Assessment of driving-related skills prediction of unsafe driving in older adults in the office setting

Exploratory` study on driving ability of people with schizophrenia: Relationships among cognitive function, symptoms, and brain activity

BACKGROUND

This study aimed to examine the relationships among cognitive function, symptoms, prefrontal activation, basic driving skills, and collision risk factors using a hazard prediction task in simulated driving.

METHODS

Participants included 42 people with schizophrenia aged 20-50 years who had actual experience of driving. The Trail making test (TMT) A and TMTB, Wechsler Memory Test-Revised (WMS-R), and Zoo Map test (ZMT) were used to evaluate cognitive function. Positive and negative syndrome scale was used to assess symptoms, and brain activity was assessed by evaluating cerebral blood flow during a visual working memory task using functional near-infrared spectroscopy. Driving tasks that tested basic skills, such as brake reaction, steering wheel skills, and standard deviation of lateral position, were analyzed using multiple regression analysis. Three hazard prediction tasks were performed using discriminant analysis.

RESULTS

Brake reaction associated with cerebral blood flow and TMT-A. Steering wheel skills associated with WMS-R, driving experience and depression. Significant differences were found between the collision and noncollision groups in the hazard prediction task, as shown by the ZMT, driving experience, and brake reaction.

CONCLUSIONS

Brain activity in the frontal lobe during a desk task may be useful data for driving assessment. Assessment of processing speed and learning ability may be particularly important in the evaluation of basic skills for safe driving. In addition, for people with schizophrenia, foresight, as represented by proactive planning, experience, and quick braking may be an essential characteristic to anticipate danger and react quickly enough to avoid collisions.

Visual-Motor Processing Speed and Reaction Time Differences between Medically-At-Risk Drivers and Healthy Controls

This cross-sectional study compared visual-motor processing speed and reaction times between medically-at-risk drivers and normal controls to determine if the time in seconds distinguished between drivers who pass, fail, or need restrictions based on a road test. The medically-at-risk drivers' data (N = 35, 28-89 years) were collected as part of a comprehensive driving evaluation and coded by diagnosis (e.g., cognitive, neurological, medical) and driving outcome. The healthy control (N = 121, 21-79 years) data were collected in previous studies. The Vision Coach™ Full Field 60 task was used to collect reaction times in seconds between the two groups. Independent t-tests showed a significant difference (p < .001) in trial times between healthy controls and medically-at-risk adults. No significant difference (p = .141) was found between the three diagnoses groups. The resulting scores from the Vision Coach™ demonstrated a significant different (p < .001) between those who were determined fit to drive without restrictions and those who were determined not fit to drive after a comprehensive driving evaluation, showing the potential to be used as a screening tool for determining driving risk.

Towards the Validation of an Observational Tool to Detect Impaired Drivers-An Online Video Study

Abuse of alcohol and other drugs is a major risk factor at work. To reduce this risk, workplace drug testing is performed in transportation and other industries. VERIFY, an observational method, is one of the key elements in a procedure adopted by the police of the canton of Zurich, Switzerland, for detecting impaired drivers. The observational method has been successfully applied by adequately trained police officers since 2014. The aim of this study is to examine the interrater reliability of the observational method, the effect of training in use of the method, and the role of having experience in the police force and traffic police force on the outcome when rating a driver’s impairment. For this purpose, driver impairment in staged road traffic controls presented in videos was rated by laypeople (n = 81), and police officers without (n = 146) and with training (n = 172) in the VERIFY procedure. In general, the results recorded for police officers with training revealed a moderate to very good interrater reliability of the observational method. Among the three groups, impaired drivers were best identified by officers with training (ranging between 82.6% and 89.5% correct identification). Trained officers reported a higher impairment severity of the impaired drivers than the other two groups, indicating that training increases sensitivity to signs of impairment. Our findings also suggest that online video technology could be helpful in identifying impaired drivers. Trained police officers could be connected to a road traffic control to make observations via live video. By this method efficiency and reliability in detecting abuse of alcohol and other drugs could be improved. Our findings also apply to workplace drug testing in general.

Driving Performance and Its Correlation with Neuropsychological Tests in Senior Drivers with Cognitive Impairment in Japan

BACKGROUND

With the rapid aging of the population, the issue of driving by dementia patients has been causing increasing concern worldwide.

OBJECTIVE

To investigate the driving difficulties faced by senior drivers with cognitive impairment and identify the specific neuropsychological tests that can reflect specific domains of driving maneuvers.

METHODS

Senior drivers with cognitive impairment were investigated. Neuropsychological tests and a questionnaire on demographic and driving characteristics were administered. Driving simulator tests were used to quantify participants' driving errors in various domains of driving.

