Predictors of driving cessation in mild-to-moderate dementia

Mild cognitive impairment, Alzheimer's disease dementia, and predictors of driving cessation: A 7-year longitudinal prospective study

BackgroundPatients with dementia face driving difficulties and, at some point, cease driving.ObjectiveWe sought to identify predictors of driving cessation among patients with mild cognitive impairment (MCI) or mild Alzheimer's disease dementia (AD).MethodsWe enrolled in this longitudinal study patients with MCI, AD (Clinical Dementia Rating < 2) and cognitively normal (NC) individuals. At baseline evaluation, participants underwent a neurological, neuropsychological and driving simulator assessment. Re-evaluations after 48 and 84 months included a structured interview with the patients and their caregiver. Primary endpoints were driving cessation, death and progression to dementia.Results109 individuals were included (32 NC, mean age 65.8 years/47 MCI, mean age 69.1 years/30 AD, mean age 72.8 years). Dangerous driving events during follow-up were referred for 45% and 59% of MCI and AD patients, respectively. 18 MCI (38%, mean time to cease 35 months) and 25 AD (83%, mean time to cease 15 months) patients ceased driving during follow-up. 36% of MCI patients progressed to dementia during follow-up. Cox Regression multivariate analysis revealed age (Hazard Ratio-HR 1.080), semantic verbal fluency-SVF (HR 0.822) and Tandem Walking Test modified with simultaneous reverse number counting-mTWT (HR 1.099) as significant predictors of driving cessation. Simulator accident probability reached statistical significance only in the univariate model (HR 1.040).ConclusionsAge, SVF and mTWT are significant predictors of driving cessation among MCI and AD patients. Driving simulator may be a promising component of driving evaluation. Large-scale studies are prerequisite for the implementation of a multi-disciplinary driving fitness evaluation protocol.

Young onset dementia and driving cessation: a scoping review of lived experiences

BACKGROUND

Driving cessation is one of the most challenging life transitions, associated with multiple negative consequences for individuals living with late-onset dementia. This paper extends the literature as to date there is no published review that details the experiences of people living with young onset dementia ("YOD").

METHODS

A comprehensive search of the literature was conducted using the scoping review methodology.

RESULTS

Ten studies were included for full text review of 1634 initially identified through database searching. The results of the included articles indicated areas of concern for people living with YOD and their family members including, loss of independence; role change; threat to self-identify; feelings of isolation, grief; acceptance; predictors of driving cessation.

CONCLUSION

There is a lack of robust evidence related to driving cessation and the experiences of people living with YOD. No published paper reported psychosocial interventions specifically targeted at supporting persons with YOD through driving cessation.

A qualitative study exploring the experiences and needs of people living with young onset dementia related to driving cessation: 'It's like you get your legs cut off'

BACKGROUND

driving disruptions have significant impact on individuals living with dementia, their care partners and family members. Previous studies show that for older people with dementia, stopping driving is one of the hardest things that they cope with. To date, no studies exist that address the expressed needs and experiences of people living with young onset dementia (YOD) who are adjusting to life without driving, whose needs are not well understood and whose needs might be expected to differ from those of older people with dementia.

METHODS

a multi-perspective, qualitative descriptive phenomenological approach was undertaken. A topic guide was developed in consultation with lived experience experts. In-depth interviews (n = 18) with 10 people with YOD and eight family caregivers were conducted, to elicit lived experiences in relation to changing and cessation of driving. Interviews were recorded and transcribed verbatim. Data were analysed using a hybrid approach, employing deductive and inductive coding.

RESULTS

core findings reflected the impact and coping strategies employed by people with YOD and their care partners across four themes: (i) losses and burdens, (ii) the unique challenges of YOD, (iii) coping and adjustment and (iv) how to meet needs.

CONCLUSIONS

driving disruptions often come at a time when people living with YOD are likely to have significant financial and family commitments, or they/their partners may be employed or raising a family, negatively impacting individual's roles and self-identities. Intervention to support emotional and practical adjustment and reduce social isolation is essential for coping.

Distinguishing apathy and depression in dementia: A longitudinal study

OBJECTIVES

Apathy is a common symptom in dementia, though can be difficult to distinguish from depression due to shared features and frequent co-occurrence. As such, a significant limitation of much previous research on apathy is the failure to control for depression. The current study sought to address this by examining the trajectory and clinical correlates of apathy after controlling for depression.

METHODS

Seven hundred and seventy-nine patients with dementia were recruited from nine memory clinics around Australia. Measures of dementia severity, cognition, functional ability, neuropsychiatric symptoms, caregiver burden and medication use were completed at baseline and at regular intervals over a 3-year period. Driving and institutionalisation data were obtained throughout the study. Mortality data were obtained from state registries 8 years after baseline.

RESULTS

Of the 662 patients with completed measures of neuropsychiatric symptoms, 342 (51.7%) had apathy and 332 (50.2%) had depression at baseline, while 212 (32.0%) had both. Whereas apathy increased over time, depression remained relatively stable. Apathy, but not depression, was associated with greater dementia severity, poorer cognition and function, driving cessation and mortality. Both apathy and depression were associated with greater neuropsychiatric symptoms, psychosis, caregiver burden and institutionalisation.

CONCLUSIONS

Apathy increases over the course of dementia and is associated with worse clinical outcomes independent of depression. Distinguishing apathy and depression appears important given their different implications for prognosis and management.

Association Between Young-Onset Dementia and Risk of Hospitalization for Motor Vehicle Crash Injury in Taiwan

IMPORTANCE

Several studies have suggested that older-onset dementia is associated with an increased risk of motor vehicle crash injury (MVCI). However, evidence of an association between young-onset dementia and the risk of MVCI is insufficient, particularly in Asia.

OBJECTIVE

To investigate the association between young-onset dementia and MVCI-related hospitalization in Taiwan.

