drivers, and multi-destination trips for rural drivers. Countermeasures implemented by older drivers to address these challenges primarily involved route selection and avoidance. Technological advances of DSS systems provide a unique opportunity to support the information needs for route selection and avoidance preferences of drivers. Using the content analysis results, a framework was built to determine additional and modified DSS features to meet the specific challenges of older drivers in urban, suburban, and rural settings. These findings suggest that there is heterogeneity in the driving challenges and preferences of older drivers based on their location. Consequently, DSS technologies and vehicle automation need to be tailored to not only meet the driving safety and mobility needs of older drivers as a population, but also to their driving environment.

Patients' maximum acceptable waiting time for cataract surgery: a comparison at two time-points 7 years apart

PURPOSE

To evaluate the maximum acceptable waiting time (MAWT) of cataract patients and assess the determinants of their perception of MAWT at two time-points 7 years apart.

METHODS

In 2007 (prior to the transformation of our cataract service to a day case unit) and 2014, 500 consecutive patients with cataract were asked to fill in a preoperative questionnaire addressing their MAWT to undergo cataract surgery. The patients' visual impairment (VF-14 score), education and social status were evaluated.

RESULTS

The mean MAWT was 3.2 months in both periods, whereas the actual waiting time decreased significantly by 1.7 months (p < 0.001). Patients who had self-noted visual impairment were nearly four times (p < 0.001) more likely to accept only an MAWT of <3 months in 2007. In both periods, patients with a VF-14 score lower than the mean were more likely to accept a shorter MAWT (p = 0.002 and p = 0.034). Living together with children or having relatives close by was associated with a greater acceptance of an MAWT longer than 3 months (p = 0.002 and p = 0.023).

CONCLUSION

Reducing the actual mean waiting time had no impact on the mean MAWT. Patients with poor tolerance of waiting had greater self-reported difficulty with vision. Social support was also a strong predictor from the patients' perspective. The VF-14 score had a greater impact than clinical visual acuity (VA) testing. Considering the implementation of standards for waiting lists, objective criteria to guarantee a transparent system should be taken into account.

Cross-sectional study assessing the addition of contrast sensitivity to visual acuity when testing for fitness to drive

OBJECTIVES

The aim of this study is to quantify the importance of loss of contrast sensitivity (CS) and its relationship to loss of visual acuity (VA), driving restrictions and daytime, on-road driving evaluations in drivers aged 70+.

DESIGN

A predictive cross-sectional study.

SETTING

Volunteer participants to a drivers' refresher course for adults aged 70+ delivered by the Swiss Automobile Club in western Switzerland from 2011 to 2013.

PARTICIPANTS

162 drivers, male and female, aged 70 years or older.

CLINICAL PREDICTORS

We used a vision screener to estimate VA and the The Mars Letter Contrast Sensitivity Test to test CS.

OUTCOMES

We asked drivers to report whether they found five driving restrictions useful for their condition; restrict driving to known roads, avoid driving on highways, avoid driving in the dark, avoid driving in dense traffic and avoid driving in fog. All participants also underwent a standardised on-road evaluation carried out by a driving instructor.

RESULTS

Moderate to severe loss of CS for at least one eye was frequent (21.0% (95% CI 15.0% to 28.1%)) and often isolated from a loss of VA (11/162 cases had a VA ≥0.8 decimal and a CS of ≤1.5 log(CS); 6.8% (95% CI 3.4% to 11.8%)). Drivers were more likely (R²=0.116, P=0.004) to report a belief that self-imposed driving restrictions would be useful if they had reduced CS in at least one eye. Daytime evaluation of driving performance seems limited in its ability to correctly identify difficulties related to CS loss (VA: R²=0.004, P=0.454; CS: R²=0.006, P=0.332).

CONCLUSION

CS loss is common for older drivers. Screening CS and referring for cataract surgery even in the absence of VA loss could help maintain mobility. Reduced CS and moderate reduction of VA were both poor predictors of daytime on-road driving performances in this research study.

