Driving cessation in older men with incident dementia

Driving Assessment for Persons with Dementia: How and when?

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

Refining a Driving Retirement Program for Persons With Dementia and Their Care Partners: A Mixed Methods Evaluation of CarFreeMe™-Dementia

OBJECTIVES

We adapted the CarFreeMe™-Dementia program created by The University of Queensland for drivers in the United States. CarFreeMe™-Dementia aims to assist drivers living with dementia and their care partners as they plan for or adjust to driving retirement. This semistructured program focuses on driving retirement education and support. Topics include how dementia affects driving, lifestyle planning, stress management, and alternative transportation options. This study evaluated the feasibility, acceptability, and utility of the CarFreeMe™-Dementia intervention.

METHODS

This pilot phase of the study included 16 care partners and 11 drivers with memory loss who were preparing for or adjusting to driving retirement. Participants completed 4-8 CarFreeMe™-Dementia intervention telehealth sessions. Online surveys (baseline, 1- and 3-month) and postintervention semistructured interviews informed evaluation of the intervention program using a mixed methods approach.

RESULTS

This study established initial support for CarFreeMe™-Dementia in the United States. Participants indicated the program facilitated dialogue around driving retirement and provided guidance on community engagement without driving. Respondents appreciated the program's emphasis on overall well-being, promoted through lifestyle planning and stress management. They also reported the program offered practical preparation for transitioning to driving retirement.

DISCUSSION

The CarFreeMe™-Dementia intervention, tailored to an American audience, appears to be a feasible, acceptable, and useful support program for drivers with memory loss (and/or their care partners) who are preparing for or adjusting to driving retirement. Further investigations of the efficacy of the CarFreeMe™-Dementia intervention in the United States, as well as in other countries and cultural contexts, are warranted.

Predictors of Driving Cessation in Older Adults: A 12-year Population-based Study

BACKGROUND

Changes in physical health and cognition during aging can result in some older adults to stop driving. In this population-based longitudinal study, we describe potential predictors of driving cessation in older adults.

METHODS

Age-stratified random population cohort of 1982 adults aged 65 years and older drawn from voter registration lists. Participant characteristics were measured using demographics, physical and self-rated health, sleeping habits, driving status, cognitive screening, modified Center for Epidemiologic Studies-Depression scale, clinical dementia rating, and mini-mental state examination.

RESULTS

Over 12 years of follow-up, 390 participants stopped driving. These individuals were older, more likely to be women and to have a clinical dementia rating score ≥1, had worse self-reported health, and more symptoms of depression, compared with those who were still driving. In addition, individuals with lower test performance in all cognitive domains, loss of visual acuity and fields, and bilateral hearing loss were more likely to stop driving.

CONCLUSIONS

Age, sex, cognitive impairments, physical health, and depressive symptoms were associated with driving cessation in this cohort. By identifying potential driving cessation predictors, health care providers and families may better recognize these risk factors and begin the driving cessation discussion early.

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

Background

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

Aim

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

Methods

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

Results

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

Conclusion

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

Medicolegal Implications of Mild Neurocognitive Disorder

INTRODUCTION

The syndromes of mild cognitive impairment (MCI) or mild neurocognitive disorder (MiND), often prodromal to dementia (Major Neurocognitive Disorder), are characterized by acquired clinically significant changes in one or more cognitive domains despite preserved independence. Mild impairment has significant medicolegal consequences for an affected person and their care system. We review the more common etiologies of MiND and provide a systematic review of its medicolegal implications.

METHODS

We conducted a systematic review of the peer-reviewed English literature on medicolegal aspects of MCI or MiND using comprehensive search terms and expanding our review to include sources cited by these reports.

RESULTS

Impairment of memory, executive function, social cognition, judgment, insight or abstraction can alter an individual's abilities in a variety of areas that include decision making, informed consent, designation of a surrogate decision-maker such as a health care proxy, understanding and management of financial affairs, execution of a will, or safe driving.

CONCLUSION

Even mild cognitive impairment can have significant behavioral consequences. Clinicians can assist care partners and persons with MCI or MiND by alerting them to the medicolegal concerns that often accompany cognitive decline. Early recognition and discussion can help a care system manage medicolegal risk more effectively and promote thoughtful advance planning.

Driving Habits of Older Adults: A Population-based Study

OBJECTIVES

To describe factors associated with driving history, habits, and self-reported driving difficulties of 1982 older adults in a population-based survey.

SETTING

This was a community setting.

PARTICIPANTS

Age-stratified random population sample drawn from publicly available voter registration list.

DESIGN

Participants underwent assessments including cognitive testing and self-reported current and past driving status, instrumental activities of daily living, self-rated health, social supports, physical limitations, and depressive symptoms. We built multivariable logistic regression models to identify factors associated with never having driven, having ceased driving, and reporting difficulties while driving.

RESULTS

In the multivariable model, "never drivers" were more likely than "ever drivers" to be older, female, less educated and to leave home less frequently. Former drivers were significantly older, more likely to be women, have lower test performance in the cognitive domain of attention, have more instrumental activity of daily living difficulties, leave home less frequently and have visual field deficits in the right eye than current drivers. Current drivers with reported driving difficulties were more likely than those without difficulties to have lower test performance in attention but higher in memory, were more likely to report depressive symptoms and to have both vision and hearing loss.

CONCLUSION

Age, female sex, marital status, and education appear to be associated with driving cessation. Cognitive and functional impairments, mood symptoms and physical health also seem to influence driving cessation and reduction. Our findings may have implications for clinicians in assessing and educating their patients and families on driving safety.

Dementia-Friendly Neighborhood and the Built Environment: A Scoping Review

Background and Objectives

There has been a proliferation of research on dementia-friendly communities in recent years, particularly on interpersonal and social aspects. Nonetheless, the neighborhood built environment remains a co-constituent of the lived experience of people living with dementia (PLWD) that is amenable to interventions for health and well-being in the community. This scoping review presents a narrative synthesis of empirical research on dementia-friendly neighborhoods, with a focus on the built environment and its associated sociobehavioral aspects. Planning and design principles are distilled to identify research and policy implications.