RESULTS

Of the 47 participants, 23 current drivers, though they had better cognitive functions than 24 retired drivers, were found to have impaired driving performance in the domains of Reaction, Starting and stopping, Signaling, and Overall (wayfinding and accidents). The parameters of Reaction were significantly related to the diagnosis, and the scores of MMSE, TMT-A, and TMT-B. As regards details of the driving errors, "Sudden braking" was associated with the scores of MMSE (ρ= -0.707, p < 0.01), BDT (ρ= -0.560, p < 0.05), and ADAS (ρ= 0.758, p < 0.01), "Forgetting to use turn signals" with the TMT-B score (ρ= 0.608, p < 0.05), "Centerline crossings" with the scores of MMSE (ρ= -0.582, p < 0.05) and ADAS (ρ= 0.538, p < 0.05), and "Going the wrong way" was correlated with the score of CDT (ρ= -0.624, p < 0.01).

CONCLUSION

Different neuropsychological factors serve as predictors of different specific driving maneuvers segmented from driving performance.

A Nationwide Population-Based Study on the Association between Land Transport Accident and Peripheral Vestibular Disorders

This case–control study aimed to investigate the association of peripheral vestibular disorders (PVD) with subsequent land transport accidents. Data for this study were obtained from Taiwan’s National Health Insurance (NHI) dataset. We retrieved 8704 subjects who were newly found to have land transport accidents as cases. Their diagnosis date was used as their index date. Controls were identified by propensity score matching (one per case, n = 8704 controls) from the NHI dataset with their index date being the date of their first health service claim in 2017. Multiple logistic regressions were performed to calculate the prior PVD odds ratio of cases vs. controls. We found that 2.36% of the sampled patients had been diagnosed with PVD before the index date, 3.37% among cases and 1.36% among controls. Chi-square test revealed that there was a significant association between land transport accident and PVD (p < 0.001). Furthermore, multiple logistic regression analysis suggested that cases were more likely to have had a prior PVD diagnosis when compared to controls (OR = 2.533; 95% CI = 2.041–3.143; p < 0.001). After adjusting for age, gender, hypertension, diabetes, coronary heart disease, and hyperlipidemia, cases had a greater tendency to have a prior diagnosis of PVD than controls (OR = 3.001, 95% CI = 2.410–3.741, p < 0.001). We conclude that patients with PVD are at twofold higher odds for land transport accidents.

Functional Assessment of Driving Capacity of Older Drivers Compared with Non-older Drivers Using Clinical Evaluations and Driving Simulations

Background

This study used various tools, including a self-assessment questionnaire, the Clinical Assessment of Driver-Related Skills (CADReS), and a driving simulation, to discriminate between older and non-older drivers.

Methods

We evaluated driving habits, driving-related health behaviors, and morbidities using a self-assessment questionnaire and examined visual, motor, and cognitive functions using the CADReS and a vehicle simulator of four junction scenarios that are typical of accidents involving older drivers. The areas under the receiver operating characteristic curves (AUCs) were calculated to compare the age-related discriminating ability of these tools between older (≥65 years) and non-older participants.

Results

Thirty of the 40 participants (75%) were older. Older drivers were slower than non-older drivers according to the rapid walking pace (8.0 vs. 6.1 seconds), and their cognitive function was poorer based on the trail-making test (117 vs. 51 seconds). While driving on the vehicle simulator, the rate of violating traffic rules was higher and the maximal velocity was slower in the older group than in the non-older group. The AUC values for CADReS and driving simulation outcomes ranged from 0.59 to 0.95, while the rapid walking pace, trail-making test, and velocity of the left turn at an acute junction in the dark showed high discriminatory power (AUC>0.9).Conclusions: The rapid walking pace and trail-making test in CADReS, as well as the driving simulation, were useful tools to discriminate between older and non-older drivers.

Assessing fitness to drive in older adults: Validation and extension of an economical screening tool

OBJECTIVES

Due to demographic change, the number of older drivers with impaired driving skills will increase in the next decades. The current study aimed at the validation and extension of the screening tool Safety Advice For Elderly drivers (SAFE) that allows a cost-efficient assessment of driving-related risk factors in older drivers.

METHOD

Seventy-four older drivers aged ≥65 years (M = 77 years) recruited from the general population were included in this prospective observational study. Receiver operating characteristic curve (ROC) and hierarchical logistic regression analyses were utilized to examine whether the SAFE and further evidence-based driving-related factors may allow the differentiation between fit and unfit older drivers assessed in standardized on-road driving assessments.

RESULTS

ROC analyses revealed significant diagnostic accuracy of the number of SAFE risk factors in differentiating between fit and unfit older drivers (AUC = 0.71). A stepwise logistic regression model revealed that adding further evidence-based risk factors into the SAFE clearly improved diagnostic accuracy (AUC = 0.85).

DISCUSSION

The current study shows that the risk assessed by the SAFE predicts on-road driving fitness in older adults. However, the results also suggest a need for a modification of the SAFE by the inclusion of additional evidence-based risk factors. With sensitivity and specificity scores of about 90 % and 75 %, this modified version may be more suitable for clinical use.

