Evaluating Driving as a Valued Instrumental Activity of Daily Living

Establishing the Predictive Validity of the Assessment of Motor and Process Skills for Driving Performance Outcomes

IMPORTANCE

Although the Assessment of Motor and Process Skills (AMPS) is an excellent tool for evaluating the functional performance of instrumental activities of daily living (IADLs), a limited number of studies have used the AMPS for decisions regarding the IADL of fitness to drive and community mobility.

OBJECTIVE

To determine the specificity and sensitivity of the AMPS as a tool for determining a person's fitness to drive.

DESIGN

Cross-sectional observational design.

SETTING

Three driving rehabilitation programs in three states.

PARTICIPANTS

Participants were 388 community-living adults (M age = 68.74 yr, SD = 11.53); 196 adults were recruited before completing a comprehensive driving evaluation, and 192 were recruited in two other studies of older drivers.

OUTCOME AND MEASURES

AMPS and results of comprehensive driving evaluation or on-road assessment.

RESULTS

Using a logistical regression, AMPS Motor and Process Skills scores yielded a sensitivity of 84.6% and a specificity of 88.8%. The odds ratio of the AMPS Motor Skills score was .347; for the AMPS Process Skills score, it was .014. Using cross-validations, the model with AMPS Motor and Process scores produced a cross-validation area under the curve of .918, with sensitivity and specificity of 84.6% and 88.4%, respectively, and a probability greater than .334 was used for predicting a fail or drive-with-restriction evaluation.

CONCLUSIONS AND RELEVANCE

The AMPS Motor and Process Skills scores revealed significant differences between those who failed or had driving restrictions and with those who passed the driving evaluation, which supported the AMPS as an effective tool for predicting fitness to drive. Plain-Language Summary: This study demonstrates how the Assessment of Motor and Process Skills (AMPS), as a top-down occupational therapy assessment tool, can be used to differentiate between medically at-risk drivers who are likely to pass a comprehensive driving evaluation and those who are likely to fail or need restrictions. AMPS will assist occupational therapy practitioners in determining who is most appropriate to receive driving rehabilitation services and/or when to refer a person for a comprehensive driving evaluation.

Simulator Driving Abilities, Executive Functions, and Adaptive Behavior Among Adolescents With Complex Attention Deficit Hyperactivity Disorder

OBJECTIVE

To examines the driving skills, executive functions, and adaptive behavior of adolescents diagnosed with Attention-deficit/hyperactivity disorder (ADHD) combined with emotional difficulties and/or learning disabilities (complex ADHD), compared to adolescents without ADHD.

METHOD

A cross-sectional study including 30 adolescents with complex ADHD and 33 adolescents without ADHD aged 15 to 18 years. Driving skills on a simulator, executive functions, and adaptive behavior were evaluated.

RESULTS

Adolescents without ADHD demonstrated significantly higher total scores on the driving simulator, indicating better driving performance compared to adolescents with complex ADHD. In the complex ADHD group, after controlling for different Conners Comprehensive Behavior Rating Scale-Self Report scales, driving simulator scores were partially correlated with executive functions.

CONCLUSION

These findings emphasize the unique needs of adolescents with complex ADHD. Given the significance of driving in today's society, it is crucial to consider the development of intervention programs to support this population's driving skills.

Associations Between Plasma, Imaging, and Cerebrospinal Fluid Biomarkers with Driving Behavior and Cognitive Tests: Implications for Biomarker Usefulness

Background

Declines in instrumental activities of daily living like driving are hallmarks sequelae of Alzheimer's disease (AD). Although driving has been shown to be associated with traditional imaging and cerebrospinal fluid (CSF) biomarkers, it is possible that some biomarkers have stronger associations with specific aspects of driving behavior. Furthermore, associations between newer plasma biomarkers and driving behaviors are unknown.

Objective

This study assessed the extent to which individual plasma, imaging, and CSF biomarkers are related to specific driving behaviors and cognitive functions among cognitively normal older adults.

Methods

We analyzed naturalistic driving behavior from cognitively healthy older drivers (N = 167, 47% female, mean age = 73.3 years). All participants had driving, clinical, and demographic data and completed biomarker testing, including imaging, CSF, and/or plasma, within two years of study commencement.