Association of Hearing Impairment and Subsequent Driving Mobility in Older Adults

Purpose of the Study

Hearing impairment (HI) is associated with driving safety (e.g., increased crashes and poor on-road driving performance). However, little is known about HI and driving mobility. This study examined the longitudinal association of audiometric hearing with older adults' driving mobility over 3 years.

Design and Methods

Secondary data analyses were conducted of 500 individuals (63-90 years of age) from the Staying Keen in Later Life (SKILL) study. Hearing (pure tone average of 0.5, 1, and 2kHz) was assessed in the better hearing ear and categorized into normal hearing ≤25 dB hearing level (HL); mild HI 26-40 dB HL; or moderate and greater HI ≥41 dB HL. The Useful Field of View Test (UFOV) was used to estimate the risk for adverse driving events. Multivariate analysis of covariance compared driving mobility between HI levels across time, adjusting for age, sex, race, hypertension, and stroke. Adjusting for these same covariates, Cox regression analyses examined incidence of driving cessation by HI across 3 years.

Results

Individuals with moderate or greater HI performed poorly on the UFOV, indicating increased risk for adverse driving events (p < .001). No significant differences were found among older adults with varying levels of HI for driving mobility (p values > .05), including driving cessation rates (p = .38), across time.

Implications

Although prior research indicates older adults with HI may be at higher risk for crashes, they may not modify driving over time. Further exploration of this issue is required to optimize efforts to improve driving safety and mobility among older adults.

More frequent requests for day-case cataract surgery : An impressive mind switch in the Austrian population within 7 years

BACKGROUND

Cataract surgery is the most commonly performed elective surgical procedure worldwide. While the operation has been mainly conducted as day-case (outpatient) surgery throughout the world since the beginning of this millennium, this development has been much slower in Austria. The number of patients requesting day-case surgery has markedly increased in the last few years.

METHODS

Prior to the introduction of a day clinic at our department in 2007, we evaluated the patients' acceptance of day-case surgery using a questionnaire. At the time, less than half of the patients wished to undergo day-case surgery. Another survey was performed 7 years later to determine if there were any changes.

RESULTS

The desire for day-case surgery increased significantly from 38.8 to 87.1%. The mean age of the patients and their visual impairment had decreased. Home care improved, but not to the same extent. The number of patients who had to travel more than an hour to reach the hospital had significantly increased.

CONCLUSIONS

Improvements in perioperative limitations and most of all patients becoming accustomed to the idea have led to an impressive mind switch, culminating in a clear desire for day-case cataract surgery.

Association of visual sensory function and higher-order visual processing skills with incident driving cessation

BACKGROUND

Many studies on vision and driving cessation have relied on measures of sensory function, which are insensitive to the higher-order cognitive aspects of visual processing. The purpose of this study was to examine the association between traditional measures of visual sensory function and higher-order visual processing skills with incident driving cessation in a population-based sample of older drivers.

METHODS

Two thousand licensed drivers aged 70 years or older were enrolled and followed for three years. Tests for central vision and visual processing were administered at baseline and included visual acuity, contrast sensitivity, sensitivity in the driving visual field, visual processing speed (useful field of view [UFOV] Subtest 2 and Trails B) and spatial ability measured by the Visual Closure Subtest of the Motor-free Visual Perception Test. Participants self-reported the month and year of driving cessation and provided a reason for cessation. Cox proportional hazards models were used to generate crude and adjusted hazard ratios with 95% confidence intervals between visual functioning characteristics and risk of driving cessation over a three-year period.

RESULTS

During the study period, 164 participants stopped driving, which corresponds to a cumulative incidence of 8.5 per cent. Impaired contrast sensitivity, visual fields, visual processing speed (UFOV and Trails B) and spatial ability were significant risk factors for subsequent driving cessation after adjusting for age, gender, marital status, number of medical conditions and miles driven. Visual acuity impairment was not associated with driving cessation. Medical problems (63 per cent), specifically musculoskeletal and neurological problems, as well as visual problems (17 per cent) were cited most frequently as the reason for driving cessation.