Assessing Fitness-To-Drive among Older Drivers: A Comparative Analysis of Potential Alternatives to on-Road Driving Test

To enable older drivers to maintain mobility without endangering public safety, it is necessary to develop more effective means of assessing their fitness-to-drive as alternatives to an on-road driving test. In this study, a functional ability test, simulated driving test, and on-road driving test were carried out for 136 older drivers. Influencing factors related to fitness-to-drive were selected based on the correlation between the outcome measure of each test and the pass/fail outcome of the on-road driving test. Four potential alternatives combining different tests were considered and three modeling techniques were compared when constructing the fitness-to-drive assessment model for the elderly. As a result, 92 participants completed all of the tests, of which 61 passed the on-road driving test and the remaining 31 failed. A total of seven influencing factors from all types of tests were selected. The best model was trained by the technique of gradient boosted machine using all of the seven factors, generating the highest accuracy of 92.8%, with sensitivity of 0.94 and specificity of 0.90. The proposed fitness-to-drive assessment method is considered an effective alternative to the on-road driving test, and the results offer a valuable reference for those unfit-to-drive older drivers to either adjust their driving behavior or cease driving.

Psychometric Tests and Spatial Navigation: Data From the Baltimore Longitudinal Study of Aging

Spatial cognition is the process by which individuals interact with their spatial environment. Spatial cognition encompasses the specific skills of spatial memory, spatial orientation, and spatial navigation. Prior studies have shown an association between psychometric tests of spatial ability and self-reported or virtual measures of spatial navigation. In this study, we examined whether psychometric spatial cognitive tests predict performance on a dynamic spatial navigation task that involves movement through an environment. We recruited 151 community-dwelling adult participants [mean (SD) age 69.7 (13.6), range 24.6–93.2] from the Baltimore Longitudinal Study of Aging (BLSA). Spatial navigation ability was assessed using the triangle completion task (TCT), and two quantities, the angle and distance of deviation, were computed. Visuospatial cognitive ability was assessed primarily using the Card Rotations Test. Additional tests of executive function, memory, and attention were also administered. In multiple linear regression analyses adjusting for age, sex, race, and education, cognitive tests of visuospatial ability, executive function, and perceptual motor speed and integration were significantly associated with spatial navigation, as determined by performance on the TCT. These findings suggest that dynamic spatial navigation ability is related to spatial memory, executive function, and motor processing speed.

Comparison of driving capacity among patients with amyotrophic lateral sclerosis and healthy controls using the lane change task

OBJECTIVE

Compare driving capacity of individuals with Amyotrophic Lateral Sclerosis (ALS) and healthy controls (HC) using a driving simulation program.

METHODS

A prospective study was performed on individuals with ALS who reported they were still driving, and a group of HCs. Demographic data included age and gender. Assessment included cognitive assessments (Montreal cognitive assessment [MoCA] and ALS Cognitive Behavioral Scale [ALS-CBS]); gait speed (m/s); ALS Functional Rating Scale-revised total score (ALSFRS-R); and simulated driving assessment (Lane Change Task [LCT]). The LCT is a simple assessment tool which simulates the visual, cognitive, and motor demands of driving to detect at-risk drivers and uses distractions (secondary tasks) to quantify the performance loss on the primary task (lane changes).

RESULTS

Twenty-eight individuals with ALS (22 males, mean age 64 years) and 20 HCs (7 males, mean age 59 years) were studied. Individuals with mild to moderate ALS (ALSFRS-R mean 36.2) were older, had mild cognitive difficulty (MoCA 24 vs 27; ALS-CBS 14.19 [SD 3.85]) and mobility decline (gait speed 1.1 vs 1.4 m/s) compared to HC. Driving assessment using the LCT found no differences in baseline scores or during motor, cognitive, or visually distracting conditions.

CONCLUSIONS

Individuals with ALS with mild to moderate disease progression, with cognitive and motor weakness still demonstrate similar driving capacity to HCs using a driving simulation task. Driving assessment needs to be expanded longitudinally and perhaps with more robust measures to more precisely identify types of driving challenges that lead to cessation of driving in individuals with ALS.

Driver safety in patients with primary brain tumors

BACKGROUND

Operating a motor vehicle involves multiple cognitive and sensorimotor faculties. Neurological conditions pose driving risk, but this has not been examined in patients with primary brain tumors.

METHODS

Sixty-four patients with primary brain tumors (32 left hemisphere; 69% glioblastoma) completed the Cognitive Behavioral Driver's Inventory (CBDI). A subset also completed broader cognitive testing. Patient characteristics, CBDI measures, and broader neuropsychological test scores were compared between Passing and Nonpassing groups. Follow-up logistic regression analyses identified patient characteristics and CBDI measures predictive of Pass/Nonpass outcome. Point-biserial correlations determined associations between neuropsychological tests and CBDI outcome.