Results

AD biomarkers were associated with different characteristics of driving and cognitive functioning within the same individuals. Elevated levels of plasma Aβ40 were associated with more speeding incidents, higher levels of CSF tau were related to shorter duration of trips, and higher CSF neurofilament light chain values were associated with traveling shorter distances, smaller radius of gyration, and fewer trips at night. We demonstrated that plasma, like CSF and imaging biomarkers, were helpful in predicting everyday driving behaviors.

Conclusions

These findings suggest that different biomarkers offer complementary information with respect to driving behaviors. These distinct relationships may help in understanding how different biological changes that occur during the preclinical stage of AD can impact various sensorimotor and cognitive processes.

Return to driving following surgery to the upper limb: a scoping review protocol

INTRODUCTION

Upper limb surgery is a common burden on the active and ageing population, often resulting in a transient state of functional impairment. Many activities of daily living can be affected, including ability to drive. Currently there are no guidelines regarding safe return to driving following upper limb surgery. This scoping review aims to systematically review the current literature on the topic of driving following surgery to the upper limb.

METHODS AND ANALYSIS

Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review extension guidelines, this protocol details the scoping review's methodological and analytical approaches. The review will consider all primary and secondary source articles that examine return to driving following surgery to the upper limb, including the impact of orthoses on functional ability to drive. All studies will be included regardless of methodology and text and opinion pieces will also be considered. Studies conducted in any geographical location or setting will be included in the review. Systematic searches of scientific databases such as OVID (MEDLINE, EMBASE and Cochrane), NCBI (PubMed), Scopus, PsycINFO, EBSCOhost (CINAHL), Web of Science, Google Scholar and ProQuest will be conducted. In addition, relevant organisational websites, dissertations, theses from university repositories and grey literature will be included. Further articles will be identified by searching references of relevant studies. Studies conducted in English in any year will be included. Two independent reviewers will screen identified literature sources based on predetermined inclusion/exclusion criteria. Discrepancies will be resolved through discussion, therefore, negating the need for a third reviewer. Article data will be presented in tabular or graphical format along with a narrative summary.

ETHICS AND DISSEMINATION

Ethics approval is not required. Findings will be disseminated through professional networks, peer-reviewed publications and conference presentations.

Decline in Other Instrumental Activities of Daily Living as Indicators of Driving Risk in Older Adults at an Academic Memory Clinic

BACKGROUND

Decisions around driving retirement are difficult for older persons living with cognitive decline and their caregivers. In many jurisdictions, physicians are responsible for notifying authorities of driving risks. However, there are no standardized guidelines for this assessment. Having access to a driving risk assessment tool could help older adults and their caregivers prepare for discussions around driving retirement. This study compares the clinical profiles of older adult drivers assessed in an academic memory clinic who were referred to the driving authority to older drivers who were not with a focus on instrumental activities of daily living (iADLs).

METHODS

Data on referred (R) and not-referred (NR) drivers were extracted from medical records. Elements from the medical history, cognitive history, functional abilities, Modified Mini-Mental State (3MS) examination, Trails A/B, and clock drawing were included in the analysis. Four risk factors of interest were examined in separate logistic regression analyses, adjusted for demographic variables.

RESULTS

50 participants were identified in each group. The R group was older on average than the NR. As expected, R were more likely to have Trails B scores over 3 min and have significantly abnormal clock drawing tests. R also showed lower 3MS scores and a higher average number of functional impairments (including managing appointments, medications, bills, or the television).

CONCLUSION

Beyond standard cognitive tests, impairment in iADLs may help general practitioners identify at-risk drivers in the absence of standardized guidelines and tools. This finding can also inform the design of a risk assessment tool for driving and could help with approaches for drivers with otherwise borderline test results.

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.

Association of hospitalization with driving reduction and cessation in older adults

BACKGROUND

Driving has not been considered as part of the social cost of acute illness and may go unnoticed in the post-hospital care of older adults. Decreases in driving after hospitalization and at-risk populations have not been investigated.

OBJECTIVE

To determine the association between driving reduction and cessation and hospitalization in older adults by using nationally representative data.

DESIGN

Retrospective cohort analysis.

SETTING

Health and Retirement Study survey from 2004 to 2014.