DESIGN, SETTING, AND PARTICIPANTS

In this nationwide, population-based cohort study in Taiwan, a cohort of 39 344 patients aged 40 to 64 years with incident dementia diagnosed between 2006 and 2012 was matched 1:1 with a cohort of participants without dementia by age, sex, and index year (initial diagnosis of dementia). Participants were identified from Taiwan's National Health Insurance Research Database (NHIRD). Data were analyzed between March 25 and October 22, 2021.

EXPOSURES

Dementia, defined by International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

Hospitalization for MVCI, determined using linked data from Taiwan's Police-Reported Traffic Accident Registry and the NHIRD from January 1, 2003, to December 31, 2015. Hazard ratios (HRs) for MVCI-related hospitalization were estimated using Cox proportional hazards regression models adjusted for sex, age, salary-based insurance premium, urbanization level, and comorbidities.

RESULTS

Of the 78 688 participants, 47 034 (59.8%) were male; the mean (SD) age was 54.5 (7.4) years. During the 10-year follow-up period, the incidence density of MVCI-related hospitalization was 45.58 per 10 000 person-years (95% CI, 42.77-48.39 per 10 000 person-years) among participants with dementia and 24.10 per 10 000 person-years (95% CI, 22.22-25.99 per 10 000 person-years) among participants without dementia. Compared with participants without dementia, patients with young-onset dementia were at higher risk of MVCI-related hospitalization (adjusted HR [aHR], 1.83; 95% CI, 1.63-2.06), especially those in younger age groups (aged 40-44 years: aHR, 3.54; 95% CI, 2.48-5.07) and within a shorter period (within 1 year of follow-up: aHR, 3.53; 95% CI, 2.50-4.98) after dementia was diagnosed. Patients with young-onset dementia also had a higher risk of being a pedestrian when the crash occurred (aHR, 2.89; 95% CI, 2.04-4.11), having an intracranial or internal injury (aHR, 2.44; 95% CI, 2.02-2.94), and having a severe injury (aHR, 2.90; 95% CI, 2.16-3.89).

CONCLUSIONS AND RELEVANCE

In this retrospective cohort study, patients in Taiwan with a diagnosis of young-onset dementia had a higher risk of MVCI-related hospitalization than did individuals without dementia and the risk varied by age, disease duration, transport mode, injury type, and injury severity. These findings suggest a need for the planning of strategies to prevent transportation crashes among patients with young-onset dementia.

Meaningful Activities and Psychosomatic Functions in Japanese Older Adults after Driving Cessation

The purpose of this cross-sectional study was to analyse the differences in meaningful activities and psychosomatic function depending on the driving status of community-dwelling older adults. Data from 594 older adults were obtained, including activities meaningful to individuals and psychosomatic functions, such as grip strength, depression, cognitive function, and ability of activity. Participants were divided into active driving (n = 549) and after driving cessation (n = 45) groups. In addition, the active driving group was operationally divided into three groups: high-frequency group (n = 387), medium group (n = 119), and infrequent group (n = 42). In the after driving cessation group, grip strength, and Japan Science and Technology Agency Index of Competence scores were significantly lower. Furthermore, the proportion of apathy and physical and social frailty was significantly higher in the after driving cessation group. Regarding meaningful activity, domestic life scores in the after driving cessation group were significantly higher than those of the active driving group. Decreased driving frequency in the active driving group was associated with weak muscle strength, lack of interest, and low activity. This study demonstrated that meaningful activity differed based on the driving status. Hence, we should support the activities of older adults who are considering driving cessation.

Using Serial Trichotomization with Neuropsychological Measures to Inform Clinical Decisions on Fitness-to-Drive among Older Adults with Cognitive Impairment

Decisions related to driving safety and when to cease driving are complex and costly. There is an interest in developing an off-road driving test utilizing neuropsychological tests that could help assess fitness-to-drive. Serial trichotomization has demonstrated potential as it yields 100% sensitivity and specificity in retrospective test samples. The purpose of this study was to test serial trichotomization using four common neuropsychological tests (Trail Making Test Part A and B, Clock Drawing Test, and Modified Mini-Mental State Examination). Test scores from 105 patients who were seen in a memory clinic were abstracted. After applying the model, participants were classified as unfit, fit, or requiring further testing, 38.1%, 25.8%, and 36.1%, respectively. This study provides further evidence that trichotomization can facilitate the assessment of fitness-to-drive.

Meta-analysis of Driving Cessation and Dementia: Does Sex Matter?

Objectives

The number of drivers with dementia is expected to increase over the coming decades. Because dementia is associated with a higher risk of crashes, driving cessation becomes inevitable as the disease progresses, but many people with dementia resist stopping to drive. This meta-analysis examines whether there are sex differences in the prevalence and incidence of driving cessation among drivers with dementia and compares the pattern of sex differences in drivers with dementia to those without dementia.

Method

MEDLINE, PsycINFO, Scopus, and CINAHL were searched in July 2015 for observational studies of sex differences in driving cessation. Meta-analyses were performed using a random-effects model.

Results

Twenty studies provided data on sex differences in driving cessation in older adults with or without dementia. Driving cessation was significantly more prevalent in women with dementia than men (odds ratio [OR] = 2.11, 95% confidence interval [CI] = 1.50-2.98), and the same pattern was found in women without dementia (OR = 2.74, 95% CI = 1.85-4.06).

Discussion

Our findings suggest that the patterns of driving cessation differ between men and women with dementia, and this may have implications for sex-specific approaches designed to support drivers with dementia both before and after driving cessation.

Reduced Lower Extremity Functioning Is Associated With an Increased Rate of Being a Nondriver: The National Health and Aging Trends Study

BACKGROUND

Driving a motor vehicle is an important aspect of mobility for older adults. Limited lower extremity functioning performance, as measured by the Short Physical Performance Battery (SPPB), has been associated with various negative health outcomes, but little is known about the association of SPPB scores with driving status.