RESULTS

Sixty-nine percent of patients were classified as passing the CBDI. Nonpassing patients were older and more likely to have WHO grade IV and temporal lobe tumors. Age was the most salient predictor of CBDI performance. CBDI measures of speeded visual search and set-shifting, speeded response inhibition, vigilance and freedom from distractibility, and basic visual scanning speed were predictive of Pass/Nonpass outcome. Neuropsychological tests of memory in particular, but also speeded visual scanning and discrimination, executive function, basic visual attention, visuoconstruction, and manual dexterity (dominant hand), were associated with CBDI outcome.

CONCLUSIONS

A sizeable proportion of patients with primary brain tumors appear at risk of driving difficulty, particularly those with higher-grade tumors and of older age. Memory, visual attention, and executive difficulties appear to contribute most to driving safety risk as determined by the CBDI. These results highlight the importance of driving safety screening in this population.

Older Adults' Expectations about Mortality, Driving Life and Years Left without Driving

People are living and driving longer than ever before, with little preparation for transitioning to being non-drivers. We investigated driving expectations among drivers age 65 and older, including sociodemographic and driving context predictors. Cross-sectional data from 349 older drivers were explored to determine variation in how many years they expected to continue driving. General linear models examined predictors of both expectations. In this predominantly Black/African American sample, 76% of older drivers (mean age = 73 ± 5.7 years) expected a non-driving future, forecasting living an average of 5.75 ± 7.29 years after driving cessation. Regression models on years left of driving life and years left to live post-driving cessation predicted nearly half of the variance in older drivers' expectations with five significant predictors: income, current age, age expected to live to, self-limiting driving to nearby places and difficulty, visualizing being a non-driver. Many older drivers expect to stop driving before end of life.

Association Between Vestibular Vertigo and Motor Vehicle Accidents: Data From the 2016 National Health Interview Survey

Recent evidence has shown that individuals with vestibular impairment have higher rates of self-reported driving difficulty compared with individuals without vestibular impairment. However, it is unknown whether individuals with vestibular impairment are more likely to be involved in motor vehicle accidents. We used data from the 2016 National Health Interview Survey of U.S. adults to evaluate whether individuals with vestibular vertigo are more likely to experience motor vehicle accidents relative to individuals without vestibular vertigo. In multivariate analysis, vestibular vertigo was associated with an over threefold increased odds of motor vehicle accidents (odds ratio, 3.5; 95% confidence interval, 1.7-7.3). This study supports an association between vestibular dysfunction and driving impairment, and provides a relative risk of motor vehicle accidents associated with vestibular vertigo that clinicians may utilize in counseling patients on the potential safety hazards of driving.

Relationships Between Older Drivers' Cognitive Abilities as Assessed on the MoCA and Glance Patterns During Visual-Manual Radio Tuning While Driving

Objective

Research has established that long off-road glances increase crash risk, and other work has shown increased off-road glance behavior in older drivers. This study investigated the relationship between older drivers' (M = 66.3, range 61-69 years) cognitive abilities and the duration of off-road glances while engaged in secondary visual-manual activities.

Method

Twenty-two drivers completed the Montreal Cognitive Assessment (MoCA) prior to driving an instrumented vehicle and completing a set of radio-tuning tasks. Glance behavior was recorded and manually coded into 7 glance regions (toward the forward roadway, instrument cluster, center stack, rearview mirror, left, right, and other).

Results

On average, older drivers with higher MoCA scores used shorter glances and glanced away from the forward roadway for less total time when manually tuning the radio.

Discussion

These findings suggest that lower MoCA scores may represent a driving force behind the "age" differences reported in earlier studies of off-road glance behavior. Questions are raised concerning the identification of MoCA scores that might be used as inclusion cut-points in driving research and in identifying individuals needing further evaluation related to suitability for continuance of driving.

Where the Rubber Hits the Road: What Home Healthcare Professionals Need to Know About Driving Safety for Persons With Dementia

Driving cessation for people with dementia is a significant personal safety and public health issue. Home healthcare professionals frequently encounter situations where patients/clients should not continue to drive, and family members are unaware of how to approach the issue. This article will inform readers of the current state of the healthcare driving assessment process, measures and instruments used to assess, and effective strategies and resources when working with families facing the dilemma of how and when to proceed with a driving cessation plan.

Aiding medical professionals in fitness-to-drive screenings for elderly drivers: development of an office-based screening tool

ABSTRACTBackground:Elderly drivers are an increasing group in society. Previous research has found that functional and cognitive abilities are more important for driving abilities than biological age. In an attempt to conserve independent mobility for elderly drivers, many researchers have focused on elderly drivers diagnosed with cognitive decline (mild cognitive impairment or mild Dementia). This study is the first to focus on elderly drivers with cognitive complaints or suspected of diminished fitness to drive by an (in)formal caregiver as an at-risk group.