Research Design and Methods

We reviewed 29 articles identified through a systematic search of AgeLine, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Global Health, Medical Literature Analysis and Retrieval System Online, and Scopus. Peer-reviewed articles that employed quantitative and/or qualitative methods in community settings were included.

Results

An equal number of studies focused on behavioral/psychosocial aspects of the built environment and assessment of specific environmental features. The former often used qualitative methods, whereas statistical methods were common in studies on discrete features of the neighborhood built environment. Few studies focused on rural contexts. Emerging research areas include interactions between dementia risk factors and neighborhood environments to support primary and secondary prevention.

Discussion and Implications

The body of literature needs expansion into planning and design fields to foster community participation of PLWD by optimizing environmental stimuli, minimizing environmental barriers, and engaging PLWD in dementia-friendly community initiatives. While evidence has accumulated on landmarks and social participation at the individual level, research at the community and policy levels is limited. This requires advanced mixed methods.

Association between Sarcopenia, Its Defining Indices, and Driving Cessation in Older Adults

OBJECTIVES

Driving a car is essential for older adults to support their activities of daily living and maintain their quality of life. However, physical function - which often declines with age - is a key factor to determine whether older adults can continue driving safely. As such, we sought to examine the association between sarcopenia and driving cessation in older adults.

DESIGN

A prospective study.

SETTING

A community setting.

PARTICIPANTS

We conducted a study including 2,874 older adult participants from the community (mean age: 71.0 ± 4.7 years [range: 65-93 years], women: 36.3%).

MEASUREMENTS

We assessed whether they were still driving at baseline examination as well as their degree of sarcopenia. Sarcopenia was assessed according to the clinical definition provided by the EWGSOP2 by measuring muscle mass, muscle strength, and physical performance represented by gait speed. Driving cessation was determined based on driving status at the initial visit and at a follow-up examination approximately 15 months later.

RESULTS

At the baseline assessment, there were 62 participants (2.2%) with confirmed sarcopenia and 23 participants (0.8%) with severe sarcopenia. Participants were classified into either the ongoing driving (n = 2816) or driving cessation (n = 58) group. Low muscle strength and low muscle mass were associated with driving cessation (low muscle strength: odds ratio [OR] 2.09, 95% confidence interval [CI] 1.13-3.87; low muscle mass: OR 2.00, 95% CI 1.04-3.85). Slow gait was not associated with driving cessation (OR 1.35, 95% CI 0.68-2.69). Significantly, sarcopenia was associated with driving cessation (confirmed sarcopenia: OR 4.48, 95% CI 1.63-12.29; severe sarcopenia: OR 4.46, 95% CI 1.21-16.41).

CONCLUSIONS

Sarcopenia is associated with an increased likelihood of driving cessation in community-dwelling older adults. Evaluation of physical function related to sarcopenia would be useful for judgment of the ability to drive safely among older adults.

Visual attention outperforms visual-perceptual parameters required by law as an indicator of on-road driving performance

PURPOSE

A variety of visual and psychometric tests have been developed for assessing on-road driving performance and fitness to drive. The diagnostic power of a state of the art psychometric test battery (Vienna Test System) combined with a set of standard visual parameters recommended for assessing fitness to drive is investigated using an on-road driving test. The study aimed to determine whether a psychometric test battery could predict older adults' on-road driving performance. The relevance of visual standards required by law is discussed.

METHODS

Vision impairment is more prevalent in later adulthood and many studies on visual and cognitive impact on driving safety and performance therefore focus on adults above 60 years of age. We therefore acquired an extensive set of driving-related visual and psychometric performance parameters in a group of elderly drivers (N = 84, median age 69, SD 6.6 years). Visual assessment included foveal acuity, perimetric field size, and dynamic aspects of peripheral vision (termed "PP") in the computer-based Vienna Test System (VTS; Schuhfried), as well as letter contrast thresholds in foveal and parafoveal vision in a separate setup. A selection of psychometric driving-aptitude tests that demonstrated the battery's capacity to predict aspects of driving performance and safety were further conducted on the VTS. Driving performance was assessed in a standardized on-road driving test. Two independent observers rated driving performance using a fixed scoring system assessing the number of driving errors in pre-defined traffic situations. In addition, globalized driving competence scores were assigned on a 6-point scale.

RESULTS

The test battery performed excellent in identification of good drivers but failed in the prediction of bad driving performance. Visual performance indicators required by German law were less indicative of driving ability than psychometric assessment. Selective and divided attention turned out to be much more important for predicting fitness to drive than either visual acuity, size of the visual field, or contrast sensitivity.

CONCLUSION

Predicting fitness to drive by means of visual and psychometric tests is an ambitious challenge. On the one hand sensitivity of a multi-disciplinary test-battery is too low to predict reliable driving ability in diagnostic settings which require an unambiguous interpretation of test results for individual drivers. Low sensitivity and low predictive values are incompatible with that objective. On the other hand, the results are valuable for a routine screening of fitness to drive. For that case, the assessment of attentional abilities in particular appears to be promising. Performance measures of divided and selective attention showed themselves to be the most predictive for fitness to drive in a sample pre-screened for clear visual deficits. Visual performance parameters required by law, in contrast, had no meaningful impact on driving performance, indicating a gap between mandatory regulations of state authorities and research results. Our results suggest that visual acuity tests designed for clinical diagnosis and monitoring of eye diseases should not at all be the choice for a screening of fitness to drive.

Alzheimer's Disease and its Related Dementias among Asian Americans, Native Hawaiians, and Pacific Islanders: A Scoping Review

BACKGROUND

The Asian American, Native Hawaiian, and Pacific Islander (AANHPI) aging population is rapidly growing and the burden of Alzheimer's disease and its related dementias (ADRD) will likely mirror this demographic growth. AANHPIs face significant barriers in obtaining timely ADRD diagnosis and services; yet little is known about ADRD in this population.

OBJECTIVE

The study objective is to conduct a systematic review on the published literature on ADRD among AANHPIs to identify gaps and priorities to inform future research and action plans.