CONCLUSION

Assessment of cognitive and visual functioning can provide useful information about subsequent risk of driving cessation among older drivers. In addition, a variety of factors, not just vision, influenced the decision to stop driving and may be amenable to intervention.

Development and validation of a vision and night driving questionnaire

PURPOSE

Night-time driving difficulties are a common concern of older drivers and those with eye disease. This study aimed to develop and validate a questionnaire for assessing vision-related night driving difficulties in older drivers.

METHODS

Items from existing vision-related quality of life questionnaires and driving studies were used to develop a questionnaire that was completed by 283 participants who reported visual difficulties for night driving (65% female, 50 to >80 years). The questionnaire included items relating to demographic and night driving characteristics (seven items), general vision ratings (eight items), vision-related night driving difficulties (11 items), and a single open question about specific night driving difficulties. The vision-related night driving difficulty items were analysed separately using Rasch analysis to form the vision and night driving questionnaire (VND-Q). Rasch analysis assessed validity and psychometric properties of the scale. Generalised linear regression models examined associations between VND-Q scores and age, gender, amount of night driving, self-rated vision, and eye conditions. Test-retest repeatability was assessed using intra-class correlation analysis and Bland-Altman methods of agreement for a subset of 30 participants.

RESULTS

Rasch analysis indicated that a nine-item VND-Q scale was unidimensional, valid and reliable, and showed excellent discriminant ability (person separation index 3.04; person reliability 0.90). Targeting was better for those with greater self-reported night driving difficulties. Participants with self-reported bilateral eye conditions and worse self-reported general vision ratings had significantly more night driving difficulties with the VND-Q scale than individuals without eye conditions (p = 0.03) and with better general vision ratings (p < 0.001). Females reported more difficulties than males (p < 0.001) and drove shorter distances at night per week which was also associated with greater difficulties (p < 0.001). A repeatability coefficient (Rc ) of 2.07 demonstrated excellent test-retest repeatability.

CONCLUSIONS

The nine-item VND-Q is a unidimensional and reliable questionnaire allowing quantification of the level of visual difficulties that older drivers report at night. The development of this questionnaire is an important step in providing a reliable and validated instrument for use to guide appropriate investigations, referrals, or interventions in clinical and research settings.

Quality of Life in Glaucoma: A Review of the Literature

The ultimate goal of glaucoma management is the preservation of patients’ visual function and quality of life (QoL). The disease itself as well as the medical or surgical treatment can have an enormous impact on a patient’s QoL. Even the mere diagnosis of a chronic, irreversible, potentially blinding disorder can adversely affect the patient’s sense of well-being and QoL by eliciting significant anxiety. Patients with primary open-angle glaucoma rarely present with visual symptoms, at least early in the course of the disease. A better understanding of patient-reported QoL can improve patient–physician interaction and enhance treatment adherence by customizing treatment options based on individual patient profile, thus optimizing long-term prognosis. These aspects are summarized and critically appraised in this article.

Visual disability and quality of life in glaucoma patients

Glaucoma is an optic neuropathy that can result in progressive and irreversible vision loss, thereby affecting quality of life (QoL) of patients. Several studies have shown a strong correlation between visual field damage and visual disability in patients with glaucoma, even in the early stages of the disease. Visual impairment due to glaucoma affects normal daily activities required for independent living, such as driving, walking, and reading. There is no generally accepted instrument for assessing quality of life in glaucoma patients; different factors involved in visual disability from the disease are difficult to quantify and not easily standardized. This chapter summarizes recent works from clinical and epidemiological studies, which describe how glaucoma affects the performance of important vision-related activities and QoL.

Driving self-restriction and motor vehicle collision occurrence in glaucoma

PURPOSE

To confirm that subjects with primary open-angle glaucoma (POAG) who avoid driving in high-risk situations are less likely to be involved in motor vehicle collisions (MVCs) than those who do not.

