"You just have to be careful how you do it": A qualitative study of the Healthwise decision aid for older drivers

OBJECTIVE

Decisions about driving retirement are difficult for older adults, their families, and health care providers. A large randomized trial found that an existing online Healthwise decision aid decreased decision conflict and increased knowledge about driving decisions. This study sought to discover how, when, and where the tool might be most effective for older drivers, their family members, and their health care providers.

METHODS

We used one-on-one, semistructured interviews (June-December 2023) to explore perspectives on the content of the Healthwise online driving decision aid and its potential use. Participants were health care providers or subject matter experts in older driver research or policy. Transcribed interviews were coded and analyzed with a team-based approach to identify emerging themes.

RESULTS

Across interviews (16 health care providers; 15 experts), emerging themes related to considerations (barriers, benefits, and settings for use) that were (1) individual or interpersonal or (2) institutional or cultural, as well as feedback on (3) decision aid content and structure. Findings included concerns over agism and damaging provider-patient relationships, along with identified benefits of integrating tools into electronic health records and a need for consolidated, easy-to-access resources for both providers and patients.

CONCLUSION

Attention to individual, interpersonal, institutional, and cultural factors may enhance the use and dissemination of an online decision aid about driving, as well as its effectiveness in decision making. Future work should include views of additional stakeholders and studies on implementation of decision aids into real-world settings.

Driving predictors in a cohort of cognitively impaired Mexican American and non-Hispanic White individuals

BACKGROUND

Individuals with Alzheimer's disease and Alzheimer's disease-related dementias may lose the ability to drive safely as their disease progresses. Little is known about driving prevalence in older Latinx and non-Hispanic White (NHW) individuals. We investigated the prevalence of driving status among individuals with cognitive impairment in a population-based cohort.

METHODS

This was a cross-sectional analysis of the cohort BASIC-Cognitive study in a community of Mexican American (MA) and NHW individuals in South Texas. Participants scored ≤25 on the Montreal Cognitive Assessment (MoCA), indicating a likelihood of cognitive impairment. Current driving status was assessed by the Harmonized Cognitive Assessment Protocol informant interview. Logistic regression was used to assess driving versus non-driving adjusted for pre-specified covariates. Chi-square and Mann-Whitney U tests were used to compare NHW and MA differences in driving outcomes from the American Academy of Neurology (AAN) questions for evaluating driving risk in dementia.

RESULTS

There were 635 participants, 77.0 mean age, 62.4% women, and 17.3 mean MoCA. Of these, 360 (61.4%) were current drivers with 250 of 411 (60.8%) MA participants driving, and 121 of 190 (63.70%) NHW participants driving (p = 0.50). In fully adjusted models age, sex, cognitive impairment, language preference, and Activities of Daily Living scores were significant predictors for the likelihood of driving (p < 0.0001). Severity of cognitive impairment was inversely associated with odds of driving, but this relationship was not found in those preferring Spanish language for interviews. Around one-third of all caregivers had concerns about their care-recipient driving. There were no significant differences in MA and NHW driving habits and outcomes from the AAN questionnaire.

CONCLUSIONS

The majority of participants with cognitive impairment were currently driving. This is a cause for concern for many caregivers. There were no significant ethnic driving differences. Associations with current driving in cognitively impaired persons require further research.

Views on Firearm Safety Among Caregivers of People With Alzheimer Disease and Related Dementias

IMPORTANCE

The population of adults with Alzheimer disease and related dementias (ADRD) is increasing, and many people with ADRD have access to firearms. Little is known, however, about how caregivers of people with ADRD think about or address firearm safety.

OBJECTIVE

To assess views on firearm safety risks among caregivers of persons with ADRD, experiences of caregivers with health care professional-delivered counseling, and their preferred sources of information about firearm safety.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used a probability-based online survey (National Firearms Survey, July 30 to August 11, 2019) with weights used to generate nationally representative estimates of adults living in households with firearms to assess firearm safety views of English-speaking adults 35 years or older. Respondents for the National Firearm Survery were drawn from I KnowledgePanel, a frame with approximately 55 000 US adults selected on an ongoing basis using address-based sampling methods.

MAIN OUTCOMES AND MEASURES

Caregivers were asked whether the person with ADRD owned or had access to firearms. Additional ADRD-related measures assessed perceptions about the likelihood of types of firearm injuries involving people with ADRD, support for firearm safety counseling by health care professionals with regard to dementia, and history of ever having received such counseling.