METHODS

The main objective of this study was to develop a fitness to drive screening tool for elderly drivers to be used in a doctor's office. Furthermore, this study investigated the additional value of driving simulator tests in the assessment of fitness to drive. Both screenings (functional abilities and driving simulator test) were benchmarked against the official Belgian fitness to drive licensing procedure.

RESULTS

One-hundred thirty-six elderly drivers participated in a functional abilities screening, a driving simulator assessment and an on-road driving test. Sixty-five percent of the sample was considered fit to drive. Visual acuity, physical flexibility, and knowledge of road signs were found to be the best predictive set of tests for the on-road fitness to drive outcome. A performance based driving simulator assessment increased predictive accuracy significantly.

CONCLUSION

The proposed screening procedure saves part of the at-risk elderly driver population from stressful and costly on-road driving evaluations. This procedure provides more information of an individual driver's specific driving parameters. This opens doors for personalized older driver training to maintain independent mobility in later life.

Cognitive Decline and Older Driver Crash Risk

OBJECTIVES

To examine automobile crash risk associated with cognition in older drivers without dementia.

DESIGN

Retrospective secondary analysis of longitudinal cohort study.

SETTING

Our study used data from the Adult Changes in Thought (ACT) Study merged with Washington State crash reports and licensure records. Data were available from 2002 to 2015.

PARTICIPANTS

Group Health enrollees from Washington State aged 65 and older with active driver's licenses (N=2,615).

MEASUREMENTS

Cognitive function was assessed using the Cognitive Abilities Screening Instrument scored using item response theory (CASI-IRT). The study outcome was police-reported motor vehicle crash. We used a negative binomial mixed-effects model with robust standard errors clustered on the individual and considered associations between crash risk, level of cognition, and amount of decline since the previous study visit. Covariates included age, sex, education, alcohol, depression, medical comorbidities, eyesight, hearing, and physical function. Individuals were censored at dementia diagnosis, death, or failure to renew their license.

RESULTS

Over an average of 7 years of follow-up, 350 (13%) people had at least one crash. A 1-unit lower CASI-IRT score was associated with a higher adjusted incidence rate ratio of crash of 1.26 (95% confidence interval=1.08-1.51). Beyond level of cognition, amount of cognitive decline between study visits was not associated with crash risk.

CONCLUSION

This study suggests that, in older drivers, poorer performance on the CASI-IRT may be a risk factor for motor vehicle crashes, even in individuals without diagnosed dementia. Further research is needed to understand driving behavior and inform driving decisions for older adults with poor cognitive function.

Why older people stop to drive? A cohort study of older patients admitted to a rehabilitation setting

The aim of this study is to describe the predictive factors of driving cessation at 6-month follow-up in older patients discharged from a rehabilitation setting and evaluated by an occupational therapist in a multidisciplinary team. Of 95 patients, at 6-month 27.4% ceased to drive. The reasons for driving cessation were a patients' voluntary choice (42.3%) or a choice of their family (23.1%), and only in 34.6% of the patients the license was revoked by a medical commission. In a multivariate analysis greater functional impairment-measured with the Timed Up and Go test-(OR 12.60, CI 2.74-57.89; p < 0.01) was the only predictor of driving cessation. This study shows that the ability to walk safely and independently is a significant predictor of driving cessation. The simple assessment of this factor using the TUG might be an easy screening tool to prompt a second level evaluation to accurately identify unsafe driving.

Associação entre cognição e habilitação para direção veicular em idosos

Objetivo: analizar la asociación entre la cognición y los resultados finales de los exámenes de aptitud física y mental para habilitación vehicular en adultos mayores.Método: Se trata de un estudio transversal realizado en clínicas de tránsito acreditadas para realizar exámenes de habilitación vehicular. La muestra del tipo probabilística fue constituida por 421 adultos mayores (≥ 60 años). Los datos fueron colectados por medio de Mini Examen del Estado Mental (MEEM) y consulta en el Registro Nacional de Conductores Habilitados. Para el análisis de los datos se utilizó estadística descriptiva y aplicación de los testes Kruskal-Wallis y Qui-cuadrado. Los valores de p≤0,05 indicaron significancia estadística.Resultados: Para el MEEM el puntaje promedio fue de 27,13 ± 2,53 puntos, 92,2 % (n =388) presentaron cognición normal y 7,8 % (n =33) comprometimiento cognitivo. En cuanto a los resultados de las pruebas de aptitud física y mental para habilitación vehicular 71,5 % (n =301) se consideraron aptos con restricción, el 21,9 % (n =92) aptos y el 6,7 % (n =28) inaptos temporales. Se observó una asociación significativa entre los resultados de la habilitación vehicular y los escores cognitivos (p<0,001) y no hubo asociación a las categorías cognitivas (p =0,172). Los escores más bajos de cognición se identificaron en ancianos aptos con restricción e inaptos temporalmente. Conclusión: Los resultados evidencian la inconsistencia del MEEM para evaluar la cognición. Se recomienda a las clínicas de tránsito la utilización del MEEM con cautela, como herramienta de evaluación cognitivo en conductores adultos mayores. 

