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.

An integrative review: understanding driving retirement decisions for individuals living with a dementia

AIM

To synthesise primary research exploring decision making practices used to determine the time to retire from driving for individuals living with a dementia.

BACKGROUND

Driving requires complex cognitive and physical skills potentially compromised due to the progressive nature of dementia. Whilst on-road assessments are considered reliable indicators of driving capacity by clinicians, drivers with dementia disagree.

DESIGN

Integrative literature review informed by Whittemore & Knafl (2005).

DATA SOURCES

Electronic database search of Medline, CINAHL, Web of Science, Google Scholar 1997-2012; and incremental hand search.

REVIEW METHODS

Primary studies published in peer reviewed journals were appraised against quality assessment criteria using CASP methodological assessment tools.

RESULTS

A total of 43 studies were retained for synthesis. Key findings were abstracted and a themes matrix was generated to identify patterns of meaning. Six themes emerged: (i) dementia may compromise the complex task of driving; (ii) defining onset and severity of dementia is problematic; (iii) symptom progression impacts on driving skills; (iv) assessment of fitness to drive remains subjective; (v) some drivers are reluctant to accept negative assessment outcomes; and (vi) the search for effective strategies to enhance acceptance of driver retirement continues.

CONCLUSION

This integrative literature review identified a large body of knowledge exploring the issues of driving cessation for drivers with dementia. However a challenge remains for practitioners, drivers and their family carers regarding how best to address this highly emotive issue. Findings could inform a structured approach to address this sensitive topic in a timely manner.

The relationship between cognitive performance, perceptions of driving comfort and abilities, and self-reported driving restrictions among healthy older drivers

The objective of the present study was to examine the relationship between cognitive performance, driver perceptions and self-reported driving restrictions. A cross-sectional analysis was conducted on baseline data from Candrive II, a five-year prospective cohort study of 928 older drivers aged 70-94 years from seven cities. Cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA) as well as the Trail Making Test, parts A and B. Driver perceptions were assessed using the Day and Night Driving Comfort Scales and the Perceived Driving Abilities scale, while driving practices were captured by the Situational Driving Frequency and Avoidance scales, as well as the Driving Habits and Intentions Questionnaire. The baseline data indicates this cohort is largely a cognitively intact group. Univariate regression analysis showed that longer Trails A and B completion times were significantly, but only modestly associated with reduced driving frequency and perceived driving abilities and comfort, as well as a significant tendency to avoid more difficult driving situations (all p<.05). Most of these associations persisted after adjusting for age and sex, as well as indicators of health, vision, mood and physical functioning. Exceptions were Trails A and B completion times and situational driving frequency, as well as time to complete Trails B and current driving restrictions. After adjusting for the confounding factors, the total MoCA score was not associated with any of the driving measure scores while the number of errors on Trails A was significantly associated only with situational driving frequency and number of errors on Trails B was significantly associated only with situational driving avoidance. Prospective follow-up will permit examination of whether baseline cognition or changes in cognition are associated with changes in driver perceptions, actual driving restrictions and on-road driving outcomes (e.g., crashes, violations) over time.

When it is time to hang up the keys: the driving and dementia toolkit - for persons with dementia (PWD) and caregivers - a practical resource

Background

The aim of this project was to develop a toolkit to assist persons with dementia (PWD) and their caregivers, in planning for retirement from driving. The information gathered was used to develop a tool that can assist reflection about, and make sound decisions in this challenging area of the dementia journey. The purpose is to keep safe drivers on the road and to prepare those who are moving towards being at risk of being involved in crashes, to eventually stop driving when they are unsafe.

The toolkit was prepared to address the concerns of both the PWD as well as the caregivers. Strategies and solutions are presented for both the PWD and the caregivers. A grief insert was also developed that can assist caregivers in supporting the PWD in the grief process that can accompany losing one’s driving privileges.

Mandatory testing of drivers on the basis of age and degenerative diseases: stakeholder opinions

Concerns about the driving competence of older drivers have led to policy discussions about mandatory aged-based and disorder-based assessments. This study explored the attitudes, beliefs, and preferences of older adults, law enforcement officers, and licensing authorities toward reexamination of driving skills for persons with Alzheimer's disease (AD) and Parkinson's disease (PD) and at varying ages. With few exceptions, participants across all groups supported retesting drivers with AD. Moderate support was given for further evaluation of 90-year-olds and those with PD. Least endorsement was given for reassessment of 70-year-old drivers. Findings have implications for legislative changes to address drivers with AD and PD and at older ages.

Elderly drivers: future challenges?

The objective of this paper is to describe and interpret the results from a public opinion poll about elderly drivers to provide useful information regarding future challenges related to elderly drivers. The introduction describes demographic developments, factors affecting elderly drivers, crash rates of elderly drivers and characteristics of crashes of elderly drivers. This information is used to provide a context to interpret the results of the public opinion poll. A total of 1238 drivers completed the interview, which required an average of approximately 15 min per respondent. It was administered by telephone to a random sample of Canadian drivers by Opinion Search Inc., in September 2007. Criteria for inclusion were having a valid driver's license and having driven in the past 30 days. Data were weighted according to region, gender and age to avoid bias. Univariate frequency distributions, their 95% confidence intervals and Chi-square statistics were calculated taking account of the stratified and weighted sampling design. Also, multivariate logistic regression was performed, accounting for the design effects of the used sampling design. Lower levels of concern about the issue of elderly drivers were found among the public at large and especially among elderly drivers. While general support for actions to protect elderly drivers was high, elderly drivers were less supportive for a measure requiring them to complete training to maintain their driving privileges. The results from this survey are contrasted against what is known from the literature about the issue of elderly drivers and conclusions regarding future challenges are drawn.

At the crossroads: development and evaluation of a dementia caregiver group intervention to assist in driving cessation

Deciding when an individual with dementia must reduce or stop driving can be a stressful issue for family caregivers. The purpose of this study was to develop a group intervention to assist these caregivers with driving issues and to provide a preliminary evaluation of the comparative effectiveness of this At the Crossroads intervention. Participants were randomized to one of three arms: (1) active intervention (four 2-hour manualized educational/support group meetings; n = 31); (2) written materials only (participants received written materials after a pretest; n = 23); and (3)control (participants received written materials after a posttest; n = 12).Participants were administered a battery of self-report and interview-based questionnaires at baseline and again 2 months later. At follow-up, the active intervention group scored significantly better than both other groups on key outcome variables, including self-efficacy, communication, and preparedness. The At the Crossroads caregiver intervention appears to effectively provide education and support needed for caregivers to address driving-related issues with their loved ones.