Driving rehabilitation programs for older drivers in the United States

Toward Safe and Confident Silver Drivers: Interview Study Investigating Older Adults' Driving Practices

BACKGROUND

As the aging population in the United States continues to increase rapidly, preserving the mobility and independence of older adults becomes increasingly critical for enabling aging in place successfully. While personal vehicular transport remains a popular choice among this demographic due to its provision of independence and control over their lives, age-related changes may heighten the risk of common driving errors and diminish driving abilities.

OBJECTIVE

This study aims to investigate the driving practices of older adults and their efforts to maintain safe and confident driving habits. Specifically, we sought to identify the factors that positively and negatively influence older adults' driving performance and confidence, as well as the existing efforts put into sustaining their driving abilities.

METHODS

We recruited 20 adults aged ≥65 years who remained active drivers during the recruitment from the greater New York area. Then, we conducted semistructured interviews with them to examine their perceptions, needs, and challenges regarding safe and confident driving.

RESULTS

Our findings uncovered a notable disparity between older adults' self-perceived driving skills and the challenges they face, particularly caused by age-related limitations and health conditions such as vision and memory declines and medication routines. Drawing on these findings, we proposed strategies to bridge this gap and empower older adults to drive safely and confidently, including fostering a realistic understanding of their capabilities, encouraging open dialogue regarding their driving, encouraging regular assessments, and increasing awareness of available resources.

CONCLUSIONS

This study uncovered a noticeable disparity between the perceived driving competence of older adults and the actual challenges they confront while driving. This divergence underscores a significant need for better support beyond the existing aid available to preserve older adults' driving skills. We hope that our recommendations will offer valuable insights for practitioners and scholars committed to enhancing the overall well-being and quality of life for older adults as they age in their homes.

"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.

Addressing the Complex Driving Needs of an Aging Population

This JAMA Insights reviews the complex driving needs of older individuals and how clinicians can help address these needs, including recommending use of supplemental technology, assessing fitness to drive, and reviewing medications that may impair driving ability.

The Effectiveness of a Digital Game-Based Intervention on Hazard Perception and Visual Skills in Novice Drivers: A Single Blind, Randomized Controlled Trial

Novice drivers show poorer performance than experienced drivers in terms of visual skills and hazard perception. This study aimed at evaluating the effectiveness of a digital game-based intervention on hazard perception and visual skills in novice drivers. Forty-six novice drivers (6 men, 40 women) were randomized to the intervention group (n = 23; 20.79 ± 0.81 years) or control (n = 23; 20.65 ± 0.93 years) group. The intervention group received a game-based intervention in addition to a hazard perception training, whereas the control group received only the hazard perception training. Hazard perception and visual skills were assessed in both groups before and after the 14-day interventions. Between-group comparisons revealed significantly greater improvements in visual short time memory, visual closure, visual discrimination, figure-ground and total scores in the game-based group than in the control group (p < 0.05 for all). Our results showed that 14 days of game-based intervention enhanced hazard perception and visual skills in novice drivers. Using game-based interventions in driving rehabilitation is recommended to improve hazard perception and visual skills of novice drivers.

Visual functions associated with on-road performance by older drivers evaluated by a certified driving rehabilitation specialist

PURPOSE

To assess associations between visual function and on-road driving performance evaluated by a certified driving rehabilitation specialist (CDRS).

METHODS

Adults aged 70 and older enrolled and completed assessments of visual acuity, contrast sensitivity, visual processing speed, visual field sensitivity, motion perception and spatial ability. At follow-up, on-road driving performance was evaluated on a 15-mile route. Age-adjusted odds ratios and 95% confidence intervals (95% CIs) were used to associate worse CDRS composite score and CDRS global rating for those with poorer visual function compared to those with better scores and ratings.

RESULTS

For the 144 participants who enrolled, completed vision testing and the on-road driving evaluation, the mean age was 79.2 (5.1) and 45.8% were female. The odds of worse CDRS global rating and composite score were significantly associated with moderately and severely impaired visual processing speed under divided attention (all p < 0.05). Those with poorer motion perception were at greater odds of a worse CDRS composite score (OR: 2.67, 95% CI: 1.14-6.26).

