Computerized maze navigation and on-road performance by drivers with dementia

Performance Analysis of Driving Ability (P-Drive): Investigating Construct Validity and Concordance of Australasian Data

On-road assessment is optimal for determining medical fitness-to-drive but unreliable if determined by global pass/fail decisions alone. Occupational therapists need standardized, psychometrically sound on-road scoring procedures. Performance Analysis of Driving Ability (P-Drive) is a promising on-road test developed in Sweden, but it has not been standardized for Australasia. We investigated the psychometric properties and concordance with an on-road decision of data gathered with the Australasian version of P-Drive. P-Drive was administered to older and cognitively impaired drivers (N = 134) aged 18 to 91 years (mean age 68) who were referred to 10 driving clinics in Australia and New Zealand to determine driving performance. Rasch analysis provided evidence for construct validity and concordance of the data gathered. An optimal cut-off score of 85 was set, yielding evidence of good sensitivity at 88% and specificity at 88%. The Australasian version of P-Drive produces valid and reliable data regarding on-road driving performance.

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.

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.

Predicting On-Road Driving Skills, Fitness to Drive, and Prospective Accident Risk in Older Drivers and Drivers with Mild Cognitive Impairment: The Importance of Non-Cognitive Risk Factors

BACKGROUND

On-road driving behavior can be impaired in older drivers and particularly in drivers with mild cognitive impairment (MCI).

OBJECTIVE

To determine whether cognitive and non-cognitive risk factors for driving safety may allow an accurate and economic prediction of on-road driving skills, fitness to drive, and prospective accident risk in healthy older drivers and drivers with MCI, we examined a representative combined sample of older drivers with and without MCI (N = 74) in an observational on-road study. In particular, we examined whether non-cognitive risk factors improve predictive accuracy provided by cognitive factors alone.

METHODS

Multiple and logistic hierarchical regression analyses were utilized to predict different driving outcomes. In all regression models, we included cognitive predictors alone in a first step and added non-cognitive predictors in a second step.

RESULTS

Results revealed that the combination of cognitive and non-cognitive risk factors significantly predicted driving skills (R2adjusted = 0.30) and fitness to drive (81.2% accuracy) as well as the number (R2adjusted = 0.21) and occurrence (88.3% accuracy) of prospective minor at-fault accidents within the next 12 months. In all analyses, the inclusion of non-cognitive risk factors led to a significant increase of explained variance in the different outcome variables.

CONCLUSION

Our findings suggest that a combination of the most robust cognitive and non-cognitive risk factors may allow an economic and accurate prediction of on-road driving performance and prospective accident risk in healthy older drivers and drivers with MCI. Therefore, non-cognitive risk factors appear to play an important role.

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.

Regional Gray Matter Volume Identifies High Risk of Unsafe Driving in Healthy Older People

In developed countries, the number of traffic accidents caused by older drivers is increasing. Approximately half of the older drivers who cause fatal accidents are cognitively normal. Thus, it is important to identify older drivers who are cognitively normal but at high risk of causing fatal traffic accidents. However, no standardized method for assessing the driving ability of older drivers has been established. We aimed to establish an objective assessment of driving ability and to clarify the neural basis of unsafe driving in healthy older people. We enrolled 32 healthy older individuals aged over 65 years and classified unsafe drivers using an on-road driving test. We then utilized a machine learning approach to distinguish unsafe drivers from safe drivers based on clinical features and gray matter volume data. Twenty-one participants were classified as safe drivers and 11 participants as unsafe drivers. A linear support vector machine classifier successfully distinguished unsafe drivers from safe drivers with 87.5% accuracy (sensitivity of 63.6% and specificity of 100%). Five parameters (age and gray matter volume in four cortical regions, including the left superior part of the precentral sulcus, the left sulcus intermedius primus [of Jensen], the right orbital part of the inferior frontal gyrus, and the right superior frontal sulcus), were consistently selected as features for the final classification model. Our findings indicate that the cortical regions implicated in voluntary orienting of attention, decision making, and working memory may constitute the essential neural basis of driving behavior.

Enhancing the Clinical Utility of DriveSafe DriveAware for People with Huntington's Disease

DriveSafe DriveAware (DSDA) is a cognitive screening tool assessing driving safety. Previously, we found DSDA categorised some HD participants as 'likely to pass' on-road assessments, despite displaying cognitive impairments in domains known to impact driving. As processing speed is affected early in HD, we examined whether DSDA completion time could provide supplementary cognitive information to support clinical decision-making. The HD group completed subtests significantly slower than controls, and completion times correlated with cognitive functions essential for driving. Considering DSDA completion time may tailor the assessment for people with HD so that it is more reflective of HD-related cognitive functioning.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Maze test score time adjustments when using nondominant hand in fitness-to-drive assessments