METHODS

This study evaluated 252 consecutive Japanese aged between 40 and 85 years with POAG. All participants were requested to answer a questionnaire on their driving habits, including self-restriction in driving at night, in rain, in fog, on freeways, and lane changing, and history of MVCs. Those who reported restricting their driving in one or more ways constituted the self-restriction group, and those who reported no self-restriction made up the no-restriction group. The prevalence of MVCs and the crash rate (number of MVCs/10,000 km driven) were compared between the two groups. The association between prevalence of MVCs and the number of driving self-restrictions was also evaluated.

RESULTS

The association between driving self-restriction and MVCs was observed among the male subjects, not among the female subjects. Among the male subjects, the prevalence of MVCs was significantly higher in the no-restriction group than in the self-restriction group (no-restriction group, 33/107 = 30.8%; self-restriction group, 9/66 = 13.6%, p = 0.01). The crash rate was also significantly higher in the no-restriction group (no-restriction group, 1.4 ± 0.8; self-restriction group, 0.4 ± 0.3, average ± SE, p = 0.01). No restriction was significantly associated with MVCs (multivariable-adjusted odds ratios, 2.43 [95% confidence interval, 1.03 to 5.73]). The number of driving self-restrictions was also associated with MVCs (multivariable-adjusted odds ratios, 0.41 [95% confidence interval, 0.18 to 0.99], per one increment of self-restriction).

CONCLUSIONS

Driving self-restriction may be associated with a reduced prevalence of MVCs in men with POAG.

The Impact of Health Problems on Driving Status among Older Adults

OBJECTIVE

This study assesses the impact of health problems on driving status (current driver vs. ex-driver) among older adults to identify which of those health problems have the greatest individual and population impact on driving cessation.

METHODS

Data were from baseline and 5 year follow-up waves of a longitudinal survey of adults age 55 years and older (N=1,279). The impact of several health problems on driving status was assessed using a relative risk ratio and a population attributable risk percent. Analyses controlled for age, gender, and the presence of additional baseline health problems.

RESULTS

Many health conditions were not associated with driving cessation. Functional limitations, cognitive function, and measures of vision were significant predictors of driving cessation. Self-care functional limitations were associated with the highest risk for driving cessation, while visual function was associated with the highest attributable risks.

DISCUSSION

In order to effectively address healthy aging and mobility transitions, it is important to consider the implications of targeting individuals or populations who are most at risk for driving cessation. The risk ratio is relevant for evaluating individuals; the attributable risk is relevant for developing interventions in populations.

Mediators of the association between driving cessation and mortality among older adults

OBJECTIVE

The present study examined health and physical performance as mediators of the association between driving cessation and mortality among older residents of small and large cities.

METHOD

Participants (N = 2,793) were from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study. Participants' driving status and health were measured at baseline, and mortality rates were observed across the subsequent 5 years.

RESULTS

Overall, mortality risk was 1.68 times higher for nondrivers versus drivers; this relationship was significantly mediated by physical performance and social, physical, and general health. For large-city residents, mediation effects for all mediators were significant and complete. For small-city residents, only physical and general health were significant mediators, and these effects were partial.

DISCUSSION

Health difficulties that accompany or follow driving cessation may explain the association between driving cessation and mortality, particularly for residents of large cities, where alternative transportation options may be more numerous.

Aged Drivers May Experience Decreased Visual Function While Driving

PURPOSE

To investigate conventional visual acuity (VA) and changes therein over time in older drivers.

DESIGN

A cross-sectional study.

METHODS

One hundred twenty-four drivers (41 younger drivers aged 21-39 years, 40 middle-aged drivers aged 40-59 years, and 43 older drivers aged 60-77 years) who consented to undergo conventional and functional VA testing, perform the Trail Making Test B, and complete a questionnaire on visual performance while driving at an expressway rest stop in Ashigara, Japan, were studied.

RESULTS

The overall proportion of the study subjects with a decimal bilateral VA less than 0.7, the Japanese threshold score for obtaining and renewing a driver's license, was 10%. The number of the subjects with decimal functional VA scores and minimum VA scores less than 0.7 was significantly higher in the older group than in the younger group (P < 0.05), although the conventional VA scores did not differ significantly between the older and younger groups (P = 0.621). The Trail Making Test B scores were significantly higher in the older group than in the younger and middle-aged groups (P < 0.05). The total score of the "visual performance during driving at night" category correlated significantly with the logMAR functional VA and logMAR minimum VA (P < 0.05) but not the logMAR VA.