CONCLUSIONS

The CDRS composite score of on-road driving performance by older adults was associated with slowed visual processing and impaired motion perception, suggesting that older driver performance, as rated by a CDRS, relies on visual skills. The CDRS global rating was also associated with impaired visual processing speed. The literature suggests impairments in these same visual functions elevate crash risk. While the results provide additional evidence suggesting these functional measures are associated with driving, further work is needed to identify and assess visual measures most closely related to driving safety and performance among older adults to better inform interventions, policy and future research.

The Advancing Understanding of Transportation Options (AUTO) study: design and methods of a multi-center study of decision aid for older drivers

BACKGROUND

Decision-making about when to stop driving for older adults involves assessment of driving risk, availability of support or resources, and strong emotions about loss of independence. Although the risk of being involved in a fatal crash increases with age, driving cessation can negatively impact an older adult's health and well-being. Decision aids can enhance the decision-making process by increasing knowledge of the risks and benefits of driving cessation and improve decision quality. The impact of decision aids regarding driving cessation for older adults is unknown.

METHODS

The Advancing Understanding of Transportation Options (AUTO) study is a multi-site, two-armed randomized controlled trial that will test the impact of a decision aid on older adults' decisions about changes in driving behaviors and cessation. AUTO will enroll 300 drivers age ≥ 70 years with a study partner (identified by each driver); the dyads will be randomized into two groups (n = 150/group). The decision aid group will view the web-based decision aid created by Healthwise at baseline and the control group will review information about driving that does not include evidence-based elements on risks and benefits and values clarification about driving decisions. The AUTO trial will compare the effect of the decision aid, versus control, on a) immediate decision quality (measured by the Decisional Conflict Scale; primary outcome); b) longitudinal psychosocial outcomes at 12 and 24 months (secondary outcomes); and c) longitudinal driving behaviors (including reduction or cessation) at 12 and 24 months (secondary outcomes). Planned stratified analyses will examine the effects in subgroups defined by cognitive function, decisional capacity, and readiness to stop driving.

DISCUSSION

The AUTO study is the first large-scale randomized trial of a driving decision aid for older adults. Results from this study will directly inform clinical practice about how best to support older adults in decision-making about driving.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT04141891 . Registered on October 28, 2019. Located at https://clinicaltrials.gov/ct2/show/NCT04141891.

Driver Rehabilitation Utilization and Need Among Community-Dwelling Older Adults

IMPORTANCE

Driving is one of the most important instrumental activities of daily living. As adults age, many face challenges with maintaining independent driving, leading to risk for decreased occupational engagement and quality of life. The extent to which occupational therapy services meet the driver rehabilitation needs of older adults is unknown.

OBJECTIVE

To characterize driver rehabilitation service utilization among a nationally representative sample of community-dwelling older adults.

DESIGN

Exploratory, descriptive cross-sectional study using the National Health and Aging Trends Study 2016 wave.

PARTICIPANTS

Community-dwelling adults age 65 and older who received rehabilitation services in the past year (N = 1,173).

OUTCOMES AND MEASURES

Sociodemographic information, comorbidities, rehabilitation use, community mobility, and participation restrictions were collected using self-report and performance-based measures.

RESULTS

Of this sample of older adults, 63.0% reported driving as their primary mode of transportation, 25.8% reported limitations in community participation related to transportation, and 9.2% reported having received rehabilitation focused on driving or other transportation goals in the past year. Findings from this study suggest a discrepancy between utilization of driver rehabilitation and self-reported need.

CONCLUSIONS AND RELEVANCE

Many older adults reported limitations in community participation for transportation-related reasons, yet driver rehabilitation represented only a small proportion of services used. As experts in driver rehabilitation, occupational therapy practitioners should lead the way in advocating for increased utilization of driver rehabilitation and development of innovative, accessible transportation options to promote community mobility and participation among older adults.

WHAT THIS ARTICLE ADDS

The results of this study illustrate an important discrepancy between self-reported need for and utilization of driver rehabilitation services. Occupational therapy practitioners can play an important role in meeting older adults' driving and transportation needs to enable them to fully participate in their community and daily routines.

Utilization of driving and other transportation rehabilitation in the National Health and Aging Trends Study

BACKGROUND

As people age, their mobility begins to decrease. In an effort to maintain mobility, this population can seek out rehabilitation services with the goal of improving their driving. However, it is unclear who has sought out rehabilitation for this purpose.