Drivers with medical conditions may need to demonstrate their fitness by participating in clinical and on-road assessments. Scores from the clinic-based occupational therapy-drive home maze test (OT-DHMT) can contribute to fitness-to-drive recommendations. The OT-DHMT is a short, timed test that has previously been shown to be valid and reliable, and norms are available for completion with a driver's dominant hand. Following stroke or trauma, many drivers need to complete assessments and resume driving using their nondominant hand. The validity of a person's OT-DHMT score when completed with a nondominant hand is unknown. This study investigated if a person's OT-DHMT score time requires adjustment when completed with a nondominant hand. The OT-DHMT was administered with a convenience sample of 148 community-dwelling participants, aged 21-81 years (M = 48.6, SD = 19.38) using both their dominant and nondominant hands, in a random order. OT-DHMT score times were significantly faster when using dominant (M = 15.73) compared with nondominant (M = 17.64) hand, d = 1.91 [confidence interval (CI) 1.13, 2.69], t = 4.84, P < 0.01. Employing a generalized weighted least squares regression model indicated that multiplying a driver's nondominant hand time by 0.833 s for drivers aged ≤60, and by 0.929 s for drivers aged 61+ can approximate dominant hand completion times. The OT-DHMT has been validated for use with people using their nondominant hand. Time adjustments are required for people using their nondominant hand when completing the OT-DHMT, and a larger adjustment is required for people aged ≤60 reinforcing previous findings that younger people have faster OT-DHMT completion times.

Reliability and validity of on-road driving tests in vulnerable adults: a systematic review

The on-road driving test is considered a ‘gold standard’ evaluation; however, its validity and reliability have not been sufficiently reviewed. This systematic review aimed to map out and synthesize literature regarding on-road driving tests using the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. Cochrane Library, PubMed, CINAHL, and Web of Science databases were searched from initiation through February 2018. All articles addressing reliability or validity of on-road driving tests involving adult rehabilitation patients were included. The search output identified 513 studies and 36 articles, which were included in the review. The Washington University Road Test/Rhode Island Road Test, performance analysis of driving ability, test ride for investigating practical fitness-to-drive, and K-score demonstrated high reliability and validity in regard to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist. The Washington University Road Test/Rhode Island Road Test and test ride for investigating practical fitness-to-drive were analyzed based on Classical Test Theory techniques, and performance analysis of driving ability and K-score were analyzed based on Item Response Theory techniques. The frequency of studies were Washington University Road Test/Rhode Island Road Test (n=9), Test Ride for Investigating Practical fitness-to-drive (n=8), performance analysis of driving ability (n=4), and K-score (n=1). From the viewpoint of accuracy and generalization, the Washington University Road Test/Rhode Island Road Test, test ride for investigating practical fitness-to-drive, and performance analysis of driving ability were identified as highly qualified concerning on-road driving tests. However, the ability to assess real-world driving depends on various environmental conditions.

Alzheimer Disease Biomarkers and Driving in Clinically Normal Older Adults: Role of Spatial Navigation Abilities

PURPOSE

Older adults experience impaired driving performance, and modify their driving habits, including limiting amount and spatial extent of travel. Alzheimer disease (AD)-related pathology, as well as spatial navigation difficulties, may influence driving performance and driving behaviors in clinically normal older adults. We examined whether AD biomarkers [cerebrospinal fluid (CSF) concentrations of Aβ42, tau, and ptau181] were associated with lower self-reported spatial navigation abilities, and whether navigation abilities mediated the relationship of AD biomarkers with driving performance and extent.

METHODS

Clinically normal older adults (n=112; aged 65+) completed an on-road driving test, the Santa Barbara Sense of Direction scale (self-report measure of spatial navigation ability), and the Driving Habits Questionnaire for an estimate of driving extent (composite of driving exposure and driving space). All participants had a lumbar puncture to obtain CSF.

RESULTS

CSF Aβ42, but not tau or ptau181, was associated with self-reported navigation ability. Lower self-reported navigation was associated with reduced driving extent, but not driving errors. Self-reported navigation mediated the relationship between CSF Aβ42 and driving extent.

CONCLUSIONS

Findings suggest that cerebral amyloid deposition is associated with lower perceived ability to navigate the environment, which may lead older adults with AD pathology to limit their driving extent.

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.

Naturalistic Driving Study Investigating Self-Regulation Behavior in Early Alzheimer's Disease: A Pilot Study

BACKGROUND

Because cognitive processes decline in the earliest stages of Alzheimer's disease (AD), the driving abilities are often affected. The naturalistic driving approach is relevant to study the driving habits and behaviors in normal or critical situations in a familiar environment of participants.

OBJECTIVE

This pilot study analyzed in-car video recordings of naturalistic driving in patients with early-stage AD and in healthy controls, with a special focus on tactical self-regulation behavior.

METHODS

Twenty patients with early-stage AD (Diagnosis and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV] criteria), and 21 healthy older adults were included in the study. Data collection equipment was installed in their personal vehicles. Two expert psychologists assessed driving performance using a specially designed Naturalistic Driving Assessment Scale (NaDAS), paying particular attention to tactical self-regulation behavior, and they recorded all critical safety events.