OBJECTIVE

The purpose of this study was to evaluate whether lower (poorer) SPPB scores are associated with an increased rate for being a current nondriver among a nationally representative sample of community-dwelling older adults.

DESIGN

The National Health and Aging Trends Study is a longitudinal cohort study.

METHODS

A population of 5935 participants, surveyed annually from 2011 to 2014 for the National Health and Aging Trends Study, was used to examine the relationship between SPPB and driving status. Using weighted data, multivariable Poisson regression with generalized estimating equations was used to calculate the rate ratios, adjusting for covariates and clustering due to the complex survey design.

RESULTS

Participants with a low (poor) SPPB score (0-5) had a rate for being a current nondriver 2.01 times the rate (or 101% increase) of those with a high (good) SPPB score (10-12) (adjusted 95% confidence interval = 1.78-2.26).

LIMITATIONS

Current nondrivers were not asked whether they planned to resume driving if they had not driven in the previous year.

CONCLUSIONS

Unlike other factors, such as cognitive decline, lower SPPB scores (poorer lower extremity functioning) are significantly associated with an increased rate of being a current nondriver and are a modifiable risk factor. Further research is needed to examine whether optimum exercises and other physical therapist interventions focused on improving lower extremity strength and balance ultimately improve driving outcomes.

A virtual second opinion: Acceptability of a computer-based decision tool to assess older drivers with dementia

Clinicians face challenges in deciding which older patients with dementia to report to transportation administrators. This study used a qualitative thematic analysis to understand the utility and limitations of implementing a computer-based Driving in Dementia Decision Tool in clinical practice. Thirteen physicians and eight nurse practitioners participated in an interview to discuss their experience using the tool. While many participants felt the tool provided a useful 'virtual second opinion', specialist physicians felt that the tool did not add value to their clinical practice. Barriers to using the Driving in Dementia Decision Tool included lack of integration with electronic medical records and inability to capture certain contextual nuances. Opinions varied about the impact of the tool on the relationship of clinicians with patients and their families. The Driving in Dementia Decision Tool was judged most useful by nurse practitioners and least useful by specialist physicians. This work highlights the importance of tailoring knowledge translation interventions to particular practices.

Driving Cessation and Cognitive Dysfunction in Patients with Mild Cognitive Impairment

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Driving Cessation in Patients Attending a Young-Onset Dementia Clinic: A Retrospective Cohort Study

Background

Although driving by persons with dementia is an important public health concern, little is known about driving cessation in younger people with dementia. We aimed to determine the prevalence and factors affecting driving cessation in individuals with and without dementia aged under 65 years attending a memory clinic in a European setting.

Methods

Subjects were consecutive patients assessed at a specialist memory service at a university teaching hospital between 2000 and 2010. The data collected included demographic, clinical, standardized cognitive assessments as well as information on driving. Dementia diagnosis was made using ICD-10 criteria.

Results

Of the 225 people who were or had been drivers, 32/79 (41%) with young-onset dementia (YOD) stopped driving compared to 25/146 (17%) patients who had cognitive impairment due to other causes. Women were more likely to cease driving and voluntarily than men (p < 0.001). Diagnosis of YOD was associated with driving cessation (1.193, 95% CI 0.570–1.815, p ≤ 0.001), and was mediated by impairment in praxis with the highest indirect mediation effect (0.754, 95% CI 0.183–1.401, p = 0.009).

Conclusions

YOD diagnosis, female gender, and impairment in praxis have a higher probability for driving cessation in those under 65 years of age with cognitive impairment.

Psychometrics of the AAN Caregiver Driving Safety Questionnaire and contributors to caregiver concern about driving safety in older adults

ABSTRACTBackground:The American Academy of Neurology (AAN) updated their practice parameters in the evaluation of driving risk in dementia and developed a Caregiver Driving Safety Questionnaire, detailed in their original manuscript (Iverson Gronseth, Reger, Classen, Dubinsky, & Rizzo, 2010). They described four factors associated with decreased driving ability in dementia patients: history of crashes or citations, informant-reported concerns, reduced mileage, and aggressive driving.

METHOD

An informant-reported AAN Caregiver Driving Safety Questionnaire was designed with these elements, and the current study was the first to explore the factor structure of this questionnaire. Additionally, we examined associations between these factors and cognitive and behavioral measures in patients with mild cognitive impairment or early Alzheimer's disease and their informants.

RESULTS

Exploratory factor analysis revealed a four-component structure, consistent with the theory behind the AAN scale composition. These four factor scores also were significantly associated with performance on cognitive screening instruments and informant reported behavioral dysfunction. Regressions revealed that behavioral dysfunction predicted caregiver concerns about driving safety beyond objective patient cognitive dysfunction.

CONCLUSIONS

In this first known quantitative exploration of the scale, our results support continued use of this scale in office driving safety assessments. Additionally, patient behavioral changes predicted caregiver concerns about driving safety over and above cognitive status, which suggests that caregivers may benefit from psychoeducation about cognitive factors that may negatively impact driving safety.

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.

Gender effect on driving cessation in pre-dementia and dementia phases: results of the 3C population-based study

OBJECTIVES

Aging entails deterioration in sensory, physical, and cognitive functions, raising doubt in the driving capacity of older drivers, especially when the deficits are severe, as in dementia. Many older drivers, especially women, adapt their driving habits in order to compensate for these deficits and eventually stop driving. The present prospective study assessed driving cessation in men and women throughout the dementia process, including a 2-year pre-dementia phase.

METHODS

The study was based on a three-city cohort of subjects who were aged 65 years and older in 2000 and followed for more than 10 years. Active dementia detection was conducted at each follow-up. The probability of driving cessation was assessed in men and women during the 2-year pre-dementia phase and until 5 years after diagnosis.