OBJECTIVE

To better understand, identify, and describe the characteristics of older adults who utilize rehabilitation with the purpose of improved driving.

METHODS

Data was analyzed from the fifth round of the National Health and Aging Trends study (NHATS), which is made up of Medicare beneficiaries over the age of 65 that are community-dwelling. Rehabilitation utilization specifically for improved driving and other transportation was analyzed. Adjusted weighted logistic regression was conducted to better understand and identify the characteristics of the study population that received rehabilitation services for the purpose of improved driving ability.

RESULTS

Nineteen percent (N = 1,335) of this cohort received rehabilitation in the past year. Of those, 10% (N = 128) received rehabilitation to specifically improve driving and 2% (N = 25) did so to improve other transportation. Older adults who were single, separated, or never married were less likely to use rehabilitation for improving driving ability, compared to older adults who were married (OR: 0.29; 95% CI: 0.11-0.80).

CONCLUSION

Older adults who are married were more likely to report they wanted to improve their driving ability with rehabilitation. The role of rehabilitation services to improve driving among older adults will play a key role in the coming years as older adults strive to maintain their independence.

A Scoping Review of Environmental Factors That Impact Driving with Arthritis: Considerations for Occupational Therapy

Using the International Classification of Functioning, Disability, and Health, this scoping review mapped environmental barriers and facilitators that can influence driving with arthritis. A search of research databases located 2445 studies from which 19 were included. The predominant diagnosis researched was rheumatoid arthritis. The most common facilitators were vehicle adaptations (e.g., supplemental mirrors, seat cushions). Barriers included a lack of knowledge among clinicians to address behind-the-wheel concerns and nonuse/abandonment of such adaptions. Results highlight key clinical and research opportunities to support drivers with arthritis.

Assessing and Counseling the Older Driver: A Concise Review for the Generalist Clinician

Older drivers are putting more miles on the road during their "golden years" than generations prior. Many older adults have safe driving habits, but unique age-related changes increase the risk for crash-related morbidity and mortality. Generalists are poised to assess and guide older adults' driving fitness. Although there is no uniformly accepted tool for driving fitness, assessment of 5 key domains (cognition, vision, physical function, medical comorbidities, and medications) using valid tools can help clinicians stratify older drivers into low, intermediate, and high risk for unsafe driving. Clinicians can then make recommendations about fitness to drive and appropriate referrals for rehabilitation or alternative transportation resources to optimize mobility, independence, and quality of life for older adults.

Physician and Family Discussions about Driving Safety: Findings from the LongROAD Study

BACKGROUND

Older adult drivers may experience decreases in driving safety with age or health status change. Discussing driving safety may help them plan for driving restriction and eventual cessation. Here, we sought to examine conversations between older adults and their family members and physicians.

METHODS

In this multi-site cross-sectional analysis of baseline data from the AAA Longitudinal Research on Aging Drivers (LongROAD) cohort study, we measured the prevalence and characteristics of family and physician driving discussions. We examined associations between having driving discussions and participant characteristics using multivariate logistic regression.

RESULTS

Of 2990 current drivers aged 65 to 79 years (53% female, 85.5% White), only 14.2% reported discussing driving safety with family and 5.5% had discussions with physicians. Men (adjusted OR, 1.32; 95% CI, 1.05 to 1.66) and those with Master's degrees or higher (adjusted OR, 1.65; 95% CI, 1.27 to 2.13) more often had family discussions. Those with at least a Master's degree were also more likely to speak with their physician (adjusted OR, 1.77; 95% CI, 1.17 to 2.68).

CONCLUSION

Few older adults had driving safety conversations with their family or physicians. Practical and effective interventions are needed to engage family and physicians in assisting older adults with risk assessment and driving cessation planning to maintain mobility and well-being.