RESULTS

Poorer driving performance was observed among AD drivers: their tactical self-regulation behavior was of lower quality. AD patients had also twice as many critical events as healthy drivers and three times more "unaware" critical events.

CONCLUSION

This pilot study used a naturalistic approach to accurately show that AD drivers have poorer tactical self-regulation behavior than healthy older drivers. Future deployment of assistance systems in vehicles should specifically target tactical self-regulation components.

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.

An International Approach to Enhancing a National Guideline on Driving and Dementia

PURPOSE OF REVIEW

The purpose of this study was to update a national guideline on assessing drivers with dementia, addressing limitations of previous versions which included a lack of developmental rigor and stakeholder involvement.

METHODS

An international multidisciplinary team reviewed 104 different recommendations from 12 previous guidelines on assessing drivers with dementia in light of a recent review of the literature. Revised guideline recommendations were drafted by consensus. A preliminary draft was sent to specialist physician and occupational therapy groups for feedback, using an a priori definition of 90% agreement as consensus.

RECENT FINDINGS

The research team drafted 23 guideline recommendations, and responses were received from 145 stakeholders. No recommendation was endorsed by less than 80% of respondents, and 14 (61%) of the recommendations were endorsed by more than 90%.The recommendations are presented in the manuscript. The revised guideline incorporates the perspectives of consensus of an expert group as well as front-line clinicians who regularly assess drivers with dementia. The majority of the recommendations were based on evidence at the level of expert opinion, revealing gaps in the evidence and future directions for research.

Investigating Simulated Driving Errors in Amnestic Single- and Multiple-Domain Mild Cognitive Impairment

The areas of driving impairment characteristic of mild cognitive impairment (MCI) remain unclear. This study compared the simulated driving performance of 24 individuals with MCI, including amnestic single-domain (sd-MCI, n = 11) and amnestic multiple-domain MCI (md-MCI, n = 13), and 20 age-matched controls. Individuals with MCI committed over twice as many driving errors (20.0 versus 9.9), demonstrated difficulty with lane maintenance, and committed more errors during left turns with traffic compared to healthy controls. Specifically, individuals with md-MCI demonstrated greater driving difficulty compared to healthy controls, relative to those with sd-MCI. Differentiating between different subtypes of MCI may be important when evaluating driving safety.

A Systematic Review and Meta-Analysis of On-Road Simulator and Cognitive Driving Assessment in Alzheimer's Disease and Mild Cognitive Impairment

BACKGROUND

Many individuals with Alzheimer's disease (AD) and mild cognitive impairment (MCI) are at an increased risk of driving impairment. There is a need for tools with sufficient validity to help clinicians assess driving ability.

OBJECTIVE

Provide a systematic review and meta-analysis of the primary driving assessment methods (on-road, cognitive, driving simulation assessments) in patients with MCI and AD.

METHODS

We investigated (1) the predictive utility of cognitive tests and domains, and (2) the areas and degree of driving impairment in patients with MCI and AD. Effect sizes were derived and analyzed in a random effects model.

RESULTS

Thirty-two articles (including 1,293 AD patients, 92 MCI patients, 2,040 healthy older controls) met inclusion criteria. Driving outcomes included: On-road test scores, pass/fail classifications, errors; caregiver reports; real world crash involvement; and driving simulator collisions/risky behavior. Executive function (ES [95% CI]; 0.61 [0.41, 0.81]), attention (0.55 [0.33, 0.77]), visuospatial function (0.50 [0.34, 0.65]), and global cognition (0.61 [0.39, 0.83]) emerged as significant predictors of driving performance. Trail Making Test Part B (TMT-B, 0.61 [0.28, 0.94]), TMT-A (0.65 [0.08, 1.21]), and Maze test (0.88 [0.60, 1.15]) emerged as the best single predictors of driving performance. Patients with very mild AD (CDR = 0.5) mild AD (CDR = 1) were more likely to fail an on-road test than healthy control drivers (CDR = 0), with failure rates of 13.6%, 33.3% and 1.6%, respectively.

CONCLUSION

The driving ability of patients with MCI and AD appears to be related to degree of cognitive impairment. Across studies, there are inconsistent cognitive predictors and reported driving outcomes in MCI and AD patients. Future large-scale studies should investigate the driving performance and associated neural networks of subgroups of AD (very mild, mild, moderate) and MCI (amnestic, non-amnestic, single-domain, multiple-domain).

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.

The Roles and Performance of Professional Driving Instructors in Novice Driver Education

This review article aimed to analyse existing literature regarding the roles and performance of professional driving instructors (PDIs) in novice driver education (DE). A systematic classification scheme was adopted to analyse identified articles to determine the study context of PDIs in novice DE, the competency level of PDIs in relation to experienced and learner drivers and the contributions of PDIs to the novice driver learning process. A total of 14 original research articles were identified, with no systematic reviews or meta-analyses available. Overall, all of the articles were found to be inadequate in providing an in-depth understanding of the roles and performance of PDIs in novice DE. There is an urgent need to improve current understanding of the roles of PDIs in novice DE and to work towards an internationally recognised PDI management approach.