RESULTS

In the 2-year pre-dementia phase, both men and women ceased driving earlier than drivers with no central nervous system pathology (p < 0,001), and women ceased driving earlier than men. A total of 45% of men and 74% of women had already ceased driving at dementia diagnosis. In contrast, the probability of cessation within 3 years after diagnosis was similar between men and women.

CONCLUSION

The study showed that, in this French urban population, few demented drivers, especially women, were still driving after diagnosis. Those who continued to drive 3 years after the diagnosis all had Alzheimer-type dementia. There is certainly a need for physicians to help these drivers to adapt their driving activity to their deficits and to prepare them to stop driving. Copyright © 2016 John Wiley & Sons, Ltd.

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

BACKGROUND

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

METHODS

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

CONCLUSIONS

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

A systematic review of intervention approaches for driving cessation in older adults

OBJECTIVE

The aim of this project was to review the literature on interventions aimed at facilitating driving cessation in older adults, with and without dementia.

METHODS

A literature search was performed using the databases MEDLINE, CINAHL, Cochrane Central, Embase, and PsycINFO, from 1994 to September 2014. Two independent raters screened articles for inclusion and extracted study data. We only included articles if they directly addressed the topic of intervention approaches to facilitate the process of driving cessation in older adults or to support the adaptation of older adults who have had to stop driving and included a control group.

RESULTS

Of an initial 477 unique records identified, 111 pertained to driving cessation in older adults, and only three articles were controlled trials of intervention approaches related to driving cessation. One article described an intervention for retired drivers with dementia, while another was aimed at caregivers of drivers with dementia, and the third included retired and retiring drivers without dementia. Outcomes such as reduced depressive symptoms, increased trips out of home, and efficacy in dealing with the driving cessation process were positive, but the specific outcome measures and magnitude of effects varied across studies.

CONCLUSIONS

Although the results summarized in this review point toward potentially promising effects of interventions for facilitating driving cessation in older adults, these findings must be interpreted with caution given the significant methodological limitations of the studies, including small samples, participant attrition, lack of blinding, and non-validated outcome measures. Copyright © 2017 John Wiley & Sons, Ltd.

Association between baseline frailty and driving status over time: a secondary analysis of The National Health and Aging Trends Study

BACKGROUND

Continued automobile driving is important for the wellbeing and independence of older adults. Frailty has been associated with a variety of negative health outcomes, but studies are lacking on the potential association between frailty and driving status. The present study uses data from The National Health and Aging Trends Study (NHATS) to assess if the presence of frailty is associated with being a current non-driver.

METHODS

NHATS is a nationally representative cohort study of Medicare beneficiaries (aged ≥65) that have been followed since 2011. We examined frailty status at baseline (Fried's frailty phenotype) and driving status over 4 years (from 2011 to 2014) excluding never drivers at baseline. Multivariable Poisson regression was used to obtain incidence rate ratios, adjusting for covariates and clustering. To account for the repeated measures in the data collection, generalized estimating equations (GEE) were employed.

RESULTS

A significant association between baseline frailty and driving status was observed at all four time points. At T4, frail participants at baseline had an incidence rate for becoming a current non-driver 1.80 times (or an 80% increase) that of non-frail participants at baseline (adjusted 95% confidence interval (CI) 1.56-2.07).

CONCLUSIONS

Frailty was associated with an increased rate of being a current non-driver. Based on this association, we posit that screening for and intervening on frailty may help certain older adults who are at risk for becoming a current non-driver to remain on the road longer.

[Assessment of ability to drive in patients with MCI and dementia]

People with mild cognitive impairment and dementia are a frequent and continuously increasing patient group in practically all fields of medicine. The associated challenges involve nearly all areas of life in addition to the direct medical treatment. Assessment of the ability to drive in patients with cognitive deficits is becoming increasingly more important. What are the options available to physicians in order to make a valid assessment? Which legal aspects must be taken into consideration? Which rights and obligations arise from the framework conditions? These questions nowadays give rise to great uncertainty for many medical personnel; however, the increasing importance of these problems necessitates a clear procedure, which allows difficult decisions to be made with utmost sovereignty and legal certainty and to be able to give patients and relatives a plausible explanation. Because age is a substantial risk factor for the development of cognitive disorders, the question of the ability to drive is affected not only by neuropsychiatric diseases, such as mild cognitive disorders or dementia but also the frequently occurring somatic comorbidities. Estimation of the ability to drive is therefore a complex approach, which should be standardized in order to appreciate all relevant aspects. It would be desirable to have a practice-oriented algorithm, the formulation of which is the aim of this article. Additionally, we would like to make a contribution to road safety and make medical personnel fully aware of this topic.

Assessment and Reporting of Driving Fitness in Patients with Dementia in Clinical Practice: Data from SveDem, the Swedish Dementia Registry

BACKGROUND

Driving constitutes a very important aspect of daily life and is dependent on cognitive functions such as attention, visuo-spatial skills and memory, which are often compromised in dementia. Therefore, the driving fitness of patients with dementia needs to be addressed by physicians and those that are deemed unfit should not be allowed to continue driving.

OBJECTIVE

We aimed at investigating to what extent physicians assess driving fitness in dementia patients and determinant factors for revoking of their licenses.

METHODS

This study includes 15113 patients with newly diagnosed dementia and driver's license registered in the Swedish Dementia Registry (SveDem). The main outcomes were reporting to the licensing authority and making an agreement about driving eligibility with the patients.

RESULTS

Physicians had not taken any action in 16% of dementia patients, whereas 9% were reported to the authority to have their licenses revoked. Males (OR = 3.04), those with an MMSE score between 20-24 (OR = 1.35) and 10-19 (OR = 1.50), patients with frontotemporal (OR = 3.09) and vascular dementia (OR = 1.26) were more likely to be reported to the authority.