PARTICIPANTS

Adults aged 65 years and older who were able to drive and had an available car (n = 12,110; 40,364 interviews).

MEASUREMENTS

Self-report of a hospitalization requiring an overnight stay, changes in driving patterns including driving cessation or limitations over a 2-year period, comorbid conditions, health utilization, and behaviors.

RESULTS

Of hospitalizations in adults aged 65 years and older, 22% were associated with a decrease in driving patterns within 2 years. The relative risk of a reduction or cessation in driving was 1.62 (95% CI: 1.54, 1.70, p < 0.001) when there was a hospitalization compared with when a hospitalization did not occur. Baseline functional, cognitive, and visual impairment, fair or poor self-rated health, and diabetes were identified as independent risk factors for decreased driving patterns after hospitalization.

CONCLUSIONS

Changes in driving patterns are common after a hospitalization in older adults. The findings suggest that driving, although not a current goal of post-hospital care, is important to the continued autonomy and community mobility of older adults and needs to be addressed as part of discharge planning and their recovery.

Pathology-supported genetic testing as a method for disability prevention in multiple sclerosis (MS). Part II. Insights from two MS cases

In Part I of this Review we evaluated the scientific evidence for a Metabolic Model of multiple sclerosis (MS). Part II outlines the implementation of an adaptive pathology-supported genetic testing (PSGT) algorithm aimed at preventing/reversing disability in two illustrative MS cases, starting with a questionnaire-based risk assessment, including family history and lifestyle factors. Measurement of iron, vitamin B12, vitamin D, cholesterol and homocysteine levels identified biochemical deficits in both cases. Case 1, after following the PSGT program for 15 years, had an expanded disability status scale (EDSS) of 2.0 (no neurological sequelae) together with preserved brain volume on magnetic resonance imaging (MRI). A novel form of iron deficiency was identified in Case 1, as biochemical testing at each hospital submission due to MS symptoms showed low serum iron, ferritin and transferrin saturation, while hematological status and erythrocyte sedimentation rate measurement of systemic inflammation remained normal. Case 2 was unable to walk unaided until her EDSS improved from 6.5 to 4.0 over 12 months after implementation of the PSGT program, with amelioration of her suboptimal biochemical markers and changes to her diet and lifestyle, allowing her to regain independence. Genotype-phenotype correlation using a pathway panel of functional single nucleotide variants (SNVs) to facilitate clinical interpretation of whole exome sequencing (WES), elucidated the underlying metabolic pathways related to the biochemical deficits. A cure for MS will remain an elusive goal if separated from nutritional support required for production and maintenance of myelin, which can only be achieved by a lifelong investment in wellness.

Determinants of driving among oldest-old Australian women

This study examined predictors of driving among oldest-old Australian women in their late 80s in accordance with the World Health Organization's healthy aging framework. The study used data from the 1921-26 cohort of the Australian Longitudinal Study on Women's Health, wave-6 (n = 4025). The result of the multivariable logistic regression showed providing care, living alone, volunteering, living in rural/outer regional Australia, having higher educational attainment, and social interactions were associated with driving. The findings indicate driving should not be dismissed based on age alone. Policymakers need to also consider social roles, driving environment and context with the goals of healthy aging.

Canadian Older Adults' Perceptions of Transitioning from Driver to Non-Driver

Ceasing driving is associated with many negative outcomes. We examined the perceived impact of driving cessation among current older drivers. Transcripts from 92 interviews with participants from several locations across Canada were analyzed using inductive thematic analysis. We identified five themes: planning for mobility change, mobility supports and neighborhoods, financial security, fearing loss of control and independence, and coping and acceptance as a part of aging. Findings highlight diverse attitudes toward driving cessation, ranging from avoidance to acceptance, and emphasize the importance of tailored resources for drivers at various stages of behavior change.

Fitness to drive practices among non-driver trained occupational therapists in an Australian community-based rehabilitation setting

INTRODUCTION

Driving is a valued occupation given the independence and freedom it provides. Safe driving performance can be impacted by medical conditions, change in functional status and ageing processes. Occupational therapy driver assessors (OTDAs) provide invaluable driving recommendations; however, this requires specialist training for the therapist and is costly for clients. The number of OTDAs is not expected to meet the growing demand for expert services in this area, and little is known about the practices that non- OTDAs use to assist clients with returning to driving. The aims of this study were to investigate the practices of non-OTDAs in a community-based rehabilitation setting in Australia with respect to knowledge, confidence and skills in assessments, recommendations and outcomes for clients as part of the return to driving process.