METHODS

The systematic review was conducted following the PRISMA Protocol for Systematic Reviews. Co-author (TR), an experienced Medical Librarian, searched PubMed, EMBASE, PsycINFO, Cochrane Central of Clinical Trials, Ageline, and Web of Science for peer-reviewed articles describing ADRD among AANHPIs. The search was not limited by language or publication date. Each citation was reviewed by two trained independent reviewers. Conflicts were resolved through consensus.

RESULTS

The title/abstract and full texts of 1,447 unique articles were screened for inclusion, yielding 168 articles for analysis. Major research topics included prevalence, risk factors, comorbidities, interventions and outreach, knowledge and attitudes, caregiving, and detection tools. A limited number of studies reported on national data, on NHPI communities generally, and on efficacy of interventions targeting AANHPI communities.

CONCLUSION

To our knowledge, this is the first systematic review on ADRD among AANHPI populations. Our review provides a first step in mapping the extant literature on ADRD among this underserved and under-researched population and will serve as a guide for future research, policy, and intervention.

Being watched over by a conversation robot may enhance safety in simulated driving

INTRODUCTION

In an aging society that is more and more information-oriented, being able to replace human passengers' protective effects on vehicle drivers with those of social robots is both essential and promising. However, the effects of a social robot's presence on drivers have not yet been fully explored. Thus, using a driving simulator and a conversation robot, this experimental study had two main goals: (a) to find out whether social robots' anthropomorphic qualities (i.e., not the practical information the robot provides drivers) have protective effects by promoting attentive driving and alleviating crash risks; and (b) by what psychological processes such effects emerge.

METHOD

Participants were recruited from young (n = 38), the middle-aged (n = 39), and the elderly (n = 49) age groups. They were assigned to either the treatment group (simulated driving in a conversation robot's presence) or the control group (simulated driving alone), and their driving performance was measured. Mental states (peaceful, concentrating, and reflective) also were assessed in a post-driving questionnaire using our original scales.

RESULTS

Although the group of older participants did not experience protective effects (perhaps due to motion sickness), the young participants drove attentively, with the robot enhancing peace of mind. The protective effect was also observed among the middle-aged participants, and the verbal data analysis ascribed this to the robot's role of expressing sympathy, especially when the middle-aged drivers nearly had not-at-fault crashes, which caused them to be stressed. In conclusion, we discuss the practical implications of the results.

To reduce or to cease: A systematic review and meta-analysis of quantitative studies on self-regulation of driving

INTRODUCTION

The ability to remain safe behind the wheels can become arduous with aging, yet important for sustaining local travel needs. This review aimed to explore safe mobility issues involving older adults and gain a broad understanding of older drivers' self-regulatory driving practices and motivators behind such behavioral changes, including strategies adopted to reduce or cease driving while maintaining safe mobility.

METHODS

A systematic literature search was performed on 11 online databases for quantitative studies describing self-regulation of driving amongst older adults aged 60 years and above from database inception until December 2018. Data were described narratively and, where possible, data were pooled using random-effects meta-analysis.

RESULTS

Of the 1556 studies identified, 54 studies met the inclusion criteria and 46 studies were included in the meta-analyses. All included studies examined car drivers only. Older adults who were single or female were found to be at higher odds of driving cessation. Physical fitness, mental health, social influence, and support systems received by older adults were important driving forces influencing mobility and adjustments made in their travel patterns.

CONCLUSIONS

Driving self-regulation amongst older adults is a multifaceted decision, impacting mobility and mental health. Therefore, future interventions and support systems should not only create opportunities for retaining mobility for those who have ceased driving, but also promote better psychological and social well-being for regulators and for those who are transitioning from driving to non-driving status. Practical applications: (a) Engage and educate older adults about self-regulation, including strategies that can be adopted and non-car mobility options available. (b) Expand the research focus to explore potential interactions of factors facilitating or hindering the transition process to develop a more comprehensive framework of self-regulation. (c) Encourage ongoing research to formulate, monitor, and evaluate the effectiveness of policies and interventions implemented. (d) Expand the research horizon to explore and understand the perspectives of older adults from developing countries.

Driving Fitness in Different Forms of Dementia: An Update

BACKGROUND/OBJECTIVES

Most forms of dementia are associated with progressive cognitive and noncognitive impairments that can severely affect fitness to drive. Whether safe driving is still possible in the single case, however, is often difficult to decide and may be dependent on both severity and type of the respective dementia syndrome. Particularly in early disease stages, Alzheimer disease dementia (ADD) and different types of non-Alzheimer dementias, such as vascular dementia (VaD), frontotemporal dementia (FTD), dementia with Lewy bodies (DLB), and Parkinson disease dementia (PDD), might differentially affect fitness to drive.

DESIGN

To examine the effects of severity and type of dementia on driving fitness, we conducted a systematic review with qualitative narrative synthesis, involving different driving outcomes in different forms and stages of dementia.

SETTING

Literature research included MEDLINE and PsycINFO databases with a focus on the most relevant and recent publications on the topic.

PARTICIPANTS

The population of interest included older drivers in different stages of ADD and different forms of non-Alzheimer dementias (VaD, FTD, DLB, and PDD).

MEASUREMENTS

Narrative description of driving outcomes in the population of interest.

RESULTS

Overall, previous studies suggest that driving fitness is severely impaired in moderate and severe dementia, irrespective of the type of dementia. In milder disease stages, fitness to drive appears to be more severely impaired in non-Alzheimer dementias than in ADD, since the non-Alzheimer syndromes are not only associated with driving-relevant cognitive but noncognitive risk factors, such as behavioral or motor symptoms.

CONCLUSIONS

Based on these findings, practical recommendations are presented, including a risk evaluation for driving safety, depending on severity and type of different dementia syndromes. J Am Geriatr Soc 67:2186-2192, 2019.