Driving with a neurodegenerative disorder: an overview of the current literature

Driving is important for employment, social activities, and for the feeling of independence. The decision to cease driving affects the quality of life and has been associated with reduced mobility, social isolation, and sadness. Patients with neurodegenerative disorders can experience difficulties while driving due to their cognitive, motor, and behavioral impairments. The aim of this review is to summarize the available literature on changes in driving competence and behavior in patients with neurodegenerative disorders, with a particular focus on Huntington's (HD), Parkinson's (PD), and Alzheimer's disease (AD). A systematic literature search was conducted in the PubMed/Medline database. Studies using on-road or simulated driving assessments were examined in this review. In addition, studies investigating the association between cognitive functioning and driving were included. The review identified 70 studies. Only a few publications were available on HD (n = 7) compared to PD (n = 32) and AD (n = 31). This review revealed that driving is impaired in patients with neurodegenerative disorders on all levels of driving competence. The errors most commonly committed were on the tactical level including lane maintenance and lane changing. Deficits in executive functioning, attention, and visuospatial abilities can partially predict driving competence, and the performance on neuropsychological tests might be useful when discussing potential driving cessation. Currently, there is no gold standard to assess driving ability using clinical measures such as neuropsychological assessments, so more studies are necessary to detect valid screening tools and develop useful and reliable evidence-based guidelines.

Studies Involving People With Dementia and Touchscreen Technology: A Literature Review

Background

Devices using touchscreen interfaces such as tablets and smartphones have been highlighted as potentially suitable for people with dementia due to their intuitive and simple control method. This population experience a lack of meaningful, engaging activities, yet the potential use of the touchscreen format to address this issue has not been fully realized.

Objective

To identify and synthesize the existing body of literature involving the use of touchscreen technology and people with dementia in order to guide future research in this area.

Methods

A systematized review of studies in the English language was conducted, where a touchscreen interface was used with human participants with dementia.

Results

A total of 45 articles met the inclusion criteria. Four questions were addressed concerning (1) the context of use, (2) reasons behind the selection of the technology, (3) details of the hardware and software, and (4) whether independent use by people with dementia was evidenced.

Conclusions

This review presents an emerging body of evidence demonstrating that people with dementia are able to independently use touchscreen technology. The intuitive control method and adaptability of modern devices has driven the selection of this technology in studies. However, its primary use to date has been as a method to deliver assessments and screening tests or to provide an assistive function or cognitive rehabilitation. Building on the finding that people with dementia are able to use touchscreen technology and which design features facilitate this, more use could be made to deliver independent activities for meaningful occupation, entertainment, and fun.

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.

Driving in Early-Stage Alzheimer's Disease: An Integrative Review of the Literature

One of the most difficult decisions for individuals with Alzheimer's disease (AD) is when to stop driving. Because driving is a fundamental activity linked to socialization, independent functioning, and well-being, making the decision to stop driving is not easy. Cognitive decline in older adults can lead to getting lost while driving, difficulty detecting and avoiding hazards, as well as increased errors while driving due to compromised judgment and difficulty in making decisions. The purpose of the current literature review was to synthesize evidence regarding how individuals with early-stage AD, their families, and providers make determinations about driving safety, interventions to increase driving safety, and methods to assist cessation and coping for individuals with early-stage AD. The evidence shows that changes in driving ability start early and progress throughout the trajectory of AD. Some individuals with mild cognitive impairment or early-stage AD may be safe to drive for a period of time. Support groups aimed at helping with the transition have been shown to be helpful for individuals who stop driving. Research and practice must support interventions to help individuals maintain safety while driving, as well as cope with driving cessation. [Res Gerontol Nurs. 2017; 10(2):86-100.].

Assessment tools predicting fitness to drive in older adults: a systematic review

This systematic review synthesizes the research on screening and assessment tools used to determine older adults' fitness to drive. After a comprehensive search of the literature targeting tools commonly used by occupational therapists, 64 studies were reviewed and synthesized. The evidence demonstrated that a single tool measuring cognition, vision, perception, or physical ability individually is not sufficient to determine fitness to drive. Although some tools have stronger evidence than others, this review supports using different and focused assessment tools together for specific medical conditions. Results indicate that behind-the-wheel assessment remains the gold standard for driving evaluation; however, emerging evidence for observation of complex instrumental tasks of daily living and driving simulation supports further investigation with these tools.

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.

Preliminary Investigation on the Association between Depressive Symptoms and Driving Performance in Heart Failure

Heart failure (HF) patients commit many errors on driving simulation tasks and cognitive dysfunction appears to be one important contributor to impaired driving in HF. Clinical modifiers of cognition may also play a key role. In particular, depression is common in HF patients, linked with cognitive dysfunction, and contributes to reduced driving fitness in non-HF samples. However, the associations among depressive symptoms, cognition, and driving in HF are unclear. Eighteen HF patients completed a validated simulated driving scenario, the Beck Depression Inventory-II (BDI-II), and a cognitive test battery. Partial correlations controlling for demographic and medical confounds showed higher BDI-II score correlated with greater number of collisions, centerline crossings, and % time out of lane. Increased depressive symptoms correlated with lower attention/executive function, and reduced performance in this domain was associated with a greater number of collisions, centerline crossing, and % time out of lane. Depressive symptoms may be related to poorer driving performance in HF, perhaps through association with cognitive dysfunction. However, larger studies with on-road testing are needed to replicate our preliminary findings before recommendations for clinical practice can be made.