RESULTS

Of 6712 invited panel members, 4030 completed the survey (completion rate, 65%). For this analysis, we excluded the youngest participants (aged 18-34 years; n = 498); among the remaining 3532 participants, 124 reported being caregivers for persons with ADRD. Of the 124 caregivers, 51% were female and the mean (SD) age was 60 (12.5) years. Most participants (71%; 95% CI, 69%-72%) thought that a person with ADRD was more likely to hurt someone else unintentionally than intentionally hurt themselves or someone else. Many participants thought health care professionals should always (45%; 95% CI, 43%-47%) or sometimes (34%; 95% CI, 32%-37%) talk about firearm safety with caregivers or patients with dementia, but only 5% of caregivers (95% CI, 2%-12%) reported that a health care professional had ever spoken to them about firearm safety. Among the 41% (95% CI, 31%-51%) of caregivers who lived with a person with dementia, 31% (95% CI, 18%-49%) said the person with dementia could access firearms in the home.

CONCLUSIONS AND RELEVANCE

In this study, few caregivers of adults with ADRD reported having received health care professional counseling about firearm safety, although most thought health care professionals should provide such counseling. These findings raise concerns about home firearm access among adults with ADRD and indicate potential opportunities for enhanced education by health care professionals and community organizations.

Prevalence and determinants of driving habits in the oldest old: Results of the multicenter prospective AgeCoDe-AgeQualiDe study

AIM

To present data on the prevalence of driving habits and to identify the determinants of driving habits among the oldest old in Germany.

METHODS

Cross-sectional data were used from the "Study on Needs, health service use, costs and health-related quality of life in a large sample of oldest-old primary care patients (85+)" (AgeQualiDe), including primary care patients aged 85 years and above (n = 549 at FU 9, mean age was 90.3 years; 86-101 years). Driving habits were measured (driving a car; frequency of driving a car and driving duration). Correlates were quantified using widely established scales (e.g., Geriatric Depression Scale, Instrumental Activities of Daily Living Scale). Multiple regression models were used to identify the determinants of driving habits.

RESULTS

Sixteen percent (87 out of 549) drove a car. Among the car-drivers, about 80% drove at least several times a week and about two-thirds drove longer distances (>15 min). Multiple logistic regressions showed that among the oldest old being a male was more likely to be a current driver compared to being a female. Other significant factors were subjective memory impairment, severe visual impairment, functional and cognitive impairment. Correlates of frequency of driving a car and driving duration were further identified.

CONCLUSION

About one in six very old Germans is still a regular car driver. Several determinants of driving habits among the oldest old were identified. Future longitudinal studies are required to clarify the factors leading to changes in driving habits.

"Are you still driving?" Metasynthesis of patient preferences for communication with health care providers

AIM

The aim of this study was to synthesize published qualitative studies to identify older adults' preferences for communication about driving with health care providers.

BACKGROUND

Health care providers play a key role in addressing driving safety and driving retirement with older adults, but conversations about driving can be difficult. Guides exist for family members and providers, but to date less is known about the types of communication and messages older drivers want from their health care providers.

DESIGN

A qualitative metasynthesis of studies published on or before October 10, 2014, in databases (PubMed, CINAHL, PsycINFO, and Web of Science) and grey literature was performed.

REVIEW METHODS

Twenty-two published studies representing 518 older adult drivers met the following inclusion criteria: the study (1) was about driving; (2) involved older drivers; (3) was qualitative (rather than quantitative or mixed methods); and (4) contained information on older drivers' perspectives about communication with health care providers.

RESULTS

We identified 5 major themes regarding older adults' communication preferences: (1) driving discussions are emotionally charged; (2) context matters; (3) providers are trusted and viewed as authority figures; (4) communication should occur over a period of time rather than suddenly; and (5) older adults desire agency in the decision to stop driving.

CONCLUSION

Various stakeholders involved in older driver safety should consider older drivers' perspectives regarding discussions about driving. Health care providers can respect and empower older drivers-and support their family members-through tactful communication about driving safety and mobility transitions during the life course.

Physician involvement in life transition planning: a survey of community-dwelling older adults

Background

With many information sources for healthy aging and life transitions, it is unknown whether community-dwelling older adults desire physician involvement in future planning decisions. The study aimed to examine older adults’ experiences and opinions concerning four future planning domains: advance care planning, driving, finances, and housing.

Methods

Adults aged ≥55 years living at a large urban, independent living facility were surveyed with an anonymous, voluntary, paper-based, mailed questionnaire. Survey domains were advance care planning, driving, finances, and housing. For each domain, questions assessed confidence, openness to discussions, information sources, and prior and desired future role of the physician in decision-making by domain. Comparisons across and within domains were determined using Chi-square tests.