CONCLUSION

For the majority of patients with dementia, driving fitness was assessed. Nevertheless, physicians did not address the issue in a sizeable proportion of dementia patients. Type of dementia, cognitive status, age, sex and burden of comorbidities are independent factors associated with the assessment of driving fitness in patients with dementia. Increased knowledge on how these factors relate to road safety may pave the way for more specific guidelines addressing the issue of driving in patients with dementia.

Driving continuity in cognitively impaired older drivers

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Mild dementia and driving ability. Part 1: Fundamentals]

Physiological changes, but most of all diseases, affect driving ability in old age, whereby cognitive and mental performance plays an important part. Impaired health and feeling of unease while driving are the main reasons for driving cessation in the elderly. The causes of crashes and crash development show typical features compared to younger drivers. In the assessment of accident frequency and crash risk, sophisticated analyses are necessary. A person with moderate to severe dementia is certainly no longer fit to drive, whereas driving ability may be maintained in mild dementia for some time. In part 2, comprehensive information on the practice of assessment and judgement of driving ability is provided.

Long-term chronic diseases and crash responsibility: a record linkage study

OBJECTIVE

To assess the population impact of chronic conditions on the risk of road traffic crashes.

METHODS

Data from three French national databases were extracted and matched: the national health care insurance database, police reports and the national police database of injurious crashes. Exposure to chronic conditions were compared between responsible and nonresponsible drivers. Analysis was performed using the Lasso (least absolute shrinkage and selection operator) method.

RESULTS

69,630 drivers involved in an injurious crash in France between 2005 and 2008, were included. 6210 (8.9%) were suffering from at least one long-term disease. When adjusted for prescription of medicines, blood alcohol, demographic driver characteristics and crash characteristics, increased risk of being responsible for a crash was found in drivers registered in the French healthcare database with the following long-term diseases: epilepsy (odds ratio [OR]=2.53 [1.53-4.20]), type 1 diabetes (OR=1.47) [1.12-1.92], alcoholic liver disease (OR=3.37 [1.40-8.13]), asthma (OR=1.72 [1.13-2.60]) and specific personality disorders (OR=1.35 [1.05-1.74]). No association was found for cardiovascular diseases or Alzheimer's disease.

CONCLUSION

The results update the list of medical conditions that may impair driving skills. However, results should be considered cautiously with regards to potential regulatory driving judgments that could have a negative impact on patients' social life.

Development and pilot testing of a decision aid for drivers with dementia

BACKGROUND

An increasing number of older adults drive automobiles. Given that the prevalence of dementia is rising, it is necessary to address the issue of driving retirement. The purpose of this study is to evaluate how a self-administered decision aid contributed to decision making about driving retirement by individuals living with dementia. The primary outcome measure in this study was decisional conflict. Knowledge, decision, satisfaction with decision, booklet use and booklet acceptability were the secondary outcome measures.

METHODS

A mixed methods approach was adopted. Drivers with dementia were recruited from an Aged Care clinic and a Primary Care center in NSW, Australia. Telephone surveys were conducted before and after participants read the decision aid.

RESULTS

Twelve participants were recruited (mean age 75, SD 6.7). The primary outcome measure, decisional conflict, improved following use of the decision aid. Most participants felt that the decision aid: (i) was balanced; (ii) presented information well; and (iii) helped them decide about driving. In addition, mean knowledge scores improved after booklet use.

CONCLUSIONS

This decision aid shows promise as an acceptable, useful and low-cost tool for drivers with dementia. A self-administered decision aid can be used to assist individuals with dementia decide about driving retirement. A randomized controlled trial is underway to evaluate the effectiveness of the tool.

Using the community health assessment to screen for continued driving

This project used the interRAI based, community health assessment (CHA) to develop a model for identifying current elder drivers whose driving behavior should be reviewed. The assessments were completed by independent housing sites in COLLAGE, a non-profit, national senior housing consortium. Secondary analysis of data drawn from older adults in COLLAGE sites in the United States was conducted using a baseline assessment with 8042 subjects and an annual follow-up assessment with 3840 subjects. Logistic regression was used to develop a Driving Review Index (DRI) based on the most useful items from among the many measures available in the CHA assessment. Thirteen items were identified by the logistic regression to predict drivers whose driving behavior was questioned by others. In particular, three variables reference compromised decision-making abilities: general daily decisions, a recent decline in ability to make daily decisions, and ability to manage medications. Two additional measures assess cognitive status: short-term memory problem and a diagnosis of non-Alzheimers dementia. Functional measures reflect restrictions and general frailty, including receiving help in transportation, use of a locomotion appliance, having an unsteady gait, fatigue, and not going out on most days. The final three clinical measures reflect compromised vision, little interest or pleasure in things normally enjoyed, and diarrhea. The DRI focuses the review process on drivers with multiple cognitive and functional problems, including a significant segment of potentially troubled drivers who had not yet been publicly identified by others. There is a need for simple and quickly identified screening tools to identify those older adults whose driving should be reviewed. The DRI, based on the interRAI CHA, fills this void. Assessment at the individual level needs to be part of the backdrop of science as society seeks to target policy to identify high risk drivers instead of simply age-based testing.

Self-rated driving habits among older adults with clinically-defined mild cognitive impairment, clinically-defined dementia, and normal cognition

Older adults with clinically-defined dementia may report reducing their driving more than cognitively normal controls. However, it is unclear how these groups compare to individuals with clinically-defined mild cognitive impairment (MCI) in terms of driving behaviors. The current study investigated self-reported driving habits among adults age 60 and older with clinical MCI (n=41), clinical mild dementia (n=40), and normal cognition (n=43). Participants reported their driving status, driving frequency (days per week), and how often they avoided accessing the community, making left turns, driving at night, driving in unfamiliar areas, driving on high-traffic roads, and driving in bad weather. After adjusting for education, a MANCOVA revealed that participants with MCI and dementia avoided unfamiliar areas and high-traffic roads significantly more than normal participants. Participants with dementia also avoided left turns and accessing the community more than those with normal cognition and MCI (p<0.05 for all). The other driving variables did not significantly differ between groups. Thus, older adults with clinically-defined MCI, as well as those with dementia, avoided some complex driving situations more than cognitively intact adults. However, all diagnostic groups had similar rates of driving cessation and frequency. Future research should examine the safety implications of such findings.