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.

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.

Screening and assessment tools for determining fitness to drive: a review of the literature for the pathways project

With a brief introduction, 10 tables summarize the findings from the literature describing screening and assessment tools used with older adults to identify risk or determine fitness to drive. With a focus on occupational therapy's duty to address driving as a valued activity, this paper offers information about tools used by occupational therapy practitioners across practice settings and specialists in driver rehabilitation. The tables are organized into groups of key research studies of assessment tools, screening batteries, tools used in combination (i.e., as a battery), driving simulation as an assessment tool, and screening/assessment for individuals with stroke, vision impairment, Parkinson's disease, dementia, and aging. Each table has a summary of important concepts to consider as occupational therapists choose the methods and tools to evaluate fitness to drive.

Car drivers with dementia: Different complications due to different etiologies?

OBJECTIVE

Older drivers with dementia are an at-risk group for unsafe driving. However, dementia refers to various etiologies and the question is whether dementias of different etiology have similar effects on driving ability.

METHODS

The literature on the effects of dementia of various etiologies on driving ability is reviewed. Studies addressing dementia etiologies and driving were identified through PubMed, PsychINFO, and Google Scholar.

RESULTS AND CONCLUSIONS

Early symptoms and prognoses differ between dementias of different etiology. Therefore, different etiologies may represent different likelihoods with regard to fitness to drive. Moreover, dementia etiologies could indicate the type of driving problems that can be expected to occur. However, there is a great lack of data and knowledge about the effects of almost all etiologies of dementia on driving. One could hypothesize that patients with Alzheimer's disease may well suffer from strategic difficulties such as finding a route, whereas patients with frontotemporal dementia are more inclined to make tactical-level errors because of impaired hazard perception. Patients with other dementia etiologies involving motor symptoms may suffer from problems on the operational level. Still, the effects of various etiologies of dementias on driving have thus far not been studied thoroughly. For the detection of driving difficulties in patients with dementia, structured interviews with patients but also their family members appear crucial. Neuropsychological assessment could support the identification of cognitive impairments. The impact of such impairments on driving could also be investigated in a driving simulator. In a driving simulator, strengths and weaknesses in driving behavior can be observed. With this knowledge, patients can be advised appropriately about their fitness to drive and options for support in driving (e.g., compensation techniques, car adaptations). However, as long as no valid, reliable, and widely accepted test battery is available for the assessment of fitness to drive, costly on-road test rides are inevitable. The development of a fitness-to-drive test battery for patients with dementia could provide an alternative for these on-road test rides, on condition that differences between dementia etiologies are taken into consideration.

Predictive validity of the Montreal Cognitive Assessment (MoCA) as a screening tool for on-road driving performance

Introduction

The objectives of this study are to determine (1) the ability of the Montreal Cognitive Assessment to predict on-road driving performance in drivers with a neurological condition and elderly drivers with suspected cognitive decline, and (2) the association between the performance on the Useful Field of View and the performance on the Montreal Cognitive Assessment.

Method

This study used a retrospective design. Clients were included who had completed the Montreal Cognitive Assessment and the on-road driving evaluation from November 2006 to May 2009 ( n = 154) in a driving rehabilitation program in the Montreal Area. Total scores on the Montreal Cognitive Assessment, Useful Field of View risk categories, pass or fail outcomes from an on-road evaluation, as well as demographic and clinical characteristics were recorded from participants’ medical charts.

Results

The Montreal Cognitive Assessment was found to have a sensitivity of 84.5% and a specificity of 50% with a cut-off of ≤25. It was significantly associated with the Useful Field of View risk category.

Conclusion

The Montreal Cognitive Assessment could be a valuable screening tool. However, its predictive validity is not strong enough to recommend its use as the sole instrument for identifying unfit drivers.

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).

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.

Systematic review of the evidence for Trails B cut-off scores in assessing fitness-to-drive

Background

Fitness-to-drive guidelines recommend employing the Trail Making B Test (a.k.a. Trails B), but do not provide guidance regarding cut-off scores. There is ongoing debate regarding the optimal cut-off score on the Trails B test.

The objective of this study was to address this controversy by systematically reviewing the evidence for specific Trails B cut-off scores (e.g., cut-offs in both time to completion and number of errors) with respect to fitness-to-drive.

Methods

Systematic review of all prospective cohort, retrospective cohort, case-control, correlation, and cross-sectional studies reporting the ability of the Trails B to predict driving safety that were published in English-language, peer-reviewed journals.