Results

The response rate was 56 % (N = 457; median age: 75 years; 74 % female). Among advance care planning, driving, and finances, respondents were more confident about what it means to have an advance directive (87 %, 95 % CI 84 − 90 %) than alternative transportation options (46 %, 95 % CI 42 − 51 %). Nearly two-thirds of respondents (64 %, 95 % CI 59 − 68 %) were open to discussing driving cessation, though only one-third (32 %, 95 % CI 28 − 37 %) were open to having a family member determine timing of driving cessation. More individuals (44 %, 95 % CI 39 − 49 %) were open to a physician deciding about when to stop driving. Past discussions with family or friends about advance care planning or finances were common, although past discussions about driving were less common. Respondents reported personal experience and family as key information sources, which were significantly more common than healthcare providers. While prior involvement by physicians in decision-making was rare across all domains, some respondents expressed desire for future physician involvement in all domains, with advance care planning (29 %, 95 % CI 25 − 33 %) and driving safety (24 %, 95 % CI 20 − 28 %) having highest levels of support for future physician involvement.

Conclusions

Some older adults desired more physician involvement in future planning for life transitions, especially related to advance care planning and driving compared to finances and housing. Clinical implications include increased patient-centered care and anticipatory guidance by physicians for aging-related life transitions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0311-0) contains supplementary material, which is available to authorized users.

[Fitness to drive in dementia - theoretical framing and design of a recommendation for German general practice]

BACKGROUND

General practitioners (GPs) are among the first to be contacted by persons with dementia and their relatives. Fitness to drive in dementia is a subject of uncertainty and conflict for GPs.

OBJECTIVE

Development of recommendations for German general practice on managing fitness to drive in dementia.

METHODS

Specification of problem areas by using relevant parts of a metasynthesis of international qualitative dementia research with GPs; literature review on evidence regarding the pre-defined problem areas; deduction of a preliminary design for a recommendation in a multi-professional team.

RESULTS

The difficulties include the assessment of fitness to drive in the office setting, concerns about damaging the patient-physician relationship by raising the issue of driving fitness, and uncertainties about the GP's own legal role. A diagnosis of dementia does not per se preclude driving. The majority of elderly people would accept discussing fitness to drive with their GP. In Germany, GPs are not obliged to assess fitness to drive, or to report unsafe drivers to the Licensing Agency, but under certain conditions they do have the right to report. Addressing the issue of driving and dementia early with the patient seems to be a prerequisite for a resource-oriented and patient-centred management.

DISCUSSION

The distinction between medical, ethical-communicative, and legal aspects enabled us to break down this complex problem and thus provide the informative basis to draft tailored recommendations. In an ongoing project, this framework will be further developed and informed by the expertise of patients, family caregivers, and professionals from various fields.

Emergency departments and older adult motor vehicle collisions

In 2009 the Centers for Disease Control and Prevention reported that there were 33 million licensed drivers 65 years and older in the U.S. This represents a 23 percent increase from 1999, a number that is predicted to double by 2030. Although motor vehicle collisions related to emergency department visits for older adults are lower per capita than for younger adults, the older-adults MVCs require more resources, such as additional diagnostic imaging and increased odds of admission. Addressing the specific needs of older adults could lead to better outcomes, yet not enough research exists. It is important to continue training emergency physicians to treat the increasing older-patient population, but it is also imperative that we increase our injury prevention and screening methodology. We review research findings from the article “Emergency Department Visits by Older Adults for Motor Vehicle Collisions: A Five-Year National Study,” with commentary on current recommendations and policies for the growing older-adult driving population.

"I wish we could normalize driving health:" a qualitative study of clinician discussions with older drivers

BACKGROUND

Driving for older adults is a matter of balancing independence, safety and mobility, and prematurely relinquishing the car keys can impact morbidity and mortality. Discussions about "when to hang up the keys" are difficult for clinicians, drivers, and family members, and therefore are often avoided or delayed. "Advance Driving Directives" (ADDs) may facilitate conversations between health care providers and older drivers focused on prevention and advance planning for driving cessation.

OBJECTIVE

To examine clinician and older driver perspectives on ADDs and driving discussions.

DESIGN

Qualitative descriptive study using iterative focus groups and interviews with clinicians and drivers.

PARTICIPANTS

(1) Eight practicing internal medicine physicians, physician assistants or nurse practitioners working at three university-affiliated clinics; and (2) 33 community-dwelling current drivers aged 65 years or older.

APPROACH

Theme analysis of semi-structured focus groups and interviews with clinicians and older drivers was used to explore clinician and driver perspectives on "ADDs" and driving conversations. General inductive qualitative techniques were used to identify barriers and facilitators to conversations between older drivers and their healthcare providers about driving and health.

KEY RESULTS

Five dominant themes emerged: (1) clinicians usually initiate conversations, but typically not until there are "red flags;" (2) drivers are open to conversations, especially if focused on prevention rather than interventions; (3) family input influences clinicians and drivers; (4) clinical setting factors like short appointments affect conversations; and (5) both clinicians and drivers thought ADDs could be useful in some situations and recommended making general questions about driving a part of routine care.

CONCLUSIONS

Clinicians and older drivers often wait to discuss driving until there are specific "red flags", but both groups support a new framework in which physicians routinely and regularly bring up driving with patients earlier in order to facilitate planning for the future.