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.

Prevalence and correlates of potentially undetected dementia among residents of institutional care facilities in Ontario, Canada, 2009-2011

OBJECTIVES

This study aims to determine the prevalence of potentially undetected dementia among institutional care facility residents in Ontario, Canada, and to identify factors associated with undetection.

METHODS

We utilized a population-based secondary data analysis approach, pertaining to data from the Canadian Institute for Health Information's Continuing Care Reporting System, 2009-2011. Potentially undetected dementia was defined as having severely impaired cognitive function and requiring extensive assistance on activity of daily living (ADL) but no records of dementia diagnoses. Cognitive function was measured by the Cognitive Performance Scale (CPS), 0 (intact) to 6 (very severe impairment), and ADL by a hierarchy scale, 0 (independent) to 6 (total dependence).

RESULTS

Of the 242,957 residents who had no records of dementia diagnoses, 11.6% (n = 28,078) had a CPS score ≥4 (severe impairment or higher) and ADL score ≥3 (required extensive assistance or more). Data from 11,614 demented residents with corresponding CPS and ADL scores were used for comparison. Residents without dementia diagnosis were younger (77 vs. 84 years), more likely to have never married (20% vs. 6%), and have longer admission (4 vs. 2.8 years). The most significant factors for no diagnoses were never married (adjusted odds ratio = 2.1, 95% confidence interval [CI] = 1.91-2.29), admitted to hospital-based facilities (adjusted odds ratio = 1.58, 95% CI = 1.48-1.69), presence of schizophrenia (adjusted odds ratio = 1.43, 95% CI = 1.22-1.69), depression (adjusted odds ratio = 1.23, 95% CI = 1.16-1.29), and diabetes mellitus (adjusted odds ratio = 1.32, 95% CI = 1.26-1.40).

CONCLUSIONS

A large number of residents who had poor cognitive function and inadequate ADL ability did not have dementia diagnoses on record. Social and comorbid conditions were contributing factors to potentially undetected dementia.

Driving assessment for maintaining mobility and safety in drivers with dementia

BACKGROUND

Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance; extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 years of age screened, but at the price of stopping the driving of 121 people who would not have had a crash.

OBJECTIVES

PRIMARY OBJECTIVES

1. to assess whether driving assessment facilitates continued driving in people with dementia;2. to assess whether driving assessment reduces accidents in people with dementia.

SECONDARY OBJECTIVE

1. to assess the quality of research on assessment of drivers with dementia.

SEARCH METHODS

ALOIS, the Cochrane Dementia Group's Specialized Register was searched on 13 September 2012 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly.

SELECTION CRITERIA

We sought randomised controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment.

DATA COLLECTION AND ANALYSIS

Each review author retrieved studies and assessed for primary and secondary outcomes, study design and study quality.

MAIN RESULTS

No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented.

AUTHORS' CONCLUSIONS

In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.

Cognitive deficits are associated with poorer simulated driving in older adults with heart failure

BACKGROUND

Cognitive impairment is prevalent in older adults with heart failure (HF) and associated with reduced functional independence. HF patients appear at risk for reduced driving ability, as past work in other medical samples has shown cognitive dysfunction to be an important contributor to driving performance. The current study examined whether cognitive dysfunction was independently associated with reduced driving simulation performance in a sample of HF patients.

METHODS

18 persons with HF (67.72; SD = 8.56 year) completed echocardiogram and a brief neuropsychological test battery assessing global cognitive function, attention/executive function, memory and motor function. All participants then completed the Kent Multidimensional Assessment Driving Simulation (K-MADS), a driving simulator scenario with good psychometric properties.

RESULTS

The sample exhibited an average Mini Mental State Examination (MMSE) score of 27.83 (SD = 2.09). Independent sample t-tests showed that HF patients performed worse than healthy adults on the driving simulation scenario. Finally, partial correlations showed worse attention/executive and motor function were independently associated with poorer driving simulation performance across several indices reflective of driving ability (i.e., centerline crossings, number of collisions, % of time over the speed limit, among others).

CONCLUSION

The current findings showed that reduced cognitive function was associated with poor simulated driving performance in older adults with HF. If replicated using behind-the-wheel testing, HF patients may be at elevated risk for unsafe driving and routine driving evaluations in this population may be warranted.

Driving assessment for maintaining mobility and safety in drivers with dementia

BACKGROUND

Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance; extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 years of age screened, but at the price of stopping the driving of 121 people who would not have had a crash.

PRIMARY OBJECTIVES

1. to assess whether driving assessment facilitates continued driving in people with dementia; 2. to assess whether driving assessment reduces accidents in people with dementia.

SECONDARY OBJECTIVE

1. to assess the quality of research on assessment of drivers with dementia.

SEARCH METHODS

ALOIS, the Cochrane Dementia Group's Specialized Register was searched on 13 September 2012 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly.

SELECTION CRITERIA

We sought randomised controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment.

DATA COLLECTION AND ANALYSIS

Each review author retrieved studies and assessed for primary and secondary outcomes, study design and study quality.

MAIN RESULTS

No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented.

AUTHORS' CONCLUSIONS

In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.