Results

Forty-seven articles were reviewed. None of the articles justified sample sizes via formal calculations. Cut-off scores reported based on research include: 90 seconds, 133 seconds, 147 seconds, 180 seconds, and < 3 errors.

Conclusions

There is support for the previously published Trails B cut-offs of 3 minutes or 3 errors (the ‘3 or 3 rule’). Major methodological limitations of this body of research were uncovered including (1) lack of justification of sample size leaving studies open to Type II error (i.e., false negative findings), and (2) excessive focus on associations rather than clinically useful cut-off scores.

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

OBJECTIVES

To examine the sensitivity and specificity of the Assessment of Driving-Related Skills (ADReS), a clinical tool recommended by the American Medical Association for identifying potentially unsafe older drivers that includes tests of vision, motor function, and cognition.

DESIGN

Cross-sectional observation study.

SETTING

Memory assessment outpatient clinic of a university hospital.

PARTICIPANTS

Drivers with normal cognition (n = 47) and cognitive impairment (n = 75).

MEASUREMENTS

A neurologist completed the ADReS during an office visit. Additional cognitive tests of executive, visuospatial, and visuomotor function were also performed. On a separate day, participants completed a standardized on-road test, assessed by a professional driving instructor using a global safety rating and a quantitative driving score.

RESULTS

In this sample of currently active older drivers with and without cognitive impairment, measures of cognition-particularly the Trail-Making Test Part B-were more highly correlated with driving scores than other measures of function. Using recommended scoring procedures, the ADReS had a sensitivity of 0.81 for detecting impaired driving on the road test, with a specificity of 0.32 and an area under the receiver operating characteristic curve (AUC) of 0.57. A logistic regression model that incorporated computerized maze task and Mini-Mental State Examination scores improved overall classification accuracy, yielding a sensitivity of 0.61, a specificity of 0.84, and an AUC of 0.80.

CONCLUSION

In its present form, the ADReS has limited utility as an office screen for individuals who should undergo formal driving assessment. Improved scoring methods and screening tests with greater diagnostic accuracy than the ADReS are needed for general office practice.

The impact of cognitive deficit on self-reported car crashes in ultra-octogenarian population: data of an Italian population-based study

OBJECTIVE

To examine the usefulness of specific neurocognitive tests for predicting the crash involvement in ultra-octogenarian population.

METHODS

A total of 800 subjects (mean age 82.4 + 3.1 years) underwent a battery of neuropsychological tests. Global intellectual functioning was assessed using the Mini Mental State Examination, mental flexibility and information processing speed were assessed using the Trail Making Test parts A and B (TMT-A and TMT-B), long-term memory was evaluated with the short story, and visuo-spatial skills were tested with Clock Drawing Test. One year after this evaluation, 343 (43%) participants have been interviewed by a telephone call to know if they were currently driving and if they had a car crash during this period.

RESULTS

Two hundred ninety-seven subjects had their driving license renewed and completed the follow-up 1 year after. Data shows that less than 11% of this group had a car crash during the first year of observation (Crash Involved). Older subjects involved in a car crash showed significant worse performances on TMT-B (TMT-B pathological Crash Involved vs. Noncrash Involved 47% vs. 27%; p = 0.02) and on short story (short story pathological Crash Involved vs. Noncrash Involved 19% vs. 5%; p = 0.02).

CONCLUSIONS

Trail Making test B and short story have been demonstrated to provide a predictive value of driving performance of older people. Therefore, we suggest that a simple and standardized battery of neuropsychological tests, lasting about 30 min and administered by an experienced staff, is a good diagnostic instrument for risk prevention of driving activity of older drivers.

The Maze Test: A significant predictor of older driver crash risk

A study sponsored by the National Highway Traffic Safety Administration performed functional assessments on approximately 700 drivers age 70 and older who presented for license renewal in urban, suburban, and rural offices of the Maryland Motor Vehicle Administration. This volunteer sample received a small compensation for study participation, with an assurance that their license status would not be affected by the results. A comparison with all older drivers who visited the same sites on the same days indicated that the study sample was representative of Maryland older drivers with respect to age and prior driving safety indices. Relationships between drivers' scores on a computer touchscreen version of the Maze Test and prospective crash and serious moving violation experience were analyzed. Results identified specific mazes as highly significant predictors of future safety risk for older drivers, with a particular focus on non-intersection crashes. Study findings indicate that performance on Maze Tests was predictive of prospective crashes and may be useful, as a complement to other, established cognitive screening tools, in identifying at-risk older drivers.