Detection of Risky Driving Behaviors in the Naturalistic Environment in Healthy Older Adults and Mild Alzheimer's Disease

Analyzing naturalistic driving behavior recorded with in-car cameras is an ecologically valid method for measuring driving errors, but it is time intensive and not easily applied on a large scale. This study validated a semi-automated, computerized method using archival naturalistic driving data collected for drivers with mild Alzheimer’s disease (AD; n = 44) and age-matched healthy controls (HC; n = 16). The computerized method flagged driving situations where safety concerns are most likely to occur (i.e., rapid stops, lane deviations, turns, and intersections). These driving epochs were manually reviewed and rated for error type and severity, if present. Ratings were made with a standardized scoring system adapted from DriveCam^®. The top eight error types were applied as features to train a logistic model tree classifier to predict diagnostic group. The sensitivity and specificity were compared among the event-based method, on-road test, and composite ratings of two weeks of recorded driving. The logistic model derived from the event-based method had the best overall accuracy (91.7%) and sensitivity (97.7%) and high specificity (75.0%) compared to the other methods. Review of driving situations where risk is highest appears to be a sensitive data reduction method for detecting cognitive impairment associated driving behaviors and may be a more cost-effective method for analyzing large volumes of naturalistic data.

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.

Vestibular Dysfunction and Difficulty with Driving: Data from the 2001-2004 National Health and Nutrition Examination Surveys

BACKGROUND AND OBJECTIVE

There is growing understanding of the role of vestibular function in spatial navigation and orientation. Individuals with vestibular dysfunction demonstrate impaired performance on static and dynamic tests of spatial cognition, but there is sparse literature characterizing how these impairments might affect individuals in the real-world. Given the important role of visuospatial ability in driving a motor vehicle, we sought to evaluate whether individuals with vestibular dysfunction might have increased driving difficulty.

MATERIALS AND METHODS

We used data from the 2001-2004 National Health and Nutrition Examination Surveys to evaluate the influence of vestibular dysfunction in driving difficulty in a nationally representative sample of U.S. adults aged ≥50 years (n = 3,071). Vestibular function was measured with the modified Romberg test. Furthermore, since vestibular dysfunction is a known contributor to falls risk, we assessed whether individuals with vestibular dysfunction and concomitant driving difficulty were at an increased risk of falls.

RESULTS

In multivariate analyses, vestibular dysfunction was associated with a twofold increased odd of driving difficulty (odds ratio 2.16, 95% CI 1.57, 2.98). Among participants with vestibular dysfunction, concomitant driving difficulty predicted an increased risk of falls that was significantly higher than in participants with vestibular dysfunction only (odds ratio 13.01 vs. 2.91, p < 0.0001).

CONCLUSION

This study suggests that difficulty driving may be a real-world manifestation of impaired spatial cognition associated with vestibular loss. Moreover, driving difficulty may be a marker of more severe vestibular dysfunction.

Office-Based Assessment of At-Risk Driving in Older Adults With and Without Cognitive Impairment

BACKGROUND

A multitest approach is optimal for the identification of at-risk driving among older adults. This study examined the predictive validity of a combination of office-based screening tests for on-road driving performance in older adults with and without mild cognitive impairment (MCI)/dementia.

METHODS

Forty-four normal control, 20 participants with MCI, and 20 participants with dementia completed a battery of office-based assessments. On-road driving evaluation classified participants as not at-risk (n = 65) or at-risk drivers (n = 19).

RESULTS

Logistic regression revealed age and 2 tests of visual attention abilities (Useful Field of View [UFOV] Divided Attention and Neuropsychological Assessment Battery [NAB] Driving Scenes) best predicted at-risk drivers ( C statistic = 0.90); no cutoff score had both sensitivity and specificity >80%.

CONCLUSIONS

Future research on larger and more clinically representative neurological samples will improve understanding of the utility of the UFOV Divided Attention and NAB Driving Scenes in detecting at-risk older adult drivers in the clinic.

Creating a driving profile for older adults using GPS devices and naturalistic driving methodology