Construction and Validation of the 21 Item Fitness-to-Drive Screening Measure Short-Form

Introduction: The Fitness-to-Drive Screening Measure is a free online screening tool that detects at-risk older drivers, however, it's 20 min administration time may render the 54-item tool less than optimal for clinical use. Thus, this study constructed and validated a 21-item FTDS Short-Form (FTDS-SF). Method: This mixed methods study used 200 proxy rater responses and older driver on-road assessments. We conducted a Rasch analysis to examine information at the level of the item and used content validity index scores to select items. Using a receiver operator characteristics curve we determined the concurrent validity of the FTDS-SF to on-road outcomes. Results: Twenty-one items were selected for the FTDS-SF. The area under the curve = 0.72, indicated the FTDS-SF predicted on-road outcomes with acceptable accuracy. Still, 68 drivers were misclassified. Conclusion: The FTDS-SF may reduce administration time, while still yielding acceptable psychometric properties. Yet, caution needs to be executed in clinical decision making as the measure is overly specific.

Neurocognitive Disorder Diagnoses Matter: A Brief Report on Caregiver Appraisal of Driving Ability

Background: Age-associated neurocognitive disorders (NCDs) are associated with progressive loss of abilities for instrumental activities of daily living, including driving. This study assesses the impact of NCD diagnosis, while controlling for reported level of cognitive impairment, on family caregiver judgment of driving safety. Method: An intervention sample of 152 intergenerational caregivers who assist an older adult with medical tasks was used. Caregiver's pre-intervention response to a single item of confidence in the older adult driving was used to determine judgment of driving ability. Cognitive impairment was assessed using caregivers' report for Clinical Dementia Rating (CDR) Sum of Boxes score. Results: Older adults with a diagnosis were rated as less capable of driving safely than those without a diagnosis, while controlling for reported level of cognitive impairment. Conclusion: Results of this study highlight the importance of NCD diagnosis on caregiver judgments. Results of this study have implications for health care and driving safety.

Prospective Validation of a Screening Tool to Identify Older Adults in Need of a Driving Evaluation

OBJECTIVES

To prospectively validate and refine the 5-item "CRASH" screening tool for identifying older drivers needing a behind-the-wheel (BTW) test.

DESIGN

Prospective observational study.

SETTING

Geriatric and internal medicine primary care clinics affiliated with a tertiary care hospital and a local BTW program.

PARTICIPANTS

Cognitively intact drivers aged 65 and older (N = 315).

MEASUREMENTS

Participants completed baseline questionnaire (including CRASH tool) and assessments and BTW test (evaluator blinded to questionnaire results) and participated in 1-month telephone follow-up. Analysis included descriptive statistics and examination of predictive ability of the CRASH tool to discriminate normal (pass) from abnormal (conditional pass or fail) on the BTW test, with logistic regression and CART techniques for tool refinement.

RESULTS

Two hundred sixty-six participants (84%) had a BTW test; of these, 17% had a normal rating and 83% an abnormal rating. Forty-five percent of those with an abnormal score were advised to limit driving under particular conditions. Neither the CRASH tool nor its individual component variables were significantly associated with the summary BTW score; in refined models with other variables, the best-performing tool had approximately 67% sensitivity and specificity for an abnormal BTW score. Most participants found the BTW test useful and were willing to pay a median of $50. At 1-month follow-up, no participants had stopped driving.

CONCLUSION

The CRASH screening tool cannot be recommended for use in clinical practice. Findings on older adults' perceived utility of the BTW test and the stability of driving patterns at 1-month follow-up could be useful for future research studies and for design of older driver programs.

Discussions About Driving Between Older Adults and Primary Care Providers

OBJECTIVES

To estimate how many older adults discuss driving with a primary care provider during a calendar year and to describe discussion triggers.

DESIGN

Observational retrospective medical record review.

SETTING

Three primary care clinics (geriatric, hospital-based general internal medicine (GIM), community-based GIM) affiliated with a tertiary care hospital.

PARTICIPANTS

Random sample of 240 older (aged ≥65) adults with one or more primary care visits in 2014 (January 1 to December 31).

MEASUREMENTS

Standardized chart abstraction of participant demographic characteristics, medical diagnoses, and presence and context of discussions about driving. Provider factors (obtained from clinic administrators) included sex and average amount worked per week.