Interventions to evaluate fitness to drive among people with chronic conditions: Systematic review of literature

When an health condition has been identified, the question of whether to continue driving depends not on a medical diagnosis, but on the functional consequences of the illness. The complex nature of physical and mental impairments and their relationship with safe driving make the availability of evidence based tools necessary for health professionals. The review aims at identifying and summarizing scientific findings concerning the relationship between neuropsychological and clinical screening tests and fitness to drive among people with chronic conditions. Studies were searched for driving ability evaluation by road test or simulator, clinical/neuropsychological examinations of participants with chronic diseases or permanent disablement impairing driving performance, primary outcomes as fatal/non-fatal traffic injuries and secondary outcomes as fitness to drive assessment. Twenty-seven studies fulfilled the inclusion criteria. Some studies included more than one clinical condition. The illness investigated were Alzheimer Disease (n=6), Parkinson Disease (n=8), Cardiovascular Accident (n=4), Traumatic Brain Injuries (n=3), Sleep Apnea Syndrome (n=2), Narcolepsy (n=1), Multiple Sclerosis (n=1) and Hepatic Encephalopathy (n=1), comorbidities (n=3). No studies match inclusion criteria about Myasthenia Gravis, Diabetes Mellitus, Renal Diseases, Hearing Disorders and Sight Diseases. No studies referred to primary outcomes. The selected studies provided opposite evidences. It would be reasonable to argue that some clinical and neuropsychological tests are effective in predicting fitness to drive even if contrasting results support that driving performance decreases as a function of clinical and neuropsychological decline in some chronic diseases. Nevertheless we found no evidence that clinical and neuropsychological screening tests would lead to a reduction in motor vehicle crashes involving chronic disabled drivers. It seems necessary to develop tests with proven validity for identifying high-risk drivers so that physicians can provide guidance to their patients in chronic conditions, and also to medical advisory boards working with licensing offices.

Global processing training to improve visuospatial memory deficits after right-brain stroke

Visuospatial stimuli are normally perceived from the global structure to local details. A right-brain stroke often disrupts this perceptual organization, resulting in piecemeal encoding and thus poor visuospatial memory. Using a randomized controlled design, the present study examined whether promoting the global-to-local encoding improves retrieval accuracy in right-brain-damaged stroke survivors with visuospatial memory deficits. Eleven participants received a single session of the Global Processing Training (global-to-local encoding) or the Rote Repetition Training (no encoding strategy) to learn the Rey-Osterrieth Complex Figure. The result demonstrated that the Global Processing Training significantly improved visuospatial memory deficits after a right-brain stroke. On the other hand, rote practice without a step-by-step guidance limited the degree of memory improvement. The treatment effect was observed both immediately after the training procedure and 24 h post-training. Overall, the present findings are consistent with the long-standing principle in cognitive rehabilitation that an effective treatment is based on specific training aimed at improving specific neurocognitive deficits. Importantly, visuospatial memory deficits after a right-brain stroke may improve with treatments that promote global processing at encoding.

Executive function and activities of daily living in Alzheimer's disease: a correlational meta-analysis

BACKGROUND

The assessment of executive function (EF) and activities of daily living (ADL) are important elements in the diagnosis of Alzheimer's disease.

METHODS

Following a comprehensive search in three databases, a random-effects meta-analysis was used to investigate the association between ADL ability and seventeen tests of EF, three tests of attention and working memory and the Mini-Mental State Examination. The association between EF and ADL ability was further investigated in relation to four different methods of assessing ADL, and one specific ADL, driving.

RESULTS

Forty-nine studies met the inclusion criteria, and a total of 3,663 participants were included, the majority of whom were diagnosed with Alzheimer's disease. Most of the individual tests, including commonly used tests of EF such as the Clock Drawing Test, Letter Fluency and the Trail Making Test Part B, showed a significant moderate association with ADL. Associations between EF and ADL ability were similar for all four methods of assessing ADL ability. Driving ability was also moderately associated with EF.

CONCLUSION

The meta-analysis suggests a consistent moderate association between ADL and EF, supporting the growing evidence for a link between ADL and executive dysfunction in early dementia.

The Addenbrooke's Cognitive Examination Revised as a potential screening test for elderly drivers

Considerable research has shown that neuropsychological tests are predictive of real-world driving ability. The Mini-Mental State Examination (MMSE) is a brief cognitive test that has been commonly used in the assessment of older drivers. However, this test has inherent problems that limit its validity to evaluate cognitive abilities related to driving and to screen for driving impairments in non-demented people. Therefore, it is useful to test new screening instruments that may predict potential unsafe drivers who require an in-depth neuropsychological assessment in a specialised centre. To date, the utility of the Addenbrooke's Cognitive Examination Revised (ACE-R) as an indicator of driving ability has not been established. In the current study, fifty older drivers (mean age=73.1 years) who were referred for a psychological assessment, the protocol of which included the ACE-R, underwent an on-road driving test. Using linear discriminant analyses, the results highlighted the higher classification accuracy of the ACE-R compared to the MMSE score, particularly for detecting unsafe drivers. Measures of visuospatial and executive functions, which are not incorporated in the MMSE score, had an incremental value in the prediction of driving ability. This emerging brief cognitive test may warrant additional study for use in the fitness to drive assessment of older adults.