Driving in the elderly in health and disease

Driving is a complex, multifaceted instrumental activity of daily living that has an independent influence on multiple health and well-being outcomes among older adults. Therefore, the benefits of driving to the individual must be balanced, through careful assessment and diagnosis, with the potential risk to self and others posed by a medically impaired driver. The influence of dementia changes substantially during the disease progression from very mild to mild, and driving is not advised for those who have progressed to the moderate stage of Alzheimer disease. Fortunately, validated high-quality screening instruments, including modern simulators and other technology aids, can help clinicians trichotomize risk (i.e., high, moderate, or low) and determine which patients need further evaluation by a driving specialist (e.g., those in the moderate range). Moreover, a body of evidence is building regarding the efficacy of certain intervention pathways to maintain current levels of driving performance among individuals with dementia, or at least slow its decline. Even with the progression of advanced driving technologies, understanding driving ability of patients with dementia will remain a critical challenge to clinicians for the foreseeable future.

Driving Cessation and Cognitive Dysfunction in Patients with Mild Cognitive Impairment

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

Adherence to driving cessation advice given to patients with cognitive impairment and consequences for mobility

BACKGROUND

Driving is related to social participation; therefore older drivers may be reluctant to cease driving. Continuation of driving has also been reported in a large proportion of patients with cognitive impairment. The aim of this study is to investigate whether patients with cognitive impairment adhere to driving cessation advice after a fitness-to-drive assessment and what the consequences are with regard to mobility.

METHODS

Patients with cognitive impairment (n = 172) participated in a fitness-to-drive assessment study, including an on-road driving assessment. Afterwards, patients were advised to either continue driving, to follow driving lessons, or to cease driving. Approximately seven months thereafter, patients were asked in a follow-up interview about their adherence to the driving recommendation. Factors influencing driving cessation were identified using a binary logistic regression analysis. Use of alternative transportation was also evaluated.

RESULTS

Respectively 92 and 79% of the patients adhered to the recommendation to continue or cease driving. Female gender, a higher Clinical Dementia Rating-score, perceived health decline, and driving cessation advice facilitated driving cessation. Patients who ceased driving made use of less alternative modes of transportation than patients who still drove. Nonetheless, around 40% of the patients who ceased driving increased their frequency of cycling and/or public transport use.

CONCLUSIONS

Adherence to the recommendations given after the fitness-to-drive assessments was high. Female patients were in general more likely to cease driving. However, a minority of patients did not adhere to driving cessation advice. These drivers with dementia should be made aware of the progression of their cognitive impairment and general health decline to facilitate driving cessation. There are large differences in mobility between patients with cognitive impairment. Physicians should discuss options for alternative transportation in order to promote sustained safe mobility of patients with cognitive impairment.

Update on the Risk of Motor Vehicle Collision or Driving Impairment with Dementia: A Collaborative International Systematic Review and Meta-Analysis

Guidelines that physicians use to assess fitness to drive for dementia are limited in their currency, applicability, and rigor of development. Therefore, we performed a systematic review to determine the risk of motor vehicle collisions (MVCs) or driving impairment caused by dementia, in order to update international guidelines on driving with dementia. Seven literature databases (MEDLINE, CINAHL, Embase, etc.) were searched for all research studies published after 2004 containing participants with mild, moderate, or severe dementia. From the retrieved 12,860 search results, we included nine studies in this analysis, involving 378 participants with dementia and 416 healthy controls. Two studies reported on self-/informant-reported MVC risk, one revealing a four-fold increase in MVCs per 1,000 miles driven per week in 3 years prior, and the other showing no statistically significant increase over the same time span. We found medium to large effects of dementia on driving abilities in six of the seven recent studies that examined driving impairment. We also found that persons with dementia were much more likely to fail a road test than healthy controls (RR: 10.77, 95% CI: 3.00-38.62, z = 3.65, p < 0.001), with no significant heterogeneity (χ² = 1.50, p = 0.68, I² = 0%) in a pooled analysis of four studies. Although the limited data regarding MVCs are equivocal, even mild stages of dementia place patients at a substantially higher risk of failing a performance-based road test and of demonstrating impaired driving abilities on the road.

Development of a decision-making tool for reporting drivers with mild dementia and mild cognitive impairment to transportation administrators

BACKGROUND

Driving in persons with dementia poses risks that must be counterbalanced with the importance of the care for autonomy and mobility. Physicians often find substantial challenges in the assessment and reporting of driving safety for persons with dementia. This paper describes a driving in dementia decision tool (DD-DT) developed to aid physicians in deciding when to report older drivers with either mild dementia or mild cognitive impairment to local transportation administrators.

METHODS

A multi-faceted, computerized decision support tool was developed, using a systematic literature and guideline review, expert opinion from an earlier Delphi study, as well as qualitative interviews and focus groups with physicians, caregivers of former drivers with dementia, and transportation administrators. The tool integrates inputs from the physician-user about the patient's clinical and driving history as well as cognitive findings, and it produces a recommendation for reporting to transportation administrators. This recommendation is translated into a customized reporting form for the transportation authority, if applicable, and additional resources are provided for the patient and caregiver.

CONCLUSIONS

An innovative approach was needed to develop the DD-DT. The literature and guideline review confirmed the algorithm derived from the earlier Delphi study, and barriers identified in the qualitative research were incorporated into the design of the tool.

Older Drivers and Driving Cessation

Driving is a complex and valued instrumental activity of daily living, which is associated with a person's freedom, independence and autonomy. With an ageing population and various cohort effects, the number of older drivers is increasing at a nearly exponential rate. While drivers over the age of 65 years have attracted media and research attention because of accident statistics, research has also begun to focus on the outcomes for older people giving up driving.

The outcomes of older people driving or giving up driving need to be considered by occupational therapists because of the potential impact on quality of life, life roles, independence and safety. Occupational therapists must be aware of legislation pertaining to older drivers and health professionals, although this is complicated by the fact that it differs between and within countries. This literature review aims to investigate the issues associated with older drivers and with driving cessation and the implications for occupational therapists.

The role of navigation instruction at intersections for older drivers and those with early Alzheimer's disease

AIMS

Our purpose was to explore the effect of navigation instruction on older drivers' driving performance at left turn intersections. Left turns at intersections are particularly complex because they require many perceptive and cognitive abilities under considerable time pressure.