Background/Objectives: Road tests and driving simulators are most commonly used in research studies and clinical evaluations of older drivers. Our objective was to describe the process and associated challenges in adapting an existing, commercial, off-the-shelf (COTS), in-vehicle device for naturalistic, longitudinal research to better understand daily driving behavior in older drivers. Design: The Azuga G2 Tracking Device ^TM was installed in each participant's vehicle, and we collected data over 5 months (speed, latitude/longitude) every 30-seconds when the vehicle was driven.  Setting: The Knight Alzheimer's Disease Research Center at Washington University School of Medicine. Participants: Five individuals enrolled in a larger, longitudinal study assessing preclinical Alzheimer disease and driving performance.  Participants were aged 65+ years and had normal cognition. Measurements:  Spatial components included Primary Location(s), Driving Areas, Mean Centers and Unique Destinations.  Temporal components included number of trips taken during different times of the day.  Behavioral components included number of hard braking, speeding and sudden acceleration events. Methods:  Individual 30-second observations, each comprising one breadcrumb, and trip-level data were collected and analyzed in R and ArcGIS.  Results: Primary locations were confirmed to be 100% accurate when compared to known addresses.  Based on the locations of the breadcrumbs, we were able to successfully identify frequently visited locations and general travel patterns.  Based on the reported time from the breadcrumbs, we could assess number of trips driven in daylight vs. night.  Data on additional events while driving allowed us to compute the number of adverse driving alerts over the course of the 5-month period. Conclusions: Compared to cameras and highly instrumented vehicle in other naturalistic studies, the compact COTS device was quickly installed and transmitted high volumes of data. Driving Profiles for older adults can be created and compared month-to-month or year-to-year, allowing researchers to identify changes in driving patterns that are unavailable in controlled conditions.

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.

Preliminary Validation of a Questionnaire Covering Risk Factors for Impaired Driving Skills in Elderly Patients

Due to rather unspecific statutory regulations in Germany, particularly for patients with neurodegenerative disorders, many seniors still drive despite severe driving-related cognitive deficits. An accurate assessment of driving fitness requires immense financial, personnel and temporal resources which go beyond daily clinical routines. In cooperation with a working group from Switzerland, we therefore developed the questionnaire Safety Advice For Elderly drivers (SAFE), an economic instrument covering different risk factors for driving safety. The main aim of the current work was a first validation of the SAFE. Twenty-two driving seniors performed the Corporal A, a test battery permitted by law to assess driving-related cognitive functions. Based upon the Corporal results and the percentile rank 16 criterion, participants were divided into cognitively impaired and unimpaired drivers. Moreover, participants were assessed using the SAFE and an extensive neuropsychological test battery. The results revealed high sensitivity and specifity scores for the SAFE suggesting that the SAFE may be a valuable and economical instrument to quantify and document individual risk factors for driving safety and to differentiate between impaired and unimpaired drivers. Notably, the results must be replicated in future studies including a larger sample, different clinical subgroups, and a practical driving lesson.

Hierarchical Mazes in Psychological Research

Hierarchical mazes have been used in psychology for more than 100 years. During this time many different maze tasks have been created and used to test.cognitive processes and distinguish personality traits. Some of these mazes seem better than others to test different abilities. This article describes the most important mazes used in psychological research and the most important procedures used with these mazes. More than 20 different hierarchical mazes (including maze sets with more than 1 maze, e.g., those of Porteus and Elithorn) were analyzed and classified to different categories.

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.

Driving evaluation methods for able-bodied persons and individuals with lower extremity disabilities: a review of assessment modalities

Assessing the driving abilities of individuals with disabilities is often a very challenging task because each medical condition is accompanied by physical impairments and because relative individual functional performance may vary depending on personal characteristics.We identified existing driving evaluation modalities for able-bodied and lower extremity-impaired subjects (spinal cord injury patients and amputees) and evaluated the potential relationships between driving performance and the motor component of driving.An extensive scoping review of the literature was conducted to identify driving assessment tools that are currently used for able-bodied individuals and for those with spinal cord injury or lower extremity amputation. The literature search focused on the assessment of the motor component of driving. References were electronically obtained via Medline from the PubMed, Ovid, Web of Science and Google Scholar databases.This article compares the current assessments of driving performance for those with lower extremity impairments with the assessments used for able-bodied persons. Very few articles were found concerning "Lower Extremity Disabilities," thus confirming the need for further studies that can provide evidence and guidance for such assessments in the future. Little is known about the motor component of driving and its association with the other driving domains, such as vision and cognition. The available research demonstrates the need for a more evidenced-based understanding of how to best evaluate persons with lower extremity impairment.

Prediction of driving ability: Are we building valid models?

The prediction of on-road driving ability using off-road measures is a key aim in driving research. The primary goal in most classification models is to determine a small number of off-road variables that predict driving ability with high accuracy. Unfortunately, classification models are often over-fitted to the study sample, leading to inflation of predictive accuracy, poor generalization to the relevant population and, thus, poor validity. Many driving studies do not report sufficient details to determine the risk of model over-fitting and few report any validation technique, which is critical to test the generalizability of a model. After reviewing the literature, we generated a model using a moderately large sample size (n=279) employing best practice techniques in the context of regression modelling. By then randomly selecting progressively smaller sample sizes we show that a low ratio of participants to independent variables can result in over-fitted models and spurious conclusions regarding model accuracy. We conclude that more stable models can be constructed by following a few guidelines.