METHODS

A descriptive study including medical record audits between April and September 2019 and staff surveys were completed at a large metropolitan community-based rehabilitation facility. Descriptive statistics and thematic analysis were used to summarise data.

RESULTS

A total of 102 client medical records were audited, and 13 clinician surveys were completed. Medical record audits identified that return to driving was not consistently addressed by occupational therapists. Clinician surveys outlined a lack of knowledge and confidence of return to driving processes and available assessment tools to guide this process.

CONCLUSION

All occupational therapists have an ethical obligation to address driving as an activity of daily living; however, non-OTDAs report that they are not equipped for this role. This may negatively impact on driver safety, independence and overall health and well-being of clients in community-based rehabilitation. Further research is indicated to develop evidence-based driving resources to support best practice of non-OTDAs.

Comparing Component-Based and Occupation-Based Interventions of a Person with Visual Deficits' Performance

This study aimed to compare the effectiveness of component-based, occupation-based, and a combined intervention for visual-scanning to improve occupational performance. This exploratory case study used a 55-year-old female, seven years post-stroke with visual field deficits, who completed a component-based intervention (Vision Coach), an occupation-based intervention (IADL activities that incorporated scanning tasks), and a combined intervention. The Assessment of Motor and Process Skills (AMPS) was completed prior to and after each intervention. Participant's data was compared between interventions and AMPS standardization sample, with observable improvements in motor skills and process skills. Visual-scanning training as a compensatory method appears to be effective for chronic visual field deficits post-stroke, particularly using component-based and occupation-based interventions in combination.

Spatial Mental Transformation Skills Discriminate Fitness to Drive in Young and Old Adults

Literature on driving research suggests a relationship between cognition and driving performance in older and younger drivers. There is little research on adults and driving, despite them being the largest age cohort behind the wheel. Among the cognitive domains, visuospatial abilities are expected to be highly predictive of driving skills and driving fitness. The relationship between specific spatial mental transformation skills (i.e., object and self-based ones) and driving performance has not yet been examined. The present study aimed to investigate the relationship between overall cognitive functioning, self and object-based spatial mental transformation skills, and driving performance in a sample of younger and older adult drivers. Participants were comprised of one hundred younger and 83 older adult Italian drivers. Participants completed a computerized driving test assessing traffic stress resilience, visual and motor reaction time, and the ability to obtain an overview of the traffic scenario (DT, vRT, mRT, and ATAV respectively in the Shufried®-Vienna Test System-DRIVESC). The Mental Rotation Test (MRT) and the Object Perspective Taking Test (OPT) were administered in order to assess object-based and self-based spatial mental transformation skills. The Montreal Cognitive Assessment Test (MoCA) was administered control for global cognitive functioning. The effects of education and gender were also controlled in the analysis. The results of the present study suggested that: (1) The effect of age, favoring younger participants, was found in DT, vRT, mRT, and ATAVT tests. (2) The effect of global cognitive functioning was found in DT and ATAV tests. (3) The effect of the spatial mental transformation tests was found in DT, vRT (MRT only), and ATAVT (OPT only) tests. Taken together, these results suggest the specific contribution of spatial mental transformation skills in the execution of complex behaviors connected to the fitness to drive. Prospectively, the results of the present study relating spatial mental transformation skills and driving processes may be a valuable source of knowledge for researchers dealing with the relationship between cognitive resources and navigation aids.

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.

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.

When Is It Safe to Drive after Mild Traumatic Brain Injury/Sports-related Concussion?

Driving an automobile has inherent danger, and driving after mild traumatic brain injury (mTBI)/sports-related concussion (SRC) can make this task even more hazardous. There is evidence to suggest that restriction from driving for the first 24 to 48 h after mTBI/SRC is probably reasonable. However, after the first 48 h have passed, there is insufficient evidence to make a recommendation regarding return to driving. Clinicians need to weigh the evidence and make decisions on how to advise their patients on a case by case basis. Further research is required to provide a standardized recommendation.