RESULTS

Participants who visited the geriatric clinic were oldest, had more medical diagnoses, and had a median of 4 visits in 2014 (vs 3 visits in GIM clinics). Documented discussions about driving occurred with a greater proportion of participants in the geriatric (n = 22, 28%, 95% confidence interval (CI) = 18-39%) and GIM hospital (n = 15, 19%, 95% CI = 11-29%) clinics than the GIM community clinic (n = 6, 7.5%, 95% CI = 2.8-16%). Medical diagnoses that might affect driving were prevalent but not associated with frequency of documented discussions. In multivariable analysis, participants were more likely to have one or more documented driving discussions in 2014 if they went to the geriatric clinic or had a primary care provider younger than 45 or who worked fewer than six half-day clinics per week.

CONCLUSION

Over 1 year, a minority of older adults had a documented discussion about driving with a primary care provider, with differences according to clinic and provider characteristics. Strategies to support routine and preparatory conversations about driving should incorporate these findings and might vary among clinic settings.

Driving Rehabilitation Specialists' Perspectives on Older Driver Evaluations

OBJECTIVE

We explored driving rehabilitation specialists' (DRSs') perspectives on older driver evaluations.

METHOD

We conducted interviews with 26 DRSs across the United States who evaluate older drivers. Transcript analysis followed general inductive techniques to identify themes related to current systems and barriers to use.

RESULTS

Themes, by Social-Ecological Model level, were as follows: (1) individual occupational therapists' commitment to mobility and safety, perceived responsibilities, and experience; (2) DRSs' relationships with drivers, medical providers, and licensing bureaus; (3) the community surrounding the DRSs, including the health care system and transportation resources; and (4) societal factors, including DRS reimbursement, reporting requirements and liability coverage, and role of national organizations.

CONCLUSIONS

This qualitative study identified barriers to the development of an effective system for older driver evaluations. Future work should verify, refine, and expand these findings by targeting other stakeholder groups.

System facilitators and barriers to discussing older driver safety in primary care settings

BACKGROUND

Primary care physicians play a leading role in counselling older drivers, but discussions often do not occur until safety concerns arise. Prior work suggests that routine questioning about driving might facilitate these difficult conversations.

OBJECTIVE

To explore system-level factors affecting driving discussions in primary care settings, in order to inform the design and implementation of a programme supporting routine conversations.

METHODS

This qualitative descriptive study used iterative interviews with providers (physicians, nurses, medical assistants, social workers, and administrative staff) working at two clinics (one geriatric, one general internal medicine) at a tertiary-care teaching hospital. General inductive techniques in transcript analysis were used to identify stakeholder-perceived system-level barriers and facilitators to routine conversations with older drivers.

RESULTS

From 15 interviews, four themes emerged: (1) complexity of defined provider roles within primary care setting (which can both support team work and hamper efficiency); (2) inadequate resources to support providers (including clinical prompts, local guides, and access to social workers and driving specialists); (3) gaps in education of providers and patients about discussing driving; and (4) suggested models to enhance provider conversations with older drivers (including following successful examples and using defined pathways integrated into the electronic medical record). A fifth theme was that participants characterised their experiences in terms of current and ideal states.

CONCLUSIONS

Physicians have been tasked with assessing older driver safety and guiding older patients through the process of 'driving retirement.' Attention to system-level factors such as provider roles, resources, and training can support them in this process.

Perspectives on Tiered Older Driver Assessment in Primary Care Settings

PURPOSE OF THE STUDY

Widespread screening of older drivers, with in-depth evaluation only of those who screen positive ("tiered assessment"), might efficiently balance driver safety and mobility. To inform program development, we sought to examine the perspectives of older drivers and clinicians on the concept of tiered assessment in primary care settings.

DESIGN AND METHODS

Iterative focus groups and interviews with 33 community-dwelling current drivers aged ≥65 years and 8 primary care providers. We used inductive and deductive theme analysis to explore driver and clinician perspectives and to identify barriers and facilitators to establishing a tiered older driver assessment program in primary care settings.

RESULTS

Four dominant themes emerged. Two themes addressed the overall concept: (a) support for the concept of tiered older driver assessment and (b) concerns about the consequences of older driver assessment and how these could affect program viability. Two themes addressed screening: (c) tension inherent in using a generalized approach to the highly individualized issue of driving and (d) logistical considerations for screening in primary care settings.

IMPLICATIONS

Standardized older driver screening and referral might improve clinician-driver communication, but screening should occur in a context that includes personalized mobility counseling.