Validity of the Occupational Therapy-Drive Home Maze Test for right and left handed test takers

The Occupational Therapy-Drive Home Maze Test (OT-DHMT) is part of the OT-DORA Battery used in licensing recommendations for older and/or functionally impaired drivers. Previously published research has been conducted to investigate the predictive validity, inter-rater reliability and establish norms for this timed test with normal and cognitively impaired drivers. Anecdotal evidence from this research indicated there could be a bias against right-handers (dextrals) who may need to lift their hand to view the maze, thus increasing the time taken. Therefore this study investigated the validity of the OT-DHMT when administered to left and right handed individuals. The OT-DHMT was individually administered to a new sample of 144 healthy drivers aged 18-69 years. From this, 34 participant pairs were matched for age and gender, according to their dexterity. The results show that there were no significant differences in time taken when completing the maze test, for participants who complete the test with either writing hand t(33)=1.59, p=0.12 (95%CI: -0.63 to 5.08). While further testing is required with samples from different cultures and with more participants aged 30-69 and 70 years and over to extend generalizability of these findings, the results suggest the OT-DHMT is suitable to be administered and scored using the methods published as part of the OT-DORA Battery.

Road test and naturalistic driving performance in healthy and cognitively impaired older adults: does environment matter?

OBJECTIVES

To relate the standardized road test to video recordings of naturalistic driving in older adults with a range of cognitive impairment.

DESIGN

Cross-sectional observational study.

SETTING

Academic medical center memory disorders clinic.

PARTICIPANTS

One hundred three older drivers (44 healthy, 59 with cognitive impairment) who passed a road test.

MEASUREMENTS

Error rate and global ratings of safety (pass with and without recommendations, marginal with restrictions or training, or fail) made by a professional driving instructor.

RESULTS

There was fair agreement between global ratings on the road test and naturalistic driving. More errors were detected in the naturalistic environment, but this did not affect global ratings. Error scores between settings were significantly correlated, and the types of errors made were similar. History of crashes corrected for miles driven per week was related to road test error scores but not naturalistic driving error scores. Global cognition (Mini-Mental State Examination) was correlated with road test and naturalistic driving errors. In healthy older adults, younger age was correlated with fewer errors on the road test and more errors in naturalistic driving.

CONCLUSION

Road test performance is a reasonable proxy for estimating fitness to drive in older individuals' typical driving environments, but differences between performance assessed using these two methods remain poorly understood and deserve further study.

Naturalistic validation of an on-road driving test of older drivers

OBJECTIVE

The objective was to compare a standardized road test to naturalistic driving by older people who may have cognitive impairment to define improvements that could potentially enhance the validity of road testing in this population.

BACKGROUND

Road testing has been widely adapted as a tool to assess driving competence of older people who may be at risk for unsafe driving because of dementia; however, the validity of this approach has not been rigorously evaluated.

METHOD

For 2 weeks, 80 older drivers (38 healthy elders and 42 with cognitive impairment) who passed a standardized road test were video recorded in their own vehicles. Using a standardized rating scale, 4 hr of video was rated by a driving instructor. The authors examine weighting of individual road test items to form global impressions and to compare road test and naturalistic driving using factor analyses of these two assessments.

RESULTS

The road test score was unidimensional, reflecting a major factor related to awareness of signage and traffic behavior. Naturalistic driving reflected two factors related to lane keeping as well as traffic behavior.

CONCLUSION

Maintenance of proper lane is an important dimension of driving safety that appears to be relatively underemphasized during the highly supervised procedures of the standardized road test.

APPLICATION

Road testing in this population could be improved by standardized designs that emphasize lane keeping and that include self-directed driving. Additional information should be sought from observers in the community as well as crash evidence when advising older drivers who may be cognitively impaired.

Development of a standardised Occupational Therapy--Driver Off-Road Assessment Battery to assess older and/or functionally impaired drivers

INTRODUCTION

Research has been conducted over several years to develop a new off-road assessment battery referred to as the Occupational Therapy - Driver Off-Road Assessment Battery. This article documents the development of the Battery, and provides preliminary research evidence to support its content and predictive validity.

METHODS

Literature reviews and a focus group with nine driver assessor occupational therapists were undertaken, as well as data collection using the Occupational Therapy - Driver Off-Road Assessment Battery with 246 clients. A Classification and Regression Tree model was constructed to ascertain the predictive validity of the Battery, with fitness-to-drive as the outcome.

RESULTS

Twenty-one physical, 13 sensory and seven assessments of cognition/perception were identified as being reflective of the skills required for driving. Following rating of their psychometric properties, the best assessments were presented to focus group members. The driver assessors supported the inclusion of several assessments and encouraged the development of new assessments. A draft version of the Occupational Therapy - Driver Off-Road Assessment Battery was tested and found to have excellent predictive validity for client on-road performance of 82.6%. The Classification and Regression Tree model showed that client performance on tests included in the Battery should be used together, rather than in isolation, to support fitness-to-drive recommendations.

CONCLUSION

This research identified the most suitable physical, sensory and cognitive assessments to include in the Occupational Therapy - Driver Off-Road Assessment Battery, and provided support for its validity. The development of this standardised battery assists driver assessors to accurately and consistently assess and report the off-road driving capacity of clients.