METHODS

Fifty-four participants were recruited: 18 drivers with early-stage Alzheimer's disease (AD), 18 neurologically healthy older drivers and 18 younger individuals. Various cognitive processes were measured, and 9 left turn maneuvers with or without navigation instruction were evaluated during an in-traffic road test. The psychomotor, planning and decision-making components involved in left turn were also analyzed closely.

RESULTS

Only older drivers (both healthy drivers and those with AD) were negatively affected by navigation instruction during the maneuver. The planning and decision-making components were more likely to be affected by the navigation instruction.

CONCLUSION

This finding highlights the importance of carefully considering the use of navigation instructions when developing navigation systems. Adapting this instruction is necessary to simplify our understanding of the real-world driving environment and to avoid increasing the cognitive load of older drivers.

Students Explore Supportive Transportation Needs of Older Adults

Students in an undergraduate applied research in aging class learned about qualitative research methods by analyzing previously collected narratives. The interviews were with 32 participants who were national experts in senior transportation in the United States. The purpose of the study was to explore the specialized supportive mobility needs of community-residing older adults. The policy goal of the study was to expand the discussion on levels of assistance needed in senior transportation. The educational goal of the study was to expose undergraduate students to qualitative research methods, having them analyze transcripts and audio recordings. In preparation for the research, students reviewed the current literature in transportation and aging and learned that the ability to get to where you want to go, when you want to go there, is a key factor for aging-in-place in our communities. When that ability is compromised, the informal network of family and friends may not be a sustainable transportation option. Students were divided into three analysis groups by the domains of challenges, strategies, and policies and coded themes and subthemes through an iterative process. An important subtheme that emerged was the connection of community mobility to health care outcomes.

The Older Driver with Cognitive Impairment: Perceptions of Driving Ability and Results of a Behind the Wheel Test

Older adult drivers with cognitive impairment pose a potential safety risk to themselves and others. Providers are often uncertain about when to request a formal evaluation of driving ability, leaving subjective reports of concerns by the patient or family as common initiators of objective driving evaluation referral. This observational study evaluated the correspondence of patient and caregiver report of driving concerns relative to objective behind-the-wheel (BTW) testing. Data were analyzed from occupational therapy driving evaluations of older adult U.S. Veterans referred from cognitive disorder specialty clinics between 2005 and 2015 (n = 151). Driving ability was evaluated with a pre-testing interview of the patient and a knowledgeable caregiver, followed by objective BTW testing. Patients referred had a mean age of 77.6 (SD = 8.1) years, were 97% male, and 98% white. Results demonstrated that most patients are evaluated for driving concerns far too late, with only 3% of the sample being evaluated as independent to drive without restrictions, and 38% recommended to retire from driving. Although both patients and caregivers denied specific driving concerns (obey signs and lights) relative to objective testing, caregiver concerns were greater than their respective patient’s concerns (p < 0.001) and were associated with road test outcome (p = 0.001).

Mobility behaviour and driving status of patients with mental disorders - an exploratory study

BACKGROUND

Driving is an important activity of daily life and an integral part of mobility. However, impact of mental illness on road mobility is widely unexplored.

METHOD

Driving status in 1497 psychiatric inpatients (PPs) and a clinical control group of 313 neurological inpatients (NPs) was investigated using a brief questionnaire.

RESULTS

67% of PPs (89% NPs) reported to have a valid driver's licence and 77% of them (92% NPs) reported to regularly use their cars. Within driver's license holders, patients with organic mental disorder (32%), substance dependence (37%) and psychotic disorder (40%) had the lowest proportion of current drivers. Higher educational qualification (odds ratio [OR] from 2.978 to 17.036) and being married/partnered (OR 3.049) or divorced (OR 4.840) significantly advanced the probability of possession of a driving license. Predictive factors for driving cessation were being female, an older age, drawing a pension and having an organic mental disease or schizophrenic disorder.

CONCLUSION

Mental disease has a negative impact on driving status and this is especially true for illnesses frequently being accompanied by distinct cognitive impairments. Factors predicting road mobility elucidate the strong relationship with psychosocial status indicating that recovery of driving competence should be an integral goal of treatment strategies.

Mobility and safety issues in drivers with dementia

Although automobiles remain the mobility method of choice for older adults, late-life cognitive impairment and progressive dementia will eventually impair the ability to meet transport needs of many. There is, however, no commonly utilized method of assessing dementia severity in relation to driving, no consensus on the specific types of assessments that should be applied to older drivers with cognitive impairment, and no gold standard for determining driving fitness or approaching loss of mobility and subsequent counseling. Yet, clinicians are often called upon by patients, their families, health professionals, and driver licensing authorities to assess their patients' fitness-to-drive and to make recommendations about driving privileges. We summarize the literature on dementia and driving, discuss evidenced-based assessments of fitness-to-drive, and outline the important ethical and legal concerns. We address the role of physician assessment, referral to neuropsychology, functional screens, dementia severity tools, driving evaluation clinics, and driver licensing authority referrals that may assist clinicians with an evaluation. Finally, we discuss mobility counseling (e.g. exploration of transportation alternatives) since health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance our patients' social connectedness and quality of life, while meeting their psychological and medical needs and maintaining personal and public safety.

Consensus statements on driving for persons with dementia

The presence of dementia can have a profound effect on a person's capacity for driving, and will lead to eventual cessation of driving and reliance on alternative transportation options. This paper offers evidence and discussion that affirm eight consensus statements related to drivers with dementia and the impact of dementia on the driving task. These statements offer guidance for occupational therapy practitioners when addressing driving and community mobility, a valued instrumental task of daily living.

Driving continuity in cognitively impaired older drivers

AIM

Cognitive impairment can negatively affect driving performance and increase the risk of driving errors, leading to vehicle crashes. We used a population-based survey to identify the prevalence of cognitive impairments in older drivers.

METHODS

A total of 10,073 older adults were enrolled in the National Center for Geriatrics and Gerontology - Study of Geriatric Syndromes. We characterized general cognitive impairment using the Mini-Mental State Examination (MMSE). We also used the National Center for Geriatrics and Gerontology-Functional Assessment Tool, which includes six tasks to assess word list memory, logical memory, attention and executive function, processing speed, and visuospatial skill.

RESULTS

Just 15% of older women with moderate cognitive decline (MMSE ≤20) drove, whereas 61% of older men with moderate cognitive decline drove. Cognitively normal participants (MMSE score 27 and over) scored significantly better on six cognitive tests compared with those with mild (MMSE score 21-26) or moderate cognitive decline, and those in the mild cognitive decline group scored significantly better on six cognitive tests than those in the moderate cognitive decline group.

CONCLUSION

A total of 61% of older men with moderate cognitive decline did not cease driving. These older drivers showed poor cognitive performance in multiple domains compared with those with normal and mild cognitive decline. Further studies are required to clarify the relationships between cognitive decline and car crashes in these high-risk populations.

Family reports of medically impaired drivers in Missouri: cognitive concerns and licensing outcomes

This study investigated reasons why older adults (n=689) were reported to the Driver License Bureau, Missouri Department of Revenue, by family members as potentially unfit to drive with an emphasis on cognitive concerns and associated licensing outcomes. A total of 448 drivers were reported to have some cognitive issue; common symptoms included confusion, memory loss, and becoming lost while driving. Diagnostic labels (Alzheimer's disease (AD), cognitive impairment/dementia, brain injury/insult) were listed for 365 cases. A physician evaluation is required for license review. Of those with a diagnostic label, half (51%, n=187) failed to submit this evaluation and almost all were de-licensed immediately. Of those evaluated by a physician, diagnostic agreement between family members and physicians was high for specific conditions (100% for AD, 97% for acute brain injury), and less so for cognitive impairment/dementia (75%). This latter finding suggests that physicians and family members may understand cognitive symptoms differently. Whether cognitively impaired or not, few family reported drivers in this sample (∼2%) retained a valid license. Family members may be in the best position to recognize when medical-functional deficits impact on driving safety, and physicians and driver licensing authorities would do well to take their observations into account with respect to older driver fitness.

Automobile driving in older adults: factors affecting driving restriction in men and women

OBJECTIVES

To identify factors associated with driving restriction in elderly men and women.

DESIGN

Prospective cohort study of French drivers from 2003 to 2009.

SETTING

The Three-City Cohort of Bordeaux, a prospective study of 2,104 people aged 65 and older.

PARTICIPANTS

Five hundred twenty-three drivers with a mean age of 76 (273 male, 250 female).

MEASUREMENTS

Sociodemographic characteristics, driving habits, health variables, cognitive evaluation and dementia diagnosis. Predementia was defined as no dementia at one follow-up and dementia at the next follow-up.

RESULTS

Over the 6-year period, 54% of men and 63% of women stopped driving or reduced the distance they drove. Predementia, Parkinson's disease, older age, and a high number of kilometers previously driven were common restriction factors in both sexes. Prevalent dementia, depressive symptomatology, a decline in one or more instrumental activities of daily living, and poor visual working memory were specific factors in men. In women, low income, fear of falling, slow processing speed, and severe decline in global cognitive performance all affected driving restriction.

CONCLUSION

Older women restricted their driving activity more than older men, regardless of the number of kilometers previously driven, physical health, and cognitive status. Factors affecting driving restriction differed according to sex, and women were more likely to stop driving than men in the period preceding a dementia diagnosis.

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.

Effect of cognitive status on self-regulatory driving behavior in older adults: an assessment of naturalistic driving using in-car video recordings

Previous findings that older drivers engage in strategic self-regulatory behaviors to minimize perceived safety risks are primarily based on survey reports rather than actual behavior. This study analyzed in-car video recording of naturalistic driving of 18 patients with Alzheimer disease (AD) and 20 age-matched controls in order to (1) characterize self-regulatory behaviors engaged by older drivers and (2) assess how behaviors change with cognitive impairment. Only participants who were rated "safe" on a prior standardized road test were selected for this study. Both groups drove primarily in environments that minimized the demands on driving skill and that incurred the least risk for involvement in major crashes. Patients with AD displayed further restrictions of driving behavior beyond those of healthy elderly individuals, suggesting additional regulation on the basis of cognitive status. These data provide critical empirical support for findings from previous survey studies indicating an overall reduction in driving mobility among older drivers with cognitive impairment.

Driving cessation and dementia: results of the prospective registry on dementia in Austria (PRODEM)

OBJECTIVE

To assess the influence of cognitive, functional and behavioral factors, co-morbidities as well as caregiver characteristics on driving cessation in dementia patients.

METHODS

The study cohort consists of those 240 dementia cases of the ongoing prospective registry on dementia in Austria (PRODEM) who were former or current car-drivers (mean age 74.2 (±8.8) years, 39.6% females, 80.8% Alzheimer's disease). Reasons for driving cessation were assessed with the patients' caregivers. Standardized questionnaires were used to evaluate patient- and caregiver characteristics. Cognitive functioning was determined by Mini-Mental State Examination (MMSE), the CERAD neuropsychological test battery and Clinical Dementia Rating (CDR), activities of daily living (ADL) by the Disability Assessment for Dementia, behavior by the Neuropsychiatric Inventory (NPI) and caregiver burden by the Zarit burden scale.

RESULTS

Among subjects who had ceased driving, 136 (93.8%) did so because of "Unacceptable risk" according to caregiver's judgment. Car accidents and revocation of the driving license were responsible in 8 (5.5%) and 1(0.7%) participant, respectively. Female gender (OR 5.057; 95%CI 1.803-14.180; p = 0.002), constructional abilities (OR 0.611; 95%CI 0.445-0.839; p = 0.002) and impairment in Activities of Daily Living (OR 0.941; 95%CI 0.911-0.973; p<0.001) were the only significant and independent associates of driving cessation. In multivariate analysis none of the currently proposed screening tools for assessment of fitness to drive in elderly subjects including the MMSE and CDR were significantly associated with driving cessation.

CONCLUSION

The risk-estimate of caregivers, but not car accidents or revocation of the driving license determines if dementia patients cease driving. Female gender and increasing impairment in constructional abilities and ADL raise the probability for driving cessation. If any of these factors also relates to undesired traffic situations needs to be determined before recommendations for their inclusion into practice parameters for the assessment of driving abilities in the elderly can be derived from our data.

Caregiver and noncaregiver attitudes toward dementia screening

OBJECTIVES

To compare attitudes toward dementia screening of older adults with and without an experience of dementia caregiving.

DESIGN

A cross-sectional study.

SETTING

Primary care clinics in Indianapolis, Indiana.

PARTICIPANTS

Eighty-one participants with dementia caregiving experience (CG) and a random sample of 125 participants without dementia caregiving experience (NCG).

MEASUREMENTS

Attitudes of dementia screening, including acceptance of dementia screening and its perceived harms and benefits, as determined according to the Perceptions Regarding Investigational Screening for Memory in Primary Care questionnaire.

RESULTS

After adjusting for age, race, sex, and education, CGs had a lower dementia screening acceptance mean score (53.9 vs 60.6; P=.03) and a higher perceived suffering score (61.6 vs 55.9, P=.04) than NCGs, but there were no differences in perceived benefits of dementia screening (72.8 vs 69.0; P=.50), perceived stigma (32.9 vs 37.5; P=.12), and perceived negative effect on independence (47.6 vs 54.0; P=.20). The top three barriers to screening identified by both groups were emotional suffering by the family (86% of CGs and 75% of NCGs), loss of driving privileges (75% of CGs and 78% of NCGs), and becoming depressed (64% of CGs and 43% of NCGs).

CONCLUSION

The experience of being a dementia caregiver may influence one's own attitude about accepting dementia screening for oneself.

Conceptual evolution in Alzheimer's disease: implications for understanding the clinical phenotype of progressive neurodegenerative disease

Over the past several decades, our understanding of Alzheimer's disease (AD) has seen an evolution from the dichotomous concept of normal versus AD in the dementia state to a more accurate and complete appreciation of AD as a progressive disorder with clinical, biological, and pathological features occurring along a continuum from normal to end-stage disease. Integrating our understanding of the relationships and interplay between the clinical, biological, and pathological features of AD may allow the identification of AD at even preclinical, completely asymptomatic stages of the disease. This review attempts to summarize the clinical stages of AD in terms of epidemiology, historical evolution of disease stage diagnoses, cognitive/neuropsychologic features, psychiatric/behavioral manifestations, and functional decline in the context of our developing understanding of the biological processes responsible for the pathogenesis of AD described in detail in the accompanying articles.

The older adult driver with cognitive impairment: "It's a very frustrating life"

Although automobiles remain the transportation of choice for many older adults, late-life cognitive impairment and dementia often impair the ability to drive safely. However, there is no commonly used method of assessing dementia severity in relation to driving, no consensus on the assessment of older drivers with cognitive impairment, and no gold standard for determining driving fitness. Yet clinicians are called on by patients, their families, other health professionals, and often their state's Department of Motor Vehicles to assess their patients' fitness to drive and to make recommendations about driving privileges. This article describes the challenges of driving with cognitive impairment for both the patient and caregiver, summarizes the literature on dementia and driving, discusses evidence-based assessment of fitness to drive, and addresses important ethical and legal issues. It also describes the role of physician assessment, referral for neuropsychological testing, screening for functional ability, tools to assess dementia severity, driving evaluation clinics, and Department of Motor Vehicles referrals that may assist with evaluation. Lastly, it discusses mobility counseling (eg, exploration of transportation alternatives), because health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance patients' social connectedness and quality of life while meeting their psychological and medical needs and maintaining personal and public safety.

Cognitive impairment and driving: A review of the literature

Although some drivers with mild dementia may continue to drive after the condition has been diagnosed, the ability to drive a motor vehicle safely is eventually lost as the disease progresses. Clinicians involved in dementia care are often asked to make an assessment on whether a patient is fit to drive, even though they often lack basic knowledge and formal training in this area. The purpose of this review was to identify the factors that may differentiate safe from unsafe drivers with cognitive impairment and to discuss management strategies. Isolated information about staging measures or particular cognitive tests was found to be insufficient for decision making. Driving fitness counseling for patients with cognitive impairment requires a solid knowledge base, comprehensive assessment and thoughtful communication.

Driving Retirement in Older Adults with Dementia

In order to characterize the driving and mobility status of older adults with dementia, a questionnaire was mailed to 527 informants; 119 were returned. The majority of patients were diagnosed with Dementia of the Alzheimer's Type. Only 28% were actively driving at the time of survey. Informants rated 53% of current or recently retired drivers as potentially unsafe. Few informants reported using community/educational resources. Individuals with progressive dementia retire from driving for differing reasons, many subsequent to family recognition of impaired driving performance. Opportunities for education and supportive assistance exist but are underutilized.

Driving cessation and self-reported car crashes in older drivers: the impact of cognitive impairment and dementia in a population-based study

The complexity of driving activity has incited numerous developed countries to initiate evaluative procedures in elderly people, varying according to first evaluation age, frequency, and screening tools. The objective of this paper is to improve the knowledge of the driving cessation process regarding factors associated with crash involvement. Driving cessation and self-reported crashes during the past 5 years were analyzed with multivariate models, in a cross-sectional study including a population-based sample of 1051 drivers aged 65 years and more. Visual trouble, Parkinson disease, dementia, and stroke history were associated with driving cessation. Future dementia was associated with self-reported crashes only. Attentional and executive deficits were associated with both outcomes. The detection of attentional and executive deficits should be included in driving evaluation procedures to improve awareness of these deficits by older drivers.

Driving and dementia in older adults: Implementation and evaluation of a continuing education project

PURPOSE

We aimed to develop and evaluate a multimedia workshop curriculum to educate physicians and other health professionals about (a) driving-related assessment in older adults with dementia, and (b) strategies to encourage driving retirement for impaired individuals.

DESIGN AND METHODS

A curriculum developed by the Older Drivers Project of the American Medical Association was expanded for presentation by a multidisciplinary team. One pilot and seven test workshops were offered. A program evaluation method-testing knowledge, confidence, attitudes, and practice behaviors-was employed at four points in time: T1 (Time 1; pretest focusing on the previous 12 months), T2 (Time 2; same-day post-test), T3 (Time 3; post-test at 3 months), and T4 (Time 4; post-test at 12 months).

RESULTS

At T1, participants (N = 147) expressed high agreement that an assessment of driving ability is an important issue in clinical dementia care, but they reported low knowledge of assessment strategies, resources, and state reporting requirements. Modest gains in knowledge and confidence were demonstrated at both T3 (n = 93) and T4 (n = 63). In addition, the frequency of driving-related practice behaviors (i.e., incorporation of driving-related questions into clinical evaluation, chart documentation, reporting of impaired drivers) had increased significantly by T3 and T4.

IMPLICATIONS

The results indicate that a focused workshop curriculum, with practical and immediate applications to care, can motivate measurable changes in clinical practice. Once they are informed, health professionals can address issues of driving ability in older patients with dementia and, with the support of available resources, encourage impaired individuals to retire from driving for the safety of everyone on the road.

Systematic Review of Driving Risk and the Efficacy of Compensatory Strategies in Persons with Dementia

OBJECTIVES

To determine whether persons with dementia are at greater driving risk and, if so, to estimate the magnitude of this risk and determine whether there are efficacious methods to compensate for or accommodate it.

DESIGN

Systematic review of the literature.

SETTING

Case-control studies.

PARTICIPANTS

Drivers with a diagnosis of dementia.

MEASUREMENTS

Most studies used state and caregiver reported crash rates, performance-based road tests, and driving simulator evaluations as their outcome measures.

RESULTS

Twenty-three studies were included. Drivers with dementia universally exhibited poorer performance on road tests and simulator evaluations, although only one study using an objective measure of motor vehicle crashes was able to show that drivers with dementia were involved in more crashes than control subjects. No studies were found that examined the efficacy of methods to compensate for or accommodate their worse driving performance.

CONCLUSION

Drivers with dementia are poorer drivers than cognitively normal drivers, but studies have not consistently demonstrated higher crash rates. Clinicians and policy makers must take these findings into account when addressing issues pertinent to drivers with a diagnosis of dementia.

Predictors of driving cessation in mild-to-moderate dementia

BACKGROUND

Although physicians in most provinces are mandated to report patients whose driving ability is impaired by illness, little is known about dementia-related factors associated with driving cessation. The purpose of our study was to explore factors that may affect the likelihood of driving cessation in a sample of elderly, community-dwelling patients with dementia.

METHODS

A 3-year prospective study, the Canadian Outcomes Study in Dementia (COSID) has enrolled 883 patients with mild-to-moderate dementia at 32 centres across Canada. Assessment tools included the Mini-Mental State Examination (MMSE) for cognition, the Global Deterioration Scale (GDS) for staging (severity), the Functional Autonomy Measurement System (SMAF) for function, and the Neuropsychiatric Inventory (NPI) for behaviour. Factors associated with the decision to quit driving after the baseline assessment were tested with Cox survival analysis.

RESULTS

Of 719 subjects who were or had been drivers, 203 (28.2%) were still driving at baseline. Over an observation period that averaged 23 months, 97 (48.5%) of 200 patients quit driving. Factors predictive of driving cessation included GDS (hazard ratio [HR] 1.68, 95% confidence interval [CI] 1.15-2.45), MMSE score (HR 0.90, 95% CI 0.83-0.97) and NPI findings (HR 1.63 for presence of > or = 3 behaviours, 95% CI 1.01-2.62). Among the NPI behaviours, when they were analyzed separately, agitation led to a decreased likelihood of driving cessation (p = 0.019), whereas apathy (p = 0.031) and hallucinations (p = 0.050) led to an increased likelihood.

INTERPRETATION

Cognitive impairment and behaviours such as agitation, apathy and hallucinations were significant predictors of driving cessation in patients with a mild to moderate degree of dementia. These findings should be considered when one counsels patients and their families.

Driving and dementia of the Alzheimer type: beliefs and cessation strategies among stakeholders

PURPOSE

Although driving by persons with Alzheimer's disease (AD) is an important public health concern, we know little about the attitudes and perceptions of key stakeholders regarding driving safety in these individuals or the factors that precipitate and influence driving assessment and cessation decisions.

DESIGN AND METHODS

We convened 10 focus groups composed of persons intimately involved in driving decisions for older adults to identify and compare beliefs and perceptions concerning AD and driving and to identify effective strategies to limit or cease unsafe driving. The 68 focus-group participants included health professionals, transportation and law-enforcement professionals, current and former drivers with AD, and family caregivers of current and former drivers with the disease.

RESULTS

With few exceptions, participants said that a diagnosis of very mild AD alone did not preclude driving. Most regarded family members as pivotal in monitoring and managing unsafe driving and recognized their need for institutional and medical support, especially support from physicians in counseling and evaluation of health-related fitness of older drivers. Members of each group acknowledged their own roles and responsibilities in driving decisions and described difficulties they experienced in making assessments and implementing decisions to limit or stop the driving of given individuals with AD.

IMPLICATIONS

Education of families, professionals, and transportation specialists is needed to understand the influence of AD severity on driving abilities, identify problem driving behaviors, make appropriate referrals of unsafe drivers, and access available resources for drivers with AD and those most responsible for their safety.

Driving Cessation in Older Adults With Dementia of the Alzheimer's Type

The psychometric profile of 143 drivers with dementia who stopped driving did not differ from that of 58 individuals with dementia of similar severity who still drove. The reasons given for driving cessation by drivers with dementia as reported by a collateral source are reported.

La conduite automobile chez les sujets âgés

Impairment of cognitive performance is associated with an excess risk of accidents. Adaptation of driving behavior in subjects with benign cognitive disorders reduces risk of automobile accidents. Cessation of driving or at least not driving alone limits the excess accident risk for drivers with dementia. Alterations in visual field and acuity increase risk of traffic accidents. Drugs affecting vigilance and neurological, cardiovascular and osteoarticular disorders increase accident risk. Screening for these disorders in the elderly is a necessary public safety measure.