CONCLUSIONS

Older drivers might experience decreased functional VA and increased frequency of transient decreases in VA while driving. The functional VA test might capture visual impairment among older drivers that went undetected by the conventional VA test.

Antecedents of self-regulation in driving among older drivers

Maintaining quality of life and wellbeing into advanced age is a major challenge to societies. Driving is one factor contributing to an ageing individual's independence. Understanding antecedents of driving-related self-regulation is important for designing interventions to preserve safe driving in old age. This paper reports on a study that investigated factors associated with two forms of self-regulation in driving (SRD) – avoidance of difficult driving conditions and voluntary cessation of driving – in a sample of 860 Israeli drivers aged 70 and over. We examined roles of health, vision, driving experience, driving-related self-efficacy (DRSE) and global self-esteem in SRD. Health and DRSE had direct effects on SRD, and effects of vision and driving experience were mediated by DRSE. Participants who had ceased driving were older, with poorer vision and health, and less driving confidence and experience than active drivers. Statistical analyses demonstrated that SRD is affected by a reduced sense of confidence due to an initial lower level of driving experience, compounded by deteriorating vision, and that older drivers are sensitive to factors affecting their ability to drive safely. Our results demonstrate that older drivers tend to self-regulate their driving. Programmes for older adults can be introduced for diagnosing driving capabilities, improving skills and confidence, and/or helping to develop self-regulation habits of avoiding driving in difficult conditions, and assisting drivers who must adjust to driving cessation.

Driving patterns in older adults with glaucoma

Background

The ability to drive is important for ensuring quality of life for many older adults. Glaucoma is prevalent in this age group and may affect driving. The purpose of this study is to determine if glaucoma and glaucomatous visual field (VF) loss are associated with driving cessation, limitations, and deference to another driver in older adults.

Methods

Cross-sectional study. Eighty-one glaucoma subjects and 58 glaucoma suspect controls between age 60 and 80 reported if they had ceased driving, limited their driving in various ways, or preferred another to drive.

Results

Twenty-three percent of glaucoma subjects and 6.9% of suspects had ceased driving (p = 0.01). Glaucoma subjects also had more driving limitations than suspects (2.0 vs. 1.1, p = 0.007). In multivariable models, driving cessation was more likely for glaucoma subjects as compared to suspects (OR = 4.0; 95% CI = 1.1-14.7; p = 0.03). The odds of driving cessation doubled with each 5 decibel (dB) decrement in the better-eye VF mean deviation (MD) (OR = 2.0; 95% CI = 1.4-2.9; p < 0.001). Glaucoma subjects were also more likely than suspects to report a greater number of driving limitations (OR = 4.7; 95% CI = 1.3-16.8; p = 0.02). The likelihood of reporting more limitations increased with the VF loss severity (OR = 1.6 per 5 dB decrement in the better-eye VF MD; 95% CI = 1.1-2.4; p = 0.02). Neither glaucoma nor VF MD was associated with other driver preference (p > 0.1 for both).

Conclusions

Glaucoma and glaucomatous VF loss are associated with greater likelihood of driving cessation and greater limitation of driving in the elderly. Further prospective study is merited to assess when and why people with glaucoma change their driving habits, and to determine if their observed self-regulation of driving is adequate to ensure safety.

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

BACKGROUND

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

METHODS AND DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12612000543886.