Antecedents of self-regulation in driving among older drivers

Maintaining quality of life and wellbeing into advanced age is a major challenge to societies. Driving is one factor contributing to an ageing individual's independence. Understanding antecedents of driving-related self-regulation is important for designing interventions to preserve safe driving in old age. This paper reports on a study that investigated factors associated with two forms of self-regulation in driving (SRD) – avoidance of difficult driving conditions and voluntary cessation of driving – in a sample of 860 Israeli drivers aged 70 and over. We examined roles of health, vision, driving experience, driving-related self-efficacy (DRSE) and global self-esteem in SRD. Health and DRSE had direct effects on SRD, and effects of vision and driving experience were mediated by DRSE. Participants who had ceased driving were older, with poorer vision and health, and less driving confidence and experience than active drivers. Statistical analyses demonstrated that SRD is affected by a reduced sense of confidence due to an initial lower level of driving experience, compounded by deteriorating vision, and that older drivers are sensitive to factors affecting their ability to drive safely. Our results demonstrate that older drivers tend to self-regulate their driving. Programmes for older adults can be introduced for diagnosing driving capabilities, improving skills and confidence, and/or helping to develop self-regulation habits of avoiding driving in difficult conditions, and assisting drivers who must adjust to driving cessation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Investigating driving behaviour of older drivers with mild cognitive impairment using a portable driving simulator

While there is a large body of research indicating that individuals with moderate to severe dementia are unfit to drive, relatively little is known about the driving performance of older drivers with mild cognitive impairment (MCI). The aim of the current study was to examine the driving performance of older drivers with MCI on approach to intersections, and to investigate how their healthy counterparts perform on the same driving tasks using a portable driving simulator. Fourteen drivers with MCI and 14 age-matched healthy older drivers (aged 65-87 years) completed a 10-min simulator drive in an urban environment. The simulator drive consisted of stop-sign controlled and signal-controlled intersections. Drivers were required to stop at the stop-sign controlled intersections and to decide whether or not to proceed through a critical light change at the signal-controlled intersections. The specific performance measures included; approach speed, number of brake applications on approach to the intersection (either excessive or minimal), failure to comply with stop signs, and slower braking response times on approach to a critical light change. MCI patients in our sample performed more poorly than controls across a number of variables. However, because the trends failed to reach statistical significance it will be important to replicate the study using a larger sample to qualify whether the results can be generalised to the broader population.

The influence of cognitive impairment with no dementia on driving restriction and cessation in older adults

Cognitively impaired older adults may be at increased risk of unsafe driving. Individuals with insight into their own impairments may minimize their risk by restricting or stopping driving. The purpose of this study was to examine the influence of cognitive impairment on driving status and driving habits and intentions. Participants were classified as cognitively impaired, no dementia single (CIND-single), CIND-multiple, or not cognitively impaired (NCI) and compared on their self-reported driving status, habits, and intentions to restrict or quit driving in the future. The groups differed significantly in driving status, but not in whether they restricted their driving or reduced their driving frequency. CIND-multiple group also had significantly higher intention to restrict/stop driving than the NCI group. Reasons for restricting and quitting driving were varied and many individuals reported multiple reasons, both external and internal, for their driving habits and intentions. Regardless of cognitive status, none of the current drivers were seriously thinking of restricting or quitting driving in the next 6 months. It will be important to determine, in future research, how driving practices change over time and what factors influence decisions to restrict or stop driving for people with cognitive impairment.

Impaired knowledge of driving laws is associated with recommended driving cessation in cognitively impaired older adults

Background/Aims

The present study examined if knowledge of driving laws independently predicts on-the-road driving performance among cognitively impaired older adults.

Methods

The current study consisted of retrospective observational analyses on 55 cognitively impaired older adults (77.9 ± 6.4 years) that completed an on-the-road driving evaluation, a 20-item knowledge test of driving laws, and a brief cognitive test battery.

Results

Logistic regression found poorer performance on the knowledge test was significantly associated with greater likelihood of recommended driving cessation beyond important demographic and cognitive variables (p < 0.05).

Conclusion

Cognitively impaired patients’ ability to drive may be related to their knowledge regarding common driving laws, in addition to their current level of cognitive functioning.

Differences in perceptions regarding driving between young and old drivers and non-drivers in Japan

OBJECTIVE

The issue of driving cessation for dementia patients is one of the urgent public health priorities in Japan and is often complicated, with family or social barriers yet to be sufficiently addressed. Because the possibility of dementia or family caregiving can befall anyone, we focused on the disparity in people's perceptions of driving as possible barriers. The present study aimed to assess perceptions of driving among the general public and examine differences in perceptions based on age and driving status.

METHODS

A survey was conducted in a sample of the general public aged 40 and over in Japan. Respondents were 1010 people who received a self-administered questionnaire that included questions regarding perceptions about driving and sociodemographic factors.

RESULTS

The drivers that participated in this study tended to highly agree that 'driving is a "right" which we all deserve', compared with the non-drivers. The most common reason for reluctance to stop driving among drivers was the possible loss of personal mobility. Apart from transportation, older drivers were more likely than younger drivers to value the qualitative aspects of driving, for example, driving was viewed as 'a motivating factor in my life'.

CONCLUSIONS

These disparities in the general public's perceptions about driving may be possible family or social barriers to driving cessation in the case of drivers with dementia. Our findings also suggest that when addressing the need for driving retirement, not only mobility but also the qualitative aspects of driving be paid more attention.

A prospective study of cognitive tests to predict performance on a standardised road test in people with dementia

OBJECTIVE

Previous work by Lincoln and colleagues produced a cognitive test battery for predicting safety to drive in people with dementia. The aim was to check the accuracy of this battery and assess whether it could be improved by shortening it, including additional cognitive tests, and a measure of previous driving.