Performance-based visual field testing for drivers with glaucoma: A pilot study

OBJECTIVE

Conventional visual field (VF) tests are limited in predicting on-road driving performance of individuals with glaucoma. We developed a new performance-based VF test in a driving simulator for individuals with glaucoma. The aim was to evaluate the psychometric properties of the newly developed test.

METHODS

In this pilot study, 17 drivers with glaucoma aged 65.24 ± 9.69 and 13 control drivers aged 61.27 ± 11.45 completed the performance-based VF task. Construct validity was determined by comparing performance on the new task with results on conventional visual and perimetry tests including Humphrey Visual Field Analyzer, Keystone Vision Screener, and Useful Field of View (UFOV). Concurrent validity was evaluated by comparing performance on the new task with on-road driving performance, scored using the Test Ride for Investigating Practical fitness-to-drive (TRIP). Ten individuals (7 with glaucoma and 3 controls) participated in the test-retest reliability assessment.

RESULTS

Drivers with glaucoma identified fewer symbols (P = .047) and took longer to respond to the symbols (P = .048) compared to controls. In the glaucoma group, correct responses on the performance-based VF test correlated strongly (r = -0.51, P = .046) with UFOV divided attention. Both glaucoma and control groups achieved submaximal to maximal scores on the TRIP (median [Q1-Q3], glaucoma: 193 [191-196]; controls: 196 [195-196]; P = .16). No strong correlations were found between scores on the performance-based VF test and on-road driving performance in glaucoma. The intraclass correlation coefficients ranged between 0.77 for response time and 0.92 for correct responses, indicating good to excellent test-retest reliability.

CONCLUSIONS

We established the construct validity and test-retest reliability of the performance-based VF test. Future studies should include a larger sample with more severe driving difficulties to demonstrate the concurrent validity between performance-based VF testing and on-road driving performance in glaucoma.

Self-reported health conditions and related driving reduction in older drivers

We surveyed self-reported lifetime health conditions (using National Health and Aging Trends Study questions) and related driving reduction in a large multi-site older driver cohort (n = 2990) from the AAA Longitudinal Research on Aging Drivers (LongROAD) Study's baseline assessment. Those reporting reduced driving (n = 337) largely attributed reduction to musculoskeletal (29%), neurologic (13%), and ophthalmologic (10%) conditions. Women reported health condition-related driving reduction more often than men (14% versus 8%, p<.001). Mobility affects well-being; health professionals should consider that health conditions may cause older adults to reduce driving. Gender differences deserve attention in future research and education efforts.

Assessing fitness to drive after stroke

Purpose

The assessment of fitness to drive after stroke is an emerging area of occupational therapy practice in Ireland. Despite this, little is known about occupational therapists’ evaluation practices, and there are no internationally agreed clinical guidelines to inform best practice. The purpose of this paper is to investigate occupational therapy evaluation practices for fitness to drive after stroke in Ireland.

Design/methodology/approach

This is a cross-sectional study design targeting occupational therapists working with people after stroke using an online survey. Summary and descriptive statistics were used to analyse the returned surveys.

Findings

In total, 47 occupational therapists participated. Off-road driving assessment was completed by 68 per cent of respondents. Functional assessment and non-driving-specific assessments were most widely used and perceived to be the most useful in informing the off-road assessment. A total of 89 per cent referred clients for on-road assessments; however, some referred without first completing an off-road assessment. The therapists who completed formal post graduate education/training in driving assessment reported greater confidence and competence in their skills and ability to assess fitness to drive. A vast majority of participants agreed that clinical guidelines regarding best practice in this area would be beneficial.

Research limitations/implications

A majority of occupational therapists are assessing fitness to drive after stroke in Ireland with non-driving-specific assessments and functional observations; however, there are many gaps and wide variations between services. Education/training in evaluating fitness to drive after stroke is recommended. The development of clinical guidelines to inform practice would facilitate a consistent approach nationally.

Originality/value

This is the first study completed in Ireland to investigate occupational therapy evaluation practices for fitness to drive after stroke.