Driving simulation as a performance-based test of visual impairment in glaucoma

The fundamental goal of glaucoma management is to prevent patients from developing visual impairments sufficient to produce disability in their daily lives and impair their quality of life. Ultimately, patients are interested in how their vision will impact their ability to perform daily activities, such as driving. Although technologic advancements such as automated perimetry and devices for optic nerve imaging have resulted in great improvement in our ability to quantify structural and functional damage in glaucoma, the impact on vision-related quality of life of some of the information acquired from these tests remain elusive. In contrast, performance-based measures may be better correlated to traditional measures of vision health and, more importantly, they provide a more direct measure of disability. Driving simulators can be used as a performance-based test for evaluation of functional impairment in glaucoma. Their use can potentially help in the evaluation of driving safety and performance of diseased subjects and provide insight into the different mechanisms involved in causing driving impairment in this disease. The ability to do this in an experimentally controlled and standardized setting enables testing of a much larger number of hypotheses compared with on-road evaluations. Besides evaluating driver fitness, simulators could also potentially be used as a sophisticated test to evaluate cognitive impairment in the context of an everyday task (driving) that has not been available through traditional neuropsychologic assessment.

The direction of research into visual disability and quality of life in glaucoma

BACKGROUND

Glaucoma will undoubtedly impact on a person's ability to function as they go about their day-to-day life. The purpose of this study is to investigate the amount of published knowledge in quality of life (QoL) and visual disability studies for glaucoma, and make comparisons with similar research in other chronic conditions.

METHODS

A systematic literature search of the Global Health, EMBASE Psychiatry and MEDLINE databases. Title searches for glaucoma and six other example chronic diseases were entered alongside a selection of keywords chosen to capture studies focusing on QoL and everyday task ability. These results were further filtered during a manual search of resulting abstracts. Outcomes were the number of publications per year for each disease, number relating to QoL and type of glaucoma QoL research.

RESULTS

Fifteen years ago there were no published studies relating to the impact of glaucoma on QoL but by 2009 this had risen to 1.2% of all glaucoma articles. The number of papers relating to QoL as a proportion of all papers in glaucoma in the past 10 years (0.6%) is smaller than for AMD and some other disabling chronic diseases. Most QoL studies in glaucoma (82%) involve questionnaires.

CONCLUSION

QoL studies in glaucoma are increasing in number but represent a tiny minority of the total publications in glaucoma research. There are fewer QoL articles in glaucoma compared to some other disabling chronic conditions. The majority of QoL articles in glaucoma research use questionnaires; performance-based measures of visual disability may offer an additional method of determining how the disease impacts on QoL.

Examining the aging process through the stress-coping framework: application to driving cessation in later life

The aging process is marked by a series of transitions that influence multiple domains of well-being. One important transition for older adults is the process of driving cessation. Numerous studies have examined risk factors for driving cessation among older adults to identify at-risk older drivers for road safety. Recent research has focused on the consequences of driving cessation in later life for health and well-being. However, these reports have been largely empirical and are not drawn from a defined conceptual framework. Establishing a theoretical model of 'how driving cessation interacts with other processes and domains of aging' will promote synthesis of seemingly disparate findings and also link the empirical research on cessation to the broader field of gerontology. This article describes a conceptual model for articulating and examining the components of the driving cessation process based on the stress-coping paradigm. This model situates driving cessation within the context of exogenous stressors, individual vulnerabilities and coping strategies, and environmental hazards and buffers over the lifespan. This model could assist in guiding intervention strategies aimed at reducing premature driving cessation in older drivers with ameliorable impairments while assisting at-risk older drivers to reduce or stop driving in a less stressful way.

Which factors influence patients' maximum acceptable waiting time for cataract surgery? - a questionnaire survey

PURPOSE

To evaluate patients’ maximum acceptable waiting time (MAWT) and to assess the determinants of patient perceptions of MAWT.

METHODS

A total of 500 consecutive patients with cataract were asked to fill out a preoperative questionnaire, addressing patients’ MAWT to undergo cataract surgery. Patients’ visual impairment (VF-14 score), education, profession and social status were evaluated, and an ophthalmologic examination was performed. Univariate analysis included Spearman’s correlation test, unpaired Student’s t-test and the Mann–Whitney U test. Univariate and multivariate associations were calculated using unconditional logistic regression.