METHODS

Participants with dementia, who were driving, were recruited. They were assessed on cognitive tests including measures of concentration, executive function, visuospatial perception, verbal recognition memory, and speed of information processing. Patients were then assessed on the Nottingham Neurological Driving Assessment (NNDA) by an approved driving instructor (ADI), blind to cognitive test results.

RESULTS

Seventy-five patients were recruited and completed the cognitive tests. Of these, 65 were assessed on the road. These participants were aged 59-88 (mean = 75.2, SD = 6.8) and 49 were men. Time driving varied from 19 to 73 years (mean = 52.5, SD = 10.0). Thirteen participants were unsafe and 52 safe to drive. Using a cut-off of > 0 to indicate safety to drive, the original predictive equations correctly classified 48 (76.2%) of 63 participants with complete data. Logistic regression including additional tests reduced misclassifications.

CONCLUSIONS

A lower proportion of participants were found to be unsafe on the road than in previous studies. Nevertheless, the previously identified equation predicted safety to drive in most patients. Including additional tests reduced the misclassification rate but requires independent validation. We suggest that the cognitive test battery might be used in clinical practice to identify patients with dementia who would benefit from on-road assessment.

Practice parameter update: evaluation and management of driving risk in dementia: report of the Quality Standards Subcommittee of the American Academy of Neurology

OBJECTIVE

To review the evidence regarding the usefulness of patient demographic characteristics, driving history, and cognitive testing in predicting driving capability among patients with dementia and to determine the efficacy of driving risk reduction strategies.

METHODS

Systematic review of the literature using the American Academy of Neurology's evidence-based methods.

RECOMMENDATIONS

For patients with dementia, consider the following characteristics useful for identifying patients at increased risk for unsafe driving: the Clinical Dementia Rating scale (Level A), a caregiver's rating of a patient's driving ability as marginal or unsafe (Level B), a history of crashes or traffic citations (Level C), reduced driving mileage or self-reported situational avoidance (Level C), Mini-Mental State Examination scores of 24 or less (Level C), and aggressive or impulsive personality characteristics (Level C). Consider the following characteristics not useful for identifying patients at increased risk for unsafe driving: a patient's self-rating of safe driving ability (Level A) and lack of situational avoidance (Level C). There is insufficient evidence to support or refute the benefit of neuropsychological testing, after controlling for the presence and severity of dementia, or interventional strategies for drivers with dementia (Level U).

Cognitive impairment and driving: A review of the literature

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

A community based survey of cognitive functioning, highway-code performance and traffic accidents in a cohort of older drivers

BACKGROUND

The DVLA allows driving in early dementia contingent on regular medical assessment. GPs and psychiatrists require validated and accessible assessments. Some studies have suggested that cognitive testing has utility in the assessment of driving capacity in elderly drivers. One study raises the possibility of using a highway-code questionnaire as an adjunct to these tests.

METHOD

Two hundred drivers over the age of 65 were randomly selected from two GP surgeries. Baseline assessment comprised completion of a Highway Code questionnaire (DPHC-98), the Mini Mental State Examination (MMSE) and an abbreviated version of the Alzheimer's Disease Assessment Scale Cognitive Subsection (EURO-ADAS). A history of road traffic accidents (RTAs) over the preceding 5 years was obtained. At 12-month follow-up interview driving status of the subject and occurrence of RTAs were recorded. Predictive power of DPHC-98 and cognitive testing with regards RTAs were examined through logistic regression analysis.

RESULTS

Performance on the Highway Code questionnaire was identified as the only significant regression factor in the prediction of prospective RTAs. However, none of the logistic regression models were able to identify any drivers involved in RTAs either retrospectively or prospectively.

CONCLUSION

Cognitive tests are not linked with risk of driving accidents in older adults in any useful way.

Driving assessment for maintaining mobility and safety in drivers with dementia

BACKGROUND

Demographic changes are leading to an increase in the number of older drivers: as dementia is an age-related disease, there is also an increase in the numbers of drivers with dementia. Dementia can impact on both the mobility and safety of drivers, and the impact of formal assessment of driving is unknown in terms of either mobility or safety. Those involved in assessment of older drivers need to be aware of the evidence of positive and negative effects of driving assessment. Although cognitive tests are felt by some authors to have poor face and construct validity for assessing driving performance, extrapolating from values in one large-scale prospective cohort study, the cognitive test that most strongly predicted future crashes would, if used as a screening tool, potentially prevent six crashes per 1000 people over 65 screened, but at the price of stopping the driving of 121 people who would not have had a crash.

PRIMARY OBJECTIVES

1. To assess whether driving assessment facilitates continued driving in people with dementia 2. To assess whether driving assessment reduces accidents in people with dementia.

SECONDARY OBJECTIVE

To assess the quality of research on assessment of drivers with dementia.

SEARCH STRATEGY

The Cochrane Dementia Group's Specialized Register was searched on 30 October 2007 using the terms: driving or driver* or "motor vehicle*" or "car accident*" or "traffic accident*" or automobile* or traffic. This register contains records from major healthcare databases, ongoing trial databases and grey literature sources and is updated regularly.

SELECTION CRITERIA

We sought randomized controlled trials prospectively evaluating drivers with dementia for outcomes such as transport mobility, driving cessation or motor vehicle accidents following driving assessment.

DATA COLLECTION AND ANALYSIS

Each author retrieved studies and assessed for primary and secondary outcomes, study design and study quality.

MAIN RESULTS

No studies were found that met the inclusion criteria. A description and discussion of the driving literature relating to assessment of drivers with dementia relating to the primary objectives is presented.

AUTHORS' CONCLUSIONS

In an area with considerable public health impact for drivers with dementia and other road users, the available literature fails to demonstrate the benefit of driver assessment for either preserving transport mobility or reducing motor vehicle accidents. Driving legislation and recommendations from medical practitioners requires further research that addresses these outcomes in order to provide the best outcomes for both drivers with dementia and the general public.