Predictive Value of the Cognitive Performance Test (CPT) for Staging Function and Fitness to Drive in People With Neurocognitive Disorders

The Cognitive Performance Test (CPT) is a standardized occupational therapy assessment that examines cognitive integration with functioning in an instrumental activities of daily living context. Conventional cognitive measures provide diagnostic utility but do not fully address the functional implications. Ninety-one veterans diagnosed with cognitive impairment were evaluated. We compared the predictive value of the CPT with the Large Allen Cognitive Level Screen (LACLS), Mini-Mental State Examination (MMSE), and Montreal Cognitive Assessment (MoCA) for the need to retire from driving versus ability to pass an on-road exam. Measures were also analyzed by diagnostic classification. CPT correctly classified a mild versus major neurocognitive disorder, whereas MMSE, MoCA, and LACLS did not differentiate the groups. A CPT cutoff score of <4.7/5.6 showed 89% sensitivity for failing the road exam and 75% specificity for ability to pass. CPT discriminated functional level in neurocognitive disorders and had better predictive value for fitness to drive compared with conventional cognitive measures.

Naturalistic Driving: A Framework and Advances in Using Big Data

Driving is an activity that facilitates physical, cognitive, and social stimulation in older adults, ultimately leading to better physical and cognitive health. However, aging is associated with declines in vision, physical health, and cognitive health, all of which can affect driving ability. One way of assessing driving ability is with the use of sensors in the older adult’s own vehicle. This paper provides a framework for driving assessment and addresses how naturalistic driving studies can assist in such assessments. The framework includes driving characteristics (how much driving, speed, position, type of road), actions and reactions (lane changes, intersections, passing, merging, traffic lights, pedestrians, other vehicles), destinations (variety and distance, sequencing and route planning), and driving conditions (time of day and season). Data from a subset of Ottawa drivers from the Candrive study is used to illustrate the use of naturalistic driving data. Challenges in using naturalistic driving big data and the changing technology in vehicles are discussed.

Returning Adolescents to Driving after Sports-Related Concussions: What Influences Physician Decision-Making

OBJECTIVE

To determine which data collected on an initial patient clinic visit for a sports-related concussion (SRC) might influence physicians to clear an adolescent to return to drive (RTD) after injury.

STUDY DESIGN

Retrospective cohort study of 189 adolescents with a SRC referred to a hospital-based concussion clinic between June 1, 2015, and May 31, 2016. Subjects were ≥16 years with a valid driver's license (median age = 16, IQR [16, 17]). Concussion evaluations included Post-Concussion Symptom Scale, modified Balance Error Scoring System, and postinjury computerized neurocognitive testing (CNT). Clearance for RTD was the main outcome. Statistical comparisons were conducted with Mann-Whitney U and χ² tests and logistic regression.

RESULTS

In multivariable analysis, odds of being fully cleared to drive were 5.9-fold greater among patients who were administered CNT. Stated symptoms of "headache" and "sensitivity to light" were statistically significantly associated with RTD clearance. For a subset of 113 individuals undergoing CNT, each additional 10-millisecond decrease in simple reaction time was associated with 9% greater odds of being cleared to drive. Each additional 10-millisecond decrease in choice reaction time was associated with 4% greater odds of being cleared to drive.

CONCLUSIONS

CNT and associated reaction time measures may facilitate a physician's objective decision-making. Making a RTD determination for adolescents recovering from an SRC should be a core component of a physician's assessment.

Investigating cognitive ability and self-reported driving performance of post-stroke adults in a driving simulator

Background Safe driving is a complex activity that requires calibration. This means the driver can accurately assess the level of task demand required for task completion and can accurately evaluate their driving capability. There is much debate on the calibration ability of post-stroke drivers. Objectives The aim of this study was to assess the cognition, self-rated performance, and estimation of task demand in a driving simulator with post-stroke drivers and controls. Methods A between-groups study design was employed, which included a post-stroke driver group and a group of similarly aged older control drivers. Both groups were observed driving in two simulator-based driving scenarios and asked to complete the NASA Task Load Index (TLX) to assess their perceived task demand and self-rate their driving performance. Participants also completed a battery of psychometric tasks to assess attention and executive function, which was used to determine whether post-stroke cognitive impairment impacted on calibration. Results There was no difference in the amount of perceived task demand required to complete the driving task. Despite impairments in cognition, the post-stroke drivers were not more likely to over-estimate their driving abilities than controls. On average, the post-stroke drivers self-rated themselves more poorly than the controls and this rating was related to cