Assessing executive function in relation to fitness to drive: a review of tools and their ability to predict safe driving

Using Serial Trichotomization to Determine Fitness to Drive in Medically At-Risk Drivers

IMPORTANCE

Clinical tests that identify fit and unfit drivers with 100% sensitivity and specificity would reduce uncertainty and improve efficiency of occupational therapists performing comprehensive driving evaluations (CDEs).

OBJECTIVE

To examine whether serial trichotomization of clinical tests predicts pass-fail outcomes with 100% sensitivity and specificity in a sample of medically at-risk drivers and in drivers with and without cognitive impairment (CI) referred for a CDE.

DESIGN

Retrospective data collection and analysis of scores on the Montreal Cognitive Assessment; Trail Making Test, Part A and Part B; and the Useful Field of View® Subtests 1 to 3 and outcomes on the CDE (pass-fail or indeterminate requiring lessons and retesting). Receiver operating characteristic curves of clinical tests were performed to determine 100% sensitivity and specificity cut points in predicting CDE outcomes. Clinical tests were arranged in order from most to least predictive to identify pass-fail and indeterminate outcomes.

SETTING

A driving assessment clinic.

PARTICIPANTS

Among 142 medically at-risk drivers (M age = 69.2 yr, SD = 14.1), 66 with CI, 46 passed and 39 failed the CDE; 57 were indeterminate.

OUTCOMES AND MEASURES

On-road pass-fail outcomes.

RESULTS

Together, the six clinical tests predicted 62 pass and 49 fail outcomes in the total sample; 21 pass and 34 fail outcomes in participants with CI; and 58 pass and 14 fail outcomes in participants without CI.

CONCLUSIONS AND RELEVANCE

Serial trichotomization of clinical tests increases the accuracy of making informed decisions and reduces the number of drivers undergoing unnecessary on-road assessments. Plain-Language Summary: Clinical tests and their cut points that identify fit and unfit drivers vary substantially across settings and research studies. Serial trichotomization is one method that could help control for this variation by combining clinical test scores showing 100% sensitivity and specificity to identify pass (fit drivers) and fail outcomes (unfit drivers) and to reduce the number of drivers undergoing unnecessary on-road assessments.

Cognitive correlates of reduced driving performance in healthy older adults: A meta-analytic review

AIMS / OBJECTIVES

This meta-analytic review examines the evidence for the relationship between cognitive function and driving performance in older adults. The primary aims of this review were: (a) to identify cognitive correlates of reduced driving performance in older adults and (b) to determine whether such measures reliably predict reductions in driving performance over time.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Peer reviewed studies that examined the (cross-sectional or longitudinal) relationship between standardised neuropsychological test performance measures and driving performance (e.g., via an on-road test, in-vehicle monitoring system, hazard perception test or driving simulator) in healthy adults aged 60 years and older, were included.

RESULTS/DISCUSSION

Eighteen studies were eligible for inclusion, of which 12 met requirements for meta-analysis. The results indicated that reaction time and Trail Making Test (TMT) A scores exhibited small-to-moderate correlations with driving performance, with moderate effects identified for block design, TMT B, Useful Field of View (UFOV) 2 and 3 tests. Further, no significant relationships were observed between the Mini-Mental State Examination and UFOV 1 with driving performance. Due to a paucity of data, the longitudinal relationship between such measures and driving could not be identified. The findings highlight (a) the potential of cognitive assessments to identify older adults at risk of driving impairment (as part of a larger diagnostic assessment), and (b) the urgent need for prospective longitudinal studies in investigating the impact of age-related changes in cognition on driving performance over time.

Are two naïve and distributed heads better than one? Factors influencing the performance of teams in a challenging real-time task

Introduction

Collective decisions in dynamic tasks can be influenced by multiple factors, including the operational conditions, quality and quantity of communication, and individual differences. These factors may influence whether two heads perform better than one. This study examined the "two heads are better than one" effect (2HBT1) in distributed two-person driver-navigator teams with asymmetrical roles performing a challenging simulated driving task. We also examined the influence of communication quality and quantity on team performance under different operational conditions. In addition to traditional measures of communication volume (duration and speaking turns), patterns of communication quality (optimality of timing and accuracy of instructions) were captured.

Methods

Participants completed a simulated driving task under two operational conditions (normal and fog) either as individual drivers (N = 134; 87 females, mean age = 19.80, SD = 3.35) or two-person teams (driver and navigator; N = 80; 109 females, mean age = 19.70, SD = 4.69). The normal condition was characterized by high visibility for both driver and navigator. The fog condition was characterized by reduced visibility for the driver but not for the navigator. Participants were also measured on a range of cognitive and personality constructs.

Results

Teams had fewer collisions than individuals during normal conditions but not during fog conditions when teams had an informational advantage over individuals. Furthermore, teams drove slower than individuals during fog conditions but not during normal conditions. Communication that was poorly timed and/or inaccurate was a positive predictor of accuracy (i.e., collisions) during the normal condition and communication that was well timed and accurate was a negative predictor of speed during the fog condition. Our novel measure of communication quality (i.e., content of communication) was a stronger predictor of accuracy, but volume of communication was a stronger predictor of time (i.e., speed).

Discussion

Results indicate when team performance thrives and succumbs compared with individual performance and informs theory about the 2HBT1 effect and team communication.

DriveSafe DriveAware: A systematic review

OBJECTIVES

Driving is an activity of daily living that significantly affects independence, and driving cessation is associated with poor health, lower quality of life, cognitive decline and early entry into care facilities. There is no consensus regarding the best off-road tool to assess driving safety. Therefore, this review explored the diagnostic accuracy, reliability and clinical utility of DriveSafe DriveAware (DSDA) compared with an on-road driving assessment.

METHODS

This review adhered to the PRISMA guidelines. Electronic databases for all English language articles published prior to December 2021 were searched. Studies were assessed for methodological quality and results were synthesised using a narrative descriptive approach.

RESULTS

Six studies were reviewed, consisting of 1332 participants. Four studies assessed diagnostic accuracy, two studies assessed reliability and three were relevant to clinical utility since they used DSDA as a standalone tool. Some studies demonstrated high levels of diagnostic accuracy, with specificity and sensitivity above 90% for those who fall into the safe and unsafe categories (50% of those assessed). Inter-rater reliability showed substantial agreement, and test-retest reliability was demonstrated for all age groups. DSDA was assessed as having high clinical utility (as a standalone tool) based on time taken to conduct, cost effectiveness and equipment required to complete the assessment.

CONCLUSIONS

DriveSafe DriveAware appears to be an ideal tool for the subacute setting; however, at present, inadequate evidence exists to support its use as a standalone tool for directing driving decisions. Further research is required.

Adaptation to the driving simulator and prediction of the braking time performance, with and without distraction, in older adults and middle-aged adults

CONTEXT

Many studies show the importance of evaluating the adaptation time of subjects in a virtual driving environment, looking forwards to a response as closest as a possible real vehicle.

OBJECTIVES

This study aimed to identify and analyze the adaptation to the driving simulator in older adults and middle-aged adults with and without a distraction, and a secondary aim was to identify predictors of safe performance for older adults' drives.

DESIGN

Male and female middle-aged adults (n = 62, age = 30.3 ± 7.1 years) and older adults (n = 102, age = 70.4 ± 5.8 years) were evaluated for braking time performance in a driving simulator; cognition performance assessment included the Mini-Mental State Examination; motor evaluation included ankle flexor muscle strength with the isokinetic dynamometer and handgrip strength; the postural balance was evaluated with Timed Up and Go test, with and without a cognitive distraction task.

RESULTS

Older adults (men and women) and middle-aged adult women require more time to adapt to the driving simulator. The distractor increases the adaptation time for all groups. The main predictors of braking time for older women are age, muscle strength, and postural balance associated with distraction, and for older men, muscle strength.

CONCLUSIONS

Age, sex, and distractor interfere in the adaptation of the virtual task of driving in a simulator. The evaluation model developed with multi-domains demonstrated the ability to predict which skills are related to braking time with and without the presence of the distractor.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Can executive functions of the brain predict official driving test success?

Human factors, including the level of cognitive functioning, are the most influential factors in road traffic crashes. Among cognitive abilities, executive functions (EFs) of the brain play a pivotal role in driving performance and outcomes, including crash numbers. The current study was aimed to explore, for the first time, the ability of EF tests to predict success on the official driving tests in applicants of driving license in Iran. We administered a relevant set of commonly used EF tests, including a computerized Stroop test and six tests from the Delis-Kaplan Executive Function System (D-KEFS) and the Behavioral Assessment of the Dysexecutive Syndrome (BADS), to 87 healthy new drivers applying for a driver's license (Mage = 25.9 years, SD = 8.2; 43 female). We also administered a series of demographic and psychological questionnaires. The data regarding the participants' official driving tests were extracted from the official records. To determine the relations of the EF tests with success on the driving tests, several correlation and regression analyses were conducted. Most of the EF measures had significant correlations with the road test success, while having no significant relations with the theory test success. Moreover, in our regression analyses, The EF measures predicted success on the official driving road test, but not success on the driving theory test, even after controlling for the effects of previous unlicensed driving experience and stress symptoms. The results demonstrate the predictability of the driving road test success from executive functioning.

Trait anger causes risky driving behavior by influencing executive function and hazard cognition

Drivers with a high level of trait anger feel more intensity of anger on road, contributing to more risky driving behavior and further increasing the probability of collisions. It seems that trait anger directly correlates with risky driving behavior, but how it works in detail remains unknown and previous research indicated executive function and hazard cognition may play a mediation role in it. Our research aims to explore the relationship among these variables and test if there is a multiple mediation model. We sampled 302 valid participants and used online questionnaires, containing trait anger scale (TAS), executive function index (EFI), hazard cognition scale (HCS; representing attitudes towards risky driving behavior), driver behavior questionnaire (DBQ), and self-reported traffic violations (e.g., accidents, penalty points, fines). Hierarchical multiple linear regression of DBQ results show trait anger is a medium but statistically significant predictor of risky driving behavior and drivers' attitude towards risky situations can significantly predict risky driving behavior at medium effect. But risky driving behavior cannot be predicted by executive function. Interestingly, opposing to prior research, zero-inflated Poisson regression analysis of self-reported traffic violations suggests trait anger negatively predicts accidents and fines in the zero-inflation model, and hazard cognition negatively predicts penalty points. Notably, the executive function negatively predicts penalty points and fines in the count model, which confirms our hypothetical direction. They all represent a small effect size in this nonlinear regression model. Path analysis suggested that trait anger influences risky driving behavior through executive function, and hazard cognition both separately and jointly. This study provides a theoretical framework for the transaction model of aggressive driving behavior and offers some possible interventions toward the effect of trait anger on risky driving behavior.

Ecological validity of executive function tests in predicting driving performance

Almost all of our everyday activities depend on executive function (EF) skills. In line with the increasing attention to the ecological validation of neuropsychological assessment and intervention methods, this study aimed to explore the ecological validity of a relevant set of widely used EF tests, mostly from well-known paradigms of EF assessment, in predicting driving ability. Ninety-six healthy novice drivers (Mage = 26.2 years, SD = 8.4; 48 female) completed four stages of our data collection including psychological, EF, and driving assessments. For the psychological assessment, validated measures of sensation-seeking, risk-taking, personality traits, ADHD symptoms, depression, anxiety, and stress were administered. For the EF assessment, selected tests from the Delis-Kaplan Executive Function System (D-KEFS: Trail Making, Design Fluency, and Tower) and the Behavioral Assessment of the Dysexecutive Syndrome (BADS: Key Search, Zoo Map, and Modified Six Elements) along with a computerized Stroop test were administered. For the driving assessment, we used a simulated driving test comprising of 14 key dimensions of driving skills. Several correlations and multiple regression analyses were conducted. Significant correlations were found between all the EF measures and driving performance. Moreover, the EF measures predicted the driving ability over and above the effects of previous driving experience and the psychological variables. These results provide supporting evidence for the ecological validity of the EF tests in predicting driving performance. The incorporation of assessment and intervention targeting multiple domains of EF into driving rehabilitation and education programs could be a focus of future research.

The impact of traditional kava (Piper methysticum) use on cognition: Implications for driver fitness

ETHNOPHARMACOLOGICAL RELEVANCE

Few studies have examined the impact of kava (Piper methysticum G. Forst. f.) on cognition when consumed at traditionally influenced volumes; most have used modified tablet-form kava, with the results erroneously overlaid on naturalistic kava consumption. Kava is a culturally significant Pacific drink with similar effects to Benzodiazepine. Traditionally influenced kava use sessions last, on average, 6 h in which attendees consume 3.6 L (7.6 pints) each of beverage kava, with some then driving home.

AIM OF THE STUDY

This study evaluated the impact of traditionally influenced kava consumption on participants' neurological functioning. Testing occurred before, throughout and immediately following a typical faikava (kava-drinking) session, with the data then used to assess kava's potential impacts on driver functionality and safety.

METHODS

Kava using participants (n = 20) were assessed with the Brain Gauge following and during a traditionally influenced kava session and compared against control (n = 19). Brain Gauge measures slight changes to six cognitive faculties: Speed, Accuracy, Temporal Order Judgement (TOJ), Timing Perception, Plasticity, and Focus.

RESULTS AND CONCLUSIONS

Comparisons of the within-cohort data showed a positive change in the Focus for the active group at the final testing point following 6-h of kava consumption. Between-cohort data showed a significant level of regression in the active participants' TOJ at the final testing point. No statistically significant level of impairment for the other five cognitive domains was detected. Although the results suggest that kava when consumed at traditional levels may have a slight positive effect on Focus, this result needs to be treated with caution, given the significant level of impairment noted at the final testing point for participants' TOJ. Temporal Order Judgement is associated with executive function, including decision making, behavioral control and information processing, all crucial aspects of driver safety. This is a new finding and suggests kava effects following traditional use differ from those caused by other substances commonly used for social or recreational purposes, such as cannabis, alcohol and other euphoric substances, and may impair driver safety, although again, in a different way to other commonly consumed recreational substances. The findings also add quantitative understanding to ethnographic data on kava effects, suggesting the often-used term 'kava intoxication' is misleading and incorrect.

Associations between Post-Traumatic stress disorder symptoms and automobile driving behaviors: A review of the literature

Human factors are responsible for most motor vehicle accidents that occur on the road. Recent work suggests that symptoms of posttraumatic stress disorder (PTSD) are linked to reduced driving safety, yet none have provided a comprehensive review of this small, emerging literature. The present review identified twenty-two studies reporting associations between PTSD and driving behaviors. Among these, longitudinal designs (k = 3) and studies using objective driving performance measures (e.g., simulators) (k = 2) were rare. Most studies (k = 18) relied on brief screener measures of PTSD status/symptoms or a prior chart diagnosis, while few used a standardized structured interview measure to determine PTSD status (k = 4), and only a small number of studies assessed PTSD symptom clusters (k = 7). PTSD was most frequently associated with increased rates of hostile driving behaviors (e.g., cutting off others), unintentional driving errors (e.g., lapses in attention) and negative thoughts and emotions experienced behind the wheel. Findings regarding risk of motor vehicle accident and driving-related legal issues were variable, however relatively few studies (k = 5) explored these constructs. Future directions are discussed, including the need for work focused on concurrent PTSD symptom/driving-related changes, more comprehensive PTSD and driving assessment, and consideration of the contributions of comorbid traumatic brain injury history and other neurological and psychiatric conditions on driving outcomes.

Usability of Norm Values on Results from a Simulator Device and Cognitive Tests in Traffic Medicine

Introduction

Driving is an essential everyday task for most adults, and fitness to continue car-driving after a brain injury/disease is a common issue in rehabilitation settings. There is no consensus on how this assessment should be performed and thus further research and development are of great value. The aim was to study the usability of cut-off values, based on recently developed norm values for a driving simulator device (CyberSiM), as well as cognitive tests, for patients already considered fit-to-drive after a standardized traffic medical investigation.

Methods

The study had a retrospective case-control design. Norm results (n = 129) were compared with patient results (n = 126) divided into two age groups (≤59 years and ≥60 years). Results from Useful Field of View, Trail Making Test, Nordic Stroke Driver Screening Assessment as well as a simulator device (CyberSiM) were compared.

Results

The group of patients considered fit-to-drive after a traffic medicine assessment had worse results on all cognitive tests compared with norms. Results on CyberSiM subtests II and III did not differ from norms. The proportion of patients within suggested cut-off limits (mean±2SD norm) and considered fit to drive (mean±2SD norm) were highest (75–95%) for all three subtests of CyberSiM and for Useful Field of View in both age groups.

Conclusion

Availability of norm values in decision on continued driving is of value when interpreting the results of cognitive assessments sensitive to age, but it must be handled with care because many factors are important for individuals’ ability to drive.

Age Predicts Older Adults' Driving Self-Regulation but Not Dangerous Driving Behaviors after Controlling for Executive Function

OBJECTIVES

The aim of the study was to examine the unique contributions of age to objectively measure driving frequency and dangerous driving behaviors in healthy older adults after adjusting for executive function (EF).

METHOD

A total of 28 community-dwelling older adults (mean age = 82.0 years, standard deviation [SD] = 7.5) without dementia who were in good physical health and enrolled in a longitudinal aging study completed several EF and clinical self-report measures at baseline. Participants subsequently had a sensor installed in their vehicle for a mean of 208 (SD = 38, range = 127-257) days.

RESULTS

Participants drove for an average of 54 min per day. Mixed-effects models indicated that after controlling for EF, older age was associated with less time driving per day, decreased number of trips, and less nighttime driving. Age was not associated with hard brakes or hard accelerations.

DISCUSSION

After accounting for EF, greater age is associated with higher driving self-regulation but not dangerous driving behaviors in healthy older adults. Future studies should recruit larger samples and collect sensor-measured driving data over a more extended time frame to better determine how and why these self-regulation changes take place.

Older Adults' Daily Activity and Mood Changes Detected During the COVID-19 Pandemic Using Remote Unobtrusive Monitoring Technologies

Background and Objectives

The coronavirus disease 2019 (COVID-19) pandemic has limited older adults' access to in-person medical care, including screenings for cognitive and functional decline. Remote, technology-based tools have shown recent promise in assessing changes in older adults' daily activities and mood, which may serve as indicators of underlying health-related changes (e.g., cognitive decline). This study examined changes in older adults' driving, computer use, mood, and travel events prior to and following the COVID-19 emergency declaration using unobtrusive monitoring technologies and remote online surveys. As an exploratory aim, the impact of mild cognitive impairment (MCI) on these changes was assessed.

Research Design and Methods

Participants were 59 older adults (41 cognitively intact and 18 MCI) enrolled in a longitudinal aging study. Participants had their driving and computer use behaviors recorded over a 5-month period (75 days pre- and 76 days post-COVID emergency declaration) using unobtrusive technologies. Measures of mood, overnight guests, and frequency of overnight travel were also collected weekly via remote online survey.

Results

After adjusting for age, gender, and education, participants showed a significant decrease in daily driving distance, number of driving trips, highway driving, and nighttime driving, post-COVID-19 as compared to pre-COVID-19 (p < .001) based on generalized estimating equation models. Further, participants spent more time on the computer per day post-COVID-19 (p = .03). Participants endorsed increases in blue mood (p < .01) and loneliness (p < .001) and decreases in travel away from home and overnight visitors (p < .001) from pre- to post-COVID-19. Cognitive status did not impact these relationships.

Discussion and Implications

From pre- to post-COVID-19 emergency declaration, participants drove and traveled less, used their computer more, had fewer overnight visitors, and reported greater psychological distress. These results highlight the behavioral and psychological effects of stay-at-home orders on older adults who are cognitively intact and those with MCI.

Fitness to drive after acquired brain injury: Results from patient cognitive screening and on-road assessment compared to age-adjusted norm values

Fitness to drive after acquired brain injury or disease is a common question in rehabilitation settings. The aim of the study was to compare age-matched norms with patient cognitive test results used to predict fitness to drive. A second aim was to analyze the contribution from an on-road assessment to a final decision on resumption of driving after an acquired brain injury. Retrospective cognitive test results from four traffic medicine units (n = 333) were compared with results from a healthy norm population (n = 410) in Sweden. Patients were dichotomized according to the final decision as fit or unfit to drive made by the traffic medicine team. The norm group had significantly better results in all age groups for all cognitive tests compared with the patients considered unfit to drive and fit to drive. A binary regression analysis for the patient group showed an explained value for fit to drive/unfit to drive of 88%, including results for the Nordic Stroke Driver Screening Assessment total score, Useful Field of View total score and the final outcome from an on-road assessment. Results from the present study illustrate the importance of using several tests, methods and contexts for the final decision regarding fitness to drive.

Patients with Cervical Dystonia Demonstrated Decreased Cognitive Abilities and Visual Planning Compared to Controls

Background

Cervical dystonia (CD) involves clinical and motor manifestations, and visual and cognitive dysfunctions may also be frequent.

Objective

To evaluate functional vision, visual attention, and cognitive aspects in patients with CD compared with a control group.

Methods

Fifty patients with CD were assessed using the Useful Field of View Test (UFOV), the Mini Mental State Examination (MMSE), and the Trail Making Tests (TMT-A and TMT-B), and compared with an identical number of health controls matched by sex, age, and educational level.

Results

No differences were seen between the groups in terms of MMSE score (P = 0.481), but the CD patient group had poorer scores for the TMA-A (P = 0.004) and TMT-B (P = 0.004). For the UFOV subtests, a decrease was found for visual processing speed (P < 0.001), divided attention (P < 0.001), and selective attention (P = 0.001), as well as higher frequency in the categories with higher risk index in the UFOV test (P < 0.001).

Conclusion

Patients with CD may exhibit decreased functional vision and visual attention, as well as higher risk in performing complex activities.

Functional Connectivity Within the Fronto-Parietal Network Predicts Complex Task Performance: A fNIRS Study

Performance in complex tasks is essential for many high risk operators. The achievement of such tasks is supported by high-level cognitive functions arguably involving functional activity and connectivity in a large ensemble of brain areas that form the fronto-parietal network. Here we aimed at determining whether the functional connectivity at rest within this network could predict performance in a complex task: the Space Fortress video game. Functional Near Infrared Spectroscopy (fNIRS) data from 32 participants were recorded during a Resting-State period, the completion of a simple version of Space Fortress (monotask) and the original version (multitask). The intrinsic functional connectivity within the fronto-parietal network (i.e., during the Resting-State) was a significant predictor of performance at Space Fortress multitask but not at its monotask version. The same pattern was observed for the functional connectivity during the task. Our overall results suggest that Resting-State functional connectivity within the fronto-parietal network could be used as an intrinsic brain marker for performance prediction of a complex task achievement, but not for simple task performance.

Benefits of Higher Cardiovascular and Motor Coordinative Fitness on Driving Behavior Are Mediated by Cognitive Functioning: A Path Analysis

Driving is an important skill for older adults to maintain an independent lifestyle, and to preserve the quality of life. However, the ability to drive safely in older adults can be compromised by age-related cognitive decline. Performing an additional task during driving (e.g., adjusting the radio) increases cognitive demands and thus might additionally impair driving performance. Cognitive functioning has been shown to be positively related to physical activity/fitness such as cardiovascular and motor coordinative fitness. As such, a higher fitness level might be associated with higher cognitive resources and may therefore benefit driving performance under dual-task conditions. For the first time, the present study investigated whether this association of physical fitness and cognitive functioning causes an indirect relationship between physical fitness and dual-task driving performance through cognitive functions. Data from 120 healthy older adults (age: 69.56 ± 3.62, 53 female) were analyzed. Participants completed tests on cardiovascular fitness (cardiorespiratory capacity), motor coordinative fitness (composite score: static balance, psychomotor speed, bimanual dexterity), and cognitive functions (updating, inhibition, shifting, cognitive processing speed). Further, they performed a virtual car driving scenario where they additionally engaged in cognitively demanding tasks that were modeled after typical real-life activities during driving (typing or reasoning). Structural equation modeling (path analysis) was used to investigate whether cardiovascular and motor coordinative fitness were indirectly associated with lane keeping (i.e., variability in lateral position) and speed control (i.e., average velocity) while dual-task driving via cognitive functions. Both cardiovascular and motor coordinative fitness demonstrated the hypothesized indirect effects on dual-task driving. Motor coordinative fitness showed a significant indirect effect on lane keeping, while cardiovascular fitness demonstrated a trend-level indirect effect on speed control. Moreover, both fitness domains were positively related to different cognitive functions (processing speed and/or updating), and cognitive functions (updating or inhibition), in turn, were related to dual-task driving. These findings indicate that cognitive benefits associated with higher fitness may facilitate driving performance. Given that driving with lower cognitive capacity can result in serious consequences, this study emphasizes the importance for older adults to engage in a physically active lifestyle as it might serve as a preventive measure for driving safety.

Towards Mindless Stress Regulation in Advanced Driver Assistance Systems: A Systematic Review

Background: Stress can frequently occur in the driving context. Its cognitive effects can be deleterious and lead to uncomfortable or risky situations. While stress detection in this context is well developed, regulation using dedicated advanced driver-assistance systems (ADAS) is still emergent. Objectives: This systematic review focuses on stress regulation strategies that can be qualified as "subtle" or "mindless": the technology employed to perform regulation does not interfere with an ongoing task. The review goal is 2-fold: establishing the state of the art on such technological implementation in the driving context and identifying complementary technologies relying on subtle regulation that could be applied in driving. Methods: A systematic review was conducted using search operators previously identified through a concept analysis. The patents and scientific studies selected provide an overview of actual and potential mindless technology implementations. These are then analyzed from a scientific perspective. A classification of results was performed according to the different stages of emotion regulation proposed by the Gross model. Results: A total of 47 publications were retrieved, including 21 patents and 26 studies. Six of the studies investigated mindless stress regulation in the driving context. Patents implemented strategies mostly linked to attentional deployment, while studies tended to investigate response modulation strategies. Conclusions: This review allowed us to identify several ADAS relying on mindless computing technologies to reduce stress and better understand the underlying mechanisms allowing stress reduction. Further studies are necessary to better grasp the effect of mindless technologies on driving safety. However, we have established the feasibility of their implementation as ADAS and proposed directions for future research in this field.

Components of driving competency measurement in the elderly: A scoping review

Background: Iran will face the "aging Tsunami" phenomenon by the 2040s. Therefore, paying attention to the elderly's driving to maintain and promote their independence and quality of life on the one hand and paying attention to the dangers of driving by the elderly for road safety will be important. The purpose of this research was to determine the components of driving competency in the elderly.

Methods: The research has employed a scoping review. To this end, searches of scientific databases were conducted using keywords between 1990 and 2019. The process of selecting the documentation was-based on the PRISMA chart.

Results: In the first phase, 2769 records were found, and finally, 37 records met the inclusion criteria set for this study. The results indicated that 18 components were extracted that were classified into seven main categories including cognitive, sensory, motor, mental functions, and medications, diseases, and driving history.

Conclusion: Sensory, motor, and cognitive abilities are the most important components of elderly safe driving. Therefore, as age increases, chronic disease, multiple drug use, and subsequent problems increase. This can affect the ability to drive safely and can cause traffic injuries. Therefore, it is recommended to use the results of this research to design a suitable tool and model for assessing driving competency in the elderly.

A Frontal Neuropsychological Profile in Fitness to Drive

Traffic accidents are a global concern due to the elevated mortality rates of both drivers and pedestrians. The World Health Organization declared 2011-2020 as the Decade of Action for Road Safety, endorsing initiatives to reduce traffic-related deaths. Yet, despite these incentives, fatal accidents still occur. Different studies have linked deficits in executive functions to risky driving attitudes and crashes. The present study focuses on demographic, cognitive and personality factors, related to the prefrontal cortex, that are characteristic of drivers prone to risky behavior behind the wheel. The penalty Points System was used to classify drivers as "safe", with no point loss over a two-year period, or "risky", with full point loss during the same interval. A neuropsychological assessment of prefrontal cognitive functions was carried out on each group to identify variables associated with safe and risky behavior. Neuropsychological indexes were obtained from a continuous performance task without cue (Simple Attention), a continuous performance task with cue (Conditioned Attention), the Tower of Hanoi test and the Neurologically-related Changes in Personality Inventory (NECHAPI). A Discriminant Analysis (DA) found that education level, reaction times in Simple and Conditioned Attention, learning errors in the Tower of Hanoi and vulnerability in the personality test, best predicted whether drivers were likely to be in the safe or risky group. Finally, a cross-validation analysis performed on the same sample correctly classified 87.5% of the drivers. These data suggest that prefrontal dysfunction contributes to risky behavior behind the wheel. The inclusion of cognitive programs to identify and train drivers with this propensity could reduce risky driving, and consequently, save lives on the road.

Multimethod assessment of driving in older adults using a novel driving simulator

Driving simulators may be an effective means of assessing driving performance, however many are cost-prohibitive. The present pilot study examined whether a novel, cost-effective driving simulator (Assetto Corsa (AC)) may be useful in the evaluation of older adults' driving performance, and explore associations among various driving safety indicators. A community sample of older adults completed a battery of cognitive measures, several self-reported driving measures, and a novel driving simulator task (AC). Simple attention, executive functioning, and processing speed were associated with simulator performance variables. Lower self-rated driving safety was associated with slower simulated driving. Additionally, several cognitive domains were associated with perceptions about driving-related safety and driving-related legal repercussions (e.g., traffic tickets). Findings suggested that associations between cognitive tests with AC were less robust than those found in other simulator studies. Novel associations between cognitive performance and self-reported driving were identified; however, given the small sample size of this study, such associations should be explored further.

Differences in visual-spatial working memory and driving behavior between morning-type and evening-type drivers

Circadian rhythms are changes in life activities over a cycle of approximately 24 hours. Studies on chronotypes have found that there are significant differences in physiology, personality, cognitive ability and driving behavior between morning-type and evening-type people. The purpose of this study is to explore the relationship between visual-spatial working memory and driving behavior between morning-type and evening-type drivers in China. A total of 42 Chinese drivers were selected to participate in this study according to their score on the Morningness-Eveningness Questionnaire, including 22 morning-type drivers and 20 evening-type drivers. During the experiment, the participants completed one cognitive task (visual-spatial working memory), two simulated driving tasks (car-following task and pedestrian-crossing task), and the Dula Dangerous Driving Index (DDDI). The results showed that evening-type drivers self-reported more dangerous driving behaviors but had better lateral control on the simulated driving task than morning-type drivers. In addition, evening-type drivers had greater accuracy when performing the visual-spatial working memory task. Moreover, the accuracy on the visual-spatial working memory task positively predicted the percentage of time over the speed limit by 10 mph (POS10) and negatively correlated with the reaction time measure (time to meet pedestrians) in the pedestrian-crossing task. The relationships among chronotype, cognitive ability and driving behavior are also discussed. Understanding the underlying mechanisms could help explain why evening-type drivers perform dangerous driving behaviors more often.

Reliability and Validity of a Method for Assessment of Executive Functions in Drivers

The quality of drivers’ performance is one of the crucial components related to road safety. One of the key cognitive characteristics related to the ability to drive safely are executive functions. The main goal of the presented research is to propose a new method (Trace-route task) for assessment of executive functions in drivers. The present article discusses the results of two consecutive studies. Study one aims to determine the validity and reliability of the method used and includes 134 participants, equally divided in two groups—people with disturbances in executive functions and people from the general population. Study two aims to assess the ability of the method to distinguish drivers with risky behavior. It includes 1440 participants divided in two groups—people with and without actual risky driving behavior. The results from the studies show that people with different neurological or psychiatric diseases and drivers with different road violations demonstrate worse planning ability, working memory, decision making, and cognitive flexibility. This data show that the trace-route task method is a valid and reliable instrument for assessing executive functions and has the ability to distinguish people with risky driving behavior from those who drive safely. This study reveals that the proposed method can be used for implementation in the area of traffic psychology.

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.

Driving while navigating: On-road driving performance using GPS or printed instructions

BACKGROUND.

Route navigation is a high-level skill and requires intact executive functioning to successfully find one's way while driving in unfamiliar environments.

PURPOSE.

Driving performances were compared while navigating using electronic devices and printed directions on unfamiliar driving routes as well as in an interactive driving simulator.

METHOD.

Twenty-four participants drove two on-road routes using GPS and printed directions, and navigated using printed directions in the simulator, using a point system to evaluate performance. The two unfamiliar routes, order of simulator and on-road driving, and use of GPS and printed directions were counterbalanced. Paired t test were used to compare both GPS versus printed directions and performance between on-road driving and the simulator.

FINDINGS.

Participants' performance using GPS on the road was significantly better than with printed directions. There was no significant difference between performance in the simulator and on the road.

IMPLICATIONS.

Using GPS may be an effective strategy for improving safety. Using a driving simulator may be an efficient means of evaluating the strategic level of driving, executive function, and readiness to drive.

When should the driver with a history of substance misuse be allowed to return to the wheel? A review of the substance misuse section of the Australian national guidelines

Assessing fitness to drive in applicants with a historical or current substance use disorder presents a specific clinical challenge. The Australian guidelines require evidence of remission and absence of cognitive change when considering applications for re-licensing driver or individuals applying to reengage in safety-sensitive work. This paper reviews some of the clinical and biochemical indicators that determine whether a particular person is in 'remission' and meets the criteria for return to driving or other safety-sensitive occupation. It provides an overview of the challenges in establishing an evidence-based approach to determining fitness for safety critical activities. There is no internationally accepted definition of 'remission'. Review of the literature and examination of assessment protocols from other national jurisdictions are available for alcohol and the more important drugs of interest in road safety. Assessing fitness to drive when there is a history of substance misuse and/or substance use disorders is a complex issue that requires assessment of biomarkers, clinical findings and clinical assessment before the person returns to driving. We propose that hair testing provides a reliable and reproducible way to demonstrate remission and provide cost-effective monitoring. Standardised psychological tests could provide a reproducible assessment of the cognitive effects of drug use and suitability to resume driving. We recommend that AustRoads amend the national guidelines to reflect an evidence-based approach to assessing fitness to drive after conviction for offences related to alcohol and drug use.

O efeito da idade, da dupla tarefa e da visão no senso de posicionamento do tornozelo

RESUMO O objetivo desta pesquisa foi mensurar de forma objetiva a propriocepção, em diferentes situações (com e sem o auxílio da visão, com e sem tarefa cognitiva concomitante e de forma ativa ou passiva), em indivíduos idosos e adultos. Participaram do estudo dez adultos saudáveis e dez idosos saudáveis. Foram estudados os efeitos de diferentes restrições no desempenho do movimento por meio dos erros absoluto (precisão) e relativo (consistência). A mensuração do senso de posicionamento do tornozelo foi realizada com o dinamômetro isocinético Biodex Sistem 3. A análise de variância de quatro fatores e o teste post hoc de Tukey foram utilizados para analisar os parâmetros. Os resultados mostraram que o fator sujeito interfere no erro absoluto, pois os grupos apresentaram diferença significativa: os idosos erram mais quando comparados com os adultos. Os demais fatores (visão, tarefa cognitiva e tipo de movimento) não apresentaram diferença significativa. No erro relativo os resultados mostraram que a tarefa cognitiva concomitante ao movimento foi capaz de produzir diferença significante; entretanto os demais fatores (indivíduos, visão e tipo de movimentação) não foram capazes de produzir uma diferença significativa. A idade afeta a precisão do sentido proprioceptivo, independentemente da situação. Não houve diferença entre a realização do movimento com e sem o auxílio da visão, e a dupla tarefa (motora associada à cognitiva) afeta a consistência do movimento.

Driving Dilemmas: A Guide to Driving Assessment in Primary Care

Clinical assessment of fitness to drive can be a challenging part of primary care of older adults. There are no guidelines on screening for driver safety, so it falls to provider judgment on when to assess older drivers. This review offers recommendations on when to assess for driver safety based on red flag conditions, medications, acute events, and patient or family concerns. It reviews how to assess for visual, cognitive, and neuromuscular impairments and what to do as next steps for at-risk drivers once they are identified. Laws regarding driver reporting are also reviewed.

Driving after an injury or disease affecting the brain: an analysis of clinical data

Introduction

Traffic safety may be affected if a licence holder has experienced illness or injury that may have an impact on cognition. Occupational therapists are involved in assessing cognitive functions that might affect a patient’s ability to drive a car using different evaluation tools in different countries and settings. The aim of this study was to look at the predictive value of some of the assessment tools available to occupational therapists for making judgements about resuming driving after cognitive impairment due to brain trauma or disease.

Method

A retrospective study based on clinical data from 204 patients referred to a specialist department for recommendations on ability to drive after brain injury or disease. All patients underwent three assessments: stroke drivers screening assessment, useful field of view and simulated driving skill. In addition, an on-road assessment was added in 76% of the sample.

Results

Useful field of view had the highest sensitivity (78%) and, combined with the results from the simulator, the sensitivity was 87%. The specificity for the two methods was 55%.

Conclusion

The results from useful field of view and a simulator test combined best predicted the final recommendation from the multi-professional team discussion on which clients should be recommended not to resume driving.

Executive Function Capacities, Negative Driving Behavior and Crashes in Young Drivers

Motor vehicle crashes remain a leading cause of injury and death in adolescents, with teen drivers three times more likely to be in a fatal crash when compared to adults. One potential contributing risk factor is the ongoing development of executive functioning with maturation of the frontal lobe through adolescence and into early adulthood. Atypical development resulting in poor or impaired executive functioning (as in Attention-Deficit/Hyperactivity Disorder) has been associated with risky driving and crash outcomes. However, executive function broadly encompasses a number of capacities and domains (e.g., working memory, inhibition, set-shifting). In this review, we examine the role of various executive function sub-processes in adolescent driver behavior and crash rates. We summarize the state of methods for measuring executive control and driving outcomes and highlight the great heterogeneity in tools with seemingly contradictory findings. Lastly, we offer some suggestions for improved methods and practical ways to compensate for the effects of poor executive function (such as in-vehicle assisted driving devices). Given the key role that executive function plays in safe driving, this review points to an urgent need for systematic research to inform development of more effective training and interventions for safe driving among adolescents.

Assessing Chinese coach drivers' fitness to drive: The development of a toolkit based on cognition measurements

Road traffic accidents resulting in group deaths and injuries are often related to coach drivers' inappropriate operations and behaviors. Thus, the evaluation of coach drivers' fitness to drive is an important measure for improving the safety of public transportation. Previous related research focused on drivers' age and health condition. Comprehensive studies about commercial drivers' cognitive capacities are limited. This study developed a toolkit consisting of nine cognition measurements across driver perception/sensation, attention, and reaction. A total of 1413 licensed coach drivers in Jiangsu Province, China were investigated and tested. Results indicated that drivers with accident history within three years performed overwhelmingly worse (p<0.001) on dark adaptation, dynamic visual acuity, depth perception, attention concentration, attention span, and significantly worse (p<0.05) on reaction to complex tasks compared with drivers with clear accident records. These findings supported that in the assessment of fitness to drive, cognitive capacities are sensitive to the detection of drivers with accident proneness. We first developed a simple evaluation model based on the percentile distribution of all single measurements, which defined the normal range of "fit-to-drive" by eliminating a 5% tail of each measurement. A comprehensive evaluation model was later constructed based on the kernel principal component analysis, in which the eliminated 5% tail was calculated from on integrated index. Methods to categorizing qualified, good, and excellent coach drivers and criteria for evaluating and training Chinese coach drivers' fitness to drive were also proposed.

Muscle strength, postural balance, and cognition are associated with braking time during driving in older adults

BACKGROUND

Despite the well-known declines in driving performance with advancing age, there is little understanding of the specific factors that predict changes in key determinants such as braking time.

OBJECTIVES

The aims of this study were to determine the extent to which age, muscle strength, cognition and postural balance are associated with braking performance in middle-aged and older adults.

METHODS

Male and female middle-aged adults (n=62, age=39.3±7.1years) and older adults (n=102, age=70.4±5.8years) were evaluated for braking performance, as well as in several motor and cognitive performance tasks. The motor evaluation included isokinetic ankle plantar flexor muscle strength, handgrip strength, and postural balance with and without a cognitive task. The cognitive assessment included the Mini Mental State Examination. Braking performance was measured using a driving simulator.

RESULTS

Older adults exhibited 17% slower braking time, lower strength, and poorer performance in the postural balance (p<0.001). For both older and middle-aged adults, significant correlates of braking time included performance in the postural balance tests, muscle strength, and cognitive function. However, after full model adjustment, only postural balance and cognitive function were significantly associated.

CONCLUSION

Muscle strength, postural balance, and cognition are associated with braking time, and may affect the safety of and driving performance in older adults. These findings may help to inform specific targeted interventions that could preserve driving performance during aging.

Neuropsychological Assessment of Driving Capacity

Clinicians are increasingly requested to make determinations regarding patients' driving capacity in the context of neurological injury/conditions and a growing cohort of older drivers. The capability to drive safely involves a number of cognitive, physical, and sensorimotor abilities that may be impacted by injury, illness, or substances that influence alertness. Neuropsychological measures are an important component of a multidisciplinary approach for evaluation of driving capacity. Clinicians should become familiar with measures that have the best predictive validity so they may incorporate a patient's neurocognitive strengths and weaknesses in decisions about driving ability.

Ethics of Clinical Decision-Making for Older Drivers: Reporting Health-Related Driving Risk

The number of older drivers will continue to increase as the population ages. Health care professionals have the responsibility of providing care and maintaining confidentiality for their patients while ensuring public safety. This article discusses the ethics of clinical decision-making pertaining to reporting health-related driving risk of older drivers to licensing authorities. Ethical considerations inherent in reporting driving risk, including autonomy, confidentiality, therapeutic relationships, and the uncertainty about determining individual driving safety and risk, are discussed. We also address the moral agency of reporting health-related driving risk and raise the question of whose responsibility it is to report. Issues of uncertainty surrounding clinical reasoning and concepts related to risk assessment are also discussed. Finally, we present two case studies to illustrate some of the issues and challenges faced by health care professionals as they seek to balance their responsibilities for their patients while ensuring road safety for all citizens.

Association Between Executive Function and Problematic Adolescent Driving

OBJECTIVE

Motor vehicle collisions (MVCs) are one of the leading causes of injury and death for adolescents. Driving is a complex activity that is highly reliant on executive function (EF) to safely navigate through the environment. Little research has examined the efficacy of using self-reported EF measures for assessing adolescent driving risk. This study examined the Behavior Rating Inventory of Executive Function (BRIEF) questionnaire and performance-based EF tasks as potential predictors of problematic driving outcomes in adolescents.

METHODS

Forty-six adolescent drivers completed the (1) BRIEF, (2) Trail Making Test, (3) Backwards Digit Span, and (4) self-report on 3 problematic driving outcomes: the number of times of having been pulled over by a police officer, the number of tickets issued, and the number of MVCs.

RESULTS

Greater self-reported difficulty with planning and organization was associated with greater odds of having a MVC, whereas inhibition difficulties were associated with greater odds of receiving a ticket. Greater self-reported difficulty across multiple BRIEF subscales was associated with greater odds of being pulled over.

CONCLUSION

Overall findings indicated that the BRIEF, an ecological measure of EF, showed significant association with self-reported problematic driving outcomes in adolescents. No relationship was found between performance-based EF measures and self-reported driving outcomes. The BRIEF could offer unique and quick insight into problematic driving behavior and potentially be an indicator of driving risk in adolescent drivers during clinical evaluations.

Virtual Reality for Enhanced Ecological Validity and Experimental Control in the Clinical, Affective and Social Neurosciences

An essential tension can be found between researchers interested in ecological validity and those concerned with maintaining experimental control. Research in the human neurosciences often involves the use of simple and static stimuli lacking many of the potentially important aspects of real world activities and interactions. While this research is valuable, there is a growing interest in the human neurosciences to use cues about target states in the real world via multimodal scenarios that involve visual, semantic, and prosodic information. These scenarios should include dynamic stimuli presented concurrently or serially in a manner that allows researchers to assess the integrative processes carried out by perceivers over time. Furthermore, there is growing interest in contextually embedded stimuli that can constrain participant interpretations of cues about a target’s internal states. Virtual reality environments proffer assessment paradigms that combine the experimental control of laboratory measures with emotionally engaging background narratives to enhance affective experience and social interactions. The present review highlights the potential of virtual reality environments for enhanced ecological validity in the clinical, affective, and social neurosciences.

Neurocognitive Recovery After Hospital-Treated Deliberate Self-Poisoning With Central Nervous System Depressant Drugs: A Longitudinal Cohort Study

Hospital-treated deliberate self-poisoning (DSP) by central nervous system depressant drugs (CNS-D) has been associated with impairments in cognitive and psychomotor functions at the time of discharge. We aimed to replicate this finding and to compare recovery in the first month after discharge for CNS-D and CNS nondepressant drug ingestions. We also examined a series of multivariate explanatory models of recovery of neurocognitive outcomes over time. The CNS-D group was impaired at discharge compared with the CNS-nondepressant group in cognitive flexibility, cognitive efficiency, and working memory. There were no significant differences at discharge in visual attention, processing speed, visuomotor speed, or inhibition speed. Both groups improved in the latter measures over 1 month of follow-up. However, the CNS-D group's recovery was significantly slower for key neurocognitive domains underlying driving in complex traffic situations, namely, cognitive flexibility, cognitive efficiency, and working memory. Patients discharged after DSP with CNS-D drugs have impairments of some critical cognitive functions that may require up to 1 month to recover. Although more pre- than post-DSP variables were retained as explanatory models of neurocognitive performance overall, recovery over time could not be explained by any one of the measured covariates. Tests of cognitive flexibility could be used in clinical settings as a proxy measure for recovery of driving ability. Regulatory authorities should also consider the implications of these results for the period of nondriving advised after ingestion of CNS-D in overdose. Future research, with adequate sample size, should examine contributions of other variables to the pattern of recovery over time.

Effect of activities of daily living status on resuming driving after stroke

[Purpose] This study aimed to investigate the effect of the activities of daily living status on resuming driving after stroke. [Subjects] Thirty-one participants with stroke, who visited in Korean national rehabilitation centers, were included in this study. [Methods] The activities of daily living performance and the driving ability of the participants were assessed with the Korean-Modified Barthel Index in combination with the results obtained by using a driving simulator. [Results] Significant correlations were noted among the Korean-Modified Barthel Index, on-road driving total score, reaction time, speed anticipation tests, judgment tests, and steering wheel-pedal operation tests. Results of Stepwise multiple regression also revealed that the Korean-Modified Barthel Index total score and speed anticipation, with an R(2) of 52.9%. In other words, as the Korean-Modified Barthel Index total score and speed anticipation score increased and the driving performance score also increased in patients who had suffered a stroke. [Conclusion] The activities of daily living status was positively correlated with the patients' post stroke driving ability.

The potential of function-led virtual environments for ecologically valid measures of executive function in experimental and clinical neuropsychology

The assessment of executive functions is an integral task of neuropsychological assessment. Traditional measures of executive function are often based on hypothetical constructs that may have little relevance to real-world behaviours. In fact, some traditional tests utilised today were not originally developed for clinical use. Recently, researchers have been arguing for a new generation of "function-led" neuropsychological assessments that are developed from directly observable everyday behaviours. Although virtual environments (VEs) have been presented as potential aides in enhancing ecological validity, many were modelled on construct-driven approaches found in traditional assessments. In the current paper, we review construct-driven and function-led VE-based neuropsychological assessments of executive functions. Overall, function-led VEs best represent the sorts of tasks needed for enhanced ecological validity and prediction of real-world functioning.

Clinical Utility of the Trail-Making Test as a Predictor of Driving Performance in Older Adults

OBJECTIVES

To assess the clinical utility of the Trail-Making Tests (TMTs) as screens for impaired road-test performance.

DESIGN

Secondary analyses of three data sets from previously published studies of impaired driving in older adults using comparable road test designs and outcome measures.

SETTING

Two academic driving specialty clinics.

PARTICIPANTS

Older drivers (N = 392; 303 with cognitive impairment, 89 controls) from Rhode Island and Missouri.

MEASUREMENTS

Standard operating characteristics were evaluated for the TMT Part A (TMT-A) and Part B (TMT-B), as well as optimal upper and lower test cut-points that could be useful in defining groups of drivers with indeterminate likelihood of impaired driving who would most benefit from further screening or on-road testing.

RESULTS

Discrimination remained high (>70%) when cut-points for the TMTs derived from Rhode Island data were applied to Missouri data, but calibration was poor (all P < .01). TMT-A provided the best utility for determining a range of scores (68-90 seconds) for which additional road testing would be indicated in general practice settings. A high frequency of cognitively impaired participants unable to perform the TMT-B test within the allotted time limited the utility of the test (>25%). Mere inability to complete the test in a reasonable time frame (e.g., TMT-A > 48 seconds or TMT-B > 108 seconds) may still be a useful tool in separating unsafe from safe or marginal drivers in such samples.

CONCLUSION

The TMTs (particularly TMT-A) may be useful as screens for driving impairment in older drivers in general practice settings, where most people are still safe drivers, but more-precise screening measures need to be analyzed critically in a variety of clinical settings for testing cognitively impaired older drivers.

Performance of the Maze Navigation Test in a sample of older New Zealanders

OBJECTIVE

It is often difficult to assess the driving performance of people with mild dementia. The Maze Navigation Test (MNT) was developed in the USA and has been shown to predict driving performance. The aim of this study is to evaluate how the MNT is performed against three commonly used bedside cognitive screening tools and compare our findings with the US population.

METHODS

A convenience sample of 42 cognitively intact older people (age ≥65) completed the MNT, Mini-Mental State Examination, the revised Addenbrooke's Cognitive Examination and the Trail Making Tests.

RESULTS

The mean MNT completion time was 307.6 (SD=85.6) and 444.5 (SD=157.3) for the 65-74 years and 75-84 years age group, respectively. Pearson's product-moment correlations were strongest with the Trail Making Test Part B (r=0.602).

CONCLUSIONS

The findings of this study were comparable with the initial US data. The MNT is an easy-to-administer bedside cognitive screening tool. Further validation studies using the MNT and driving performance are warranted.

Computerized and on-line neuropsychological testing for late-life cognition and neurocognitive disorders: are we there yet?

PURPOSE OF REVIEW

Cost-effective, valid, efficient and accessible tests for the detection of late-life neurocognitive disorders are crucial, as early identification facilitates appropriate early intervention. Proponents of computerized neuropsychological assessment devices (CNADs) assert that technology-based assessments improve upon traditional neuropsychological tests. However, there remain fundamental questions of validity, reliability, normative data and administration, raising the question of whether CNADs are appropriate alternatives.

RECENT FINDINGS

Since publication of the 2012 American Academy of Clinical Neuropsychology and National Academy of Neuropsychology joint position paper outlining appropriate standards for CNAD development, the field has not significantly advanced, with the majority of recommendations inadequately addressed.

SUMMARY

Whilst there is a pressing need for innovative and readily applicable cognitive tests, these requirements do not outweigh the necessity for valid measures. Overall, the psychometric quality, standardization, normative data and administration advice of CNADs for neurocognitive disorders are lacking. Therefore, the risk of diagnostic errors is potentially high and poor clinical decisions could potentially arise, having significant impact upon individuals in terms of their well being and access to treatment. We recommend clinicians and researchers make informed decisions about CNAD suitability for their clients and their individual requirements based upon published psychometric and other test information.

Determining fitness to drive: A systematic review of the methods and assessments used after mild traumatic brain injury

Introduction

Limited evidence is available to support knowledge of the time-frame and capacity for fitness to drive after mild traumatic brain injury. The aim of this systematic review was to identify what methods and assessments are, or could be used to determine fitness to drive for this population.

Method

We undertook a systematic search of six electronic databases. Two authors rated all studies for methodological content and quality, and standardised data were extracted. Narrative analysis was conducted to understand the content of eligible studies.

Findings

A total of 2022 articles were retrieved; seven articles met the inclusion criteria. Self-reported questionnaires, non-standardised assessments, questionnaires completed by next-of-kin, and simulator tests were the primary methods used to determine fitness to drive. Only one assessment has been used to aid recommendations about fitness to drive in the acute hospital setting. Six additional standardised assessments were identified that have the potential to predict fitness to drive in this population group; however, these assessments require further psychometric testing prior to use.

Conclusion

While a variety of methods and assessments are currently used, there is little research evidence to suggest when individuals are able to return to driving after mild traumatic brain injury. Research is urgently required to determine a consistent and standardised approach to assessing fitness to drive following mild traumatic brain injury.