RESULTS

The mean MAWT was 3.17 ± 2.12 months. The mean VF-14 score was 72.10 ± 22.54. Between VF-14 score and MAWT, there was a significant correlation (r = 0.180, p = 0.004). Patients with higher education (high school, university) accepted significantly longer MAWT (3.92 ± 2.38 months versus 3.02 ± 2.00 months, p = 0.009). Patients who had self-noticed visual impairment were nearly four times (OR: 3.88, 95% CI = 2.07–7.28, p < 0.001) more likely to accept only MAWT of <3 months.

CONCLUSIONS

Patients with low tolerance for waiting had greater self-reported difficulty with vision. Patients’ acceptance of waiting was not associated with clinical visual acuity measures. Education, ability to work, living independently and taking care of dependents were also strong predictors from patients’ perspective. Considering the implementation of standards for waiting lists, these facts should be taken into account.

Health literacy of older drivers and the importance of health experience for self-regulation of driving behaviour

This study provides much needed information on the education level of older drivers regarding the impact of health conditions and medications on personal driving safety, where they source this information, and how this knowledge influences self-regulation of driving. Random and convenience sampling secured 322 Australian drivers (63.9% males) aged 65 years and over (M = 77.35 years, SD = 7.35) who completed a telephone interview. The majority of respondents (86%) had good knowledge about health conditions (health knowledge) and driving safety, however more than 50% was classified as having poor knowledge on the effects of certain medications (medication knowledge) and driving safety. Poorer health knowledge was associated with a reduced likelihood of driving over 100 km in adjusted models. Being older and having more than one medical condition was found to increase the likelihood of self-regulation of driving. Results indicate that health knowledge was less important for predicting driving behaviour than health experience. Of great interest was that up to 85.7% of respondents reported not receiving advice about the potential impact of their medical condition and driving from their doctor. The findings indicate a need for improved dissemination of evidence-based health information and education for older drivers and their doctors.

Psychological distress and visual functioning in relation to vision-related disability in older individuals with cataracts

OBJECTIVE

To determine whether demographic, health status and psychological functioning measures, in addition to impaired visual acuity, are related to vision-related disability.

METHODS

Participants were 105 individuals (mean age=73.7 years) with cataracts requiring surgery and corrected visual acuity in the better eye of 6/24 to 6/36 were recruited from waiting lists at three public out-patient ophthalmology clinics. Visual disability was measured with the Visual Functioning-14 survey. Visual acuity was assessed using better and worse eye logMAR scores and the Melbourne Edge Test (MET) for edge contrast sensitivity. Data relating to demographic information, depression, anxiety and stress, health care and medication use and numbers of co-morbid conditions were obtained.

RESULTS

Principal component analysis revealed four meaningful factors that accounted for 75% of the variance in visual disability: recreational activities, reading and fine work, activities of daily living and driving behaviour. Multiple regression analyses determined that visual acuity variables were the only significant predictors of overall vision-related functioning and difficulties with reading and fine work. For the remaining visual disability domains, non-visual factors were also significant predictors. Difficulties with recreational activities were predicted by stress, as well as worse eye visual acuity, and difficulties with activities of daily living were associated with self-reported health status, age and depression as well as MET contrast scores. Driving behaviour was associated with sex (with fewer women driving), depression, anxiety and stress scores, and MET contrast scores.

CONCLUSION

Vision-related disability is common in older individuals with cataracts. In addition to visual acuity, demographic, psychological and health status factors influence the severity of vision-related disability, affecting recreational activities, activities of daily living and driving.

Driving cessation and driving limitation in glaucoma: the Salisbury Eye Evaluation Project

OBJECTIVE

To determine if glaucoma is associated with driving limitation or cessation.

DESIGN

Cross-sectional analysis within a longitudinal, population-based cohort study.

PARTICIPANTS AND CONTROLS

One thousand one hundred thirty-five ever-drivers between 73 and 93, including 70 subjects with unilateral and 68 subjects with bilateral glaucoma.

METHODS

All subjects reported their driving habits during each of 4 study rounds. During the fourth and final study round, subjects were assessed systematically for the presence of glaucoma.

MAIN OUTCOME MEASURES

Self-reported driving cessation or driving limitation, including cessation of night driving, driving fewer than 3000 miles annually, or cessation of driving in unfamiliar areas.

RESULTS

Fifteen percent of subjects without glaucoma no longer were driving at the end of the cohort study, compared with 21% of unilateral glaucoma subjects (P = 0.2) and 41% of bilateral glaucoma subjects (P<0.001). Multivariate regression analysis showed that bilateral (odds ratio [OR], 2.6; P = 0.002), but not unilateral (OR, 1.5; P = 0.3), glaucoma subjects were more likely no longer to be driving when compared with subjects without glaucoma. The odds that bilateral glaucoma subjects no longer were driving doubled for every 5 dB of visual field (VF) worsening in the better eye (P<0.001). Driving cessation within the previous 2 years was analyzed using separate multiple regression models, and both bilateral (OR, 3.6; P = 0.004) and unilateral (OR, 2.4; P = 0.06) glaucoma subjects were more likely to stop driving over this period than subjects without glaucoma. Driving cessation associated with bilateral glaucoma was present in 0.82% of the population, or 1 in every 122 individuals. Greater numbers of driving limitations were not more likely among subjects with glaucoma than subjects without glaucoma. However, bilateral glaucoma subjects did attribute more driving limitations to difficulties with their vision than subjects without glaucoma (OR, 2.2; P = 0.02).

CONCLUSIONS

Bilateral, and possibly unilateral, glaucoma is associated with significantly higher rates of driving cessation among the elderly. The substantial difference in driving patterns seen with different degrees of better-eye VF damage suggests that minimizing VF loss in the better-seeing eye is associated with better functional outcomes.

Examination of cognitive and instrumental functional performance as indicators for driving cessation risk across 3 years

PURPOSE

The purpose of this study was to prospectively examine the role of cognitive and instrumental functional performance in driving cessation while simultaneously accounting for any contributions of demographics, vision, physical performance, and health among a sample of older adults without dementia.

DESIGN AND METHODS

Included in the analyses were 1,838 participants from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study who were drivers at baseline and completed the third-year assessment. Participants completed baseline assessments of sociodemographic characteristics, health, sensory function, physical function, cognitive abilities, instrumental functional performance, and depressive symptoms. Driving status was again ascertained 3 years later.

RESULTS

We used Cox proportional hazard analyses to examine prospective predictors of driving cessation over a 3-year period. The final model indicated four significant risk factors for driving cessation: older age (hazard ratio [HR] = 1.06, p = .009), poorer balance as measured by the Turn 360 degrees test (HR = 1.17, p = .002), slower cognitive speed of processing as measured by the Useful Field of View test (HR = 1.37, p = .004), and poorer instrumental functional performance as assessed by the Everyday Problems Test (HR = 1.59, p < .001).

IMPLICATIONS

Although vision, health, and physical abilities are commonly considered when determining driving capacity, cognitive speed of processing and instrumental functional performance may be better indicators of subsequent likelihood of driving cessation across 3 years among older adults. Poor health and vision may only impact driving cessation to the extent that cognitive speed of processing and instrumental functioning are affected.

Glaucoma and disability: which tasks are affected, and at what stage of disease?

PURPOSE OF REVIEW

To summarize recent work from clinical and epidemiological studies that describe how, and at what stage, glaucoma affects the performance of important vision-related activities.

RECENT FINDINGS

Difficulties with the extremes of lighting are the most frequent complaint in glaucoma. Individuals with bilateral glaucoma also self-report difficulty with a broad array of tasks, including reading, walking, and driving. Bilateral glaucoma is associated with driving cessation and limitation, bumping into objects, slower walking, and falls. Some, but not all, studies also demonstrate higher accident rates in glaucoma. Measurable effects on reading speed have only been observed with field damage severe enough to affect binocular central acuity.

SUMMARY

Glaucoma with bilateral visual field loss is associated with increased symptoms and a measurable decline in mobility and driving. Further work is necessary to establish whether unilateral glaucoma has a significant impact on patients, to determine whether reading difficulty is common in patients with bilateral glaucoma, and to establish the effects of lighting conditions on task performance in glaucoma.