Cognitive and visual predictors of UFOV performance in older adults

Eighty two community dwelling older adults (52 females) aged 62-92 years (mean=75) completed a battery of cognitive and visual tests selected to assess functions relevant to driving performance. These were visual acuity, contrast sensitivity, general mental competence (Mini Mental State Examination, MMSE), processing speed (Inspection Time, IT), crowding across the visual field (Proficiency of Peripheral Vision Processing, ProPerVis) and change detection (DriverScan). These six tasks provided predictor variables for performance on the Useful Field of View test (UFOV), a well validated test of fitness to drive that includes subtests for (i) processing speed; (ii) divided attention; and (iii) selective attention. Relative importance regression analyses confirmed that UFOV is sensitive to attentional and speed processes but suggested that subtest (i) primarily reflects visual acuity and contrast sensitivity; subtest (ii) is better explained by change detection and processing speed; and subtest (iii) predominantly reflects crowding and contrast sensitivity. Unexpectedly, given no evidence of substantial cognitive decline, MMSE contributed significantly to performance on the more complex subtests (ii) and (iii).

Comparison of the SIMARD MD to Clinical Impression in Assessing Fitness to Drive in Patients with Cognitive Impairment

BACKGROUND

The assessment of fitness to drive in patients with cognitive impairment is complex. The SIMARD MD was developed to assist with assessing fitness to drive. This study compares the clinical decision made by a geriatrician regarding driving with the SIMARD MD score.

METHODS

Patients with a diagnosis of mild dementia or mild cognitive impairment, who had a SIMARD MD test, were included in the sample. A retrospective chart review was completed to gather diagnosis, driving status, and cognitive and functional information.

RESULTS

Sixty-three patients were identified and 57 met the inclusion criteria. The mean age was 77.1 years (SD 8.9). The most common diagnosis was Alzheimer's disease in 22 (38.6%) patients. The mean MMSE score was 24.9 (SD 3.34) and the mean MoCA was 19.9 (SD 3.58). The mean SIMARD MD score was 37.2 (SD 19.54). Twenty-four patients had a SIMARD MD score ≤ 30, twenty-eight between 31-70, and five scored > 70. The SIMARD MD scores did not differ significantly compared to the clinical decision (ANOVA p value = 0.14).

CONCLUSIONS

There was no association between the SIMARD MD scores and the geriatricians' clinical decision regarding fitness to drive in persons with mild dementia or mild cognitive impairment.

Consensus statements on the assessment of older drivers

Background

The rapidly increasing number of older drivers is accentuating the challenges in concurrently identifying older drivers posing an unacceptable risk if they continue to drive, while not discriminating against those capable of safely driving. Attendees of an invitational meeting about the assessment of older drivers were asked to participate in a modified Delphi process designed to develop consensus statements on the assessment of older drivers.

Methods

Forty-one non-student symposium attendees were invited to participate in two rounds of a survey, in which they were asked to indicate their level of agreement (or disagreement) on a five-point Likert scale to a series of statements about the assessment of older drivers. Consensus was defined as 80% + of respondents either agreeing or disagreeing with a statement.

Results

More than one-half (n = 23) completed the first round of the survey and 12 participated in the second. There was consensus on the need for a modifiable, fair, rational, and widely accessible multi-step approach to the assessment of older drivers. This would require the engagement and support of physicians and other health-care practitioners in identifying and reporting medically at-risk drivers of any age. At a societal level, alternatives to driving a personal motor vehicle should be developed.

Conclusions

An on-going dialogue about this complex issue is required. Decisions should be based on explicitly stated principles and informed by the best available evidence.

Predicting road test performance in drivers with stroke

OBJECTIVE. The aim of this study was to develop a brief screening battery to predict the on-road performance of drivers who had experienced a stroke. METHOD. We examined 72 people with stroke referred by community physicians to an academic rehabilitation center. The outcome variable was pass or fail on the modified Washington University Road Test. Predictor measures were tests of visual, motor, and cognitive functioning. RESULTS. The best predictive model for failure on the road test included Trail Making Test Part A and the Snellgrove Maze Task(®). CONCLUSION. A screening battery that can be performed in less than 5 min was able to assist in the prediction of road test performance in a sample of drivers with stroke. A probability of failure calculator may be useful for clinicians in their decision to refer clients with stroke for a comprehensive driving evaluation.

Clock drawing as a screen for impaired driving in aging and dementia: is it worth the time?

Clock drawing is recommended by medical and transportation authorities as a screening test for unsafe drivers. The objective of the present study was to assess the usefulness of different clock drawing systems as screening measures of driving performance in 122 healthy and cognitively impaired older drivers. Clock drawing was measured using four different scoring systems. Driving outcomes included global ratings of safety and the error rate on a standardized on-road test. Findings revealed that clock drawing was significantly correlated with the driving score on the road test for each of the scoring systems. However, receiver operator curve analyses showed limited clinical utility for clock drawing as a screening instrument for impaired on-road driving performance with the area under the curve ranging from 0.53 to 0.61. Results from this study indicate that clock drawing has limited utility as a solitary screening measure of on-road driving, even when considering a variety of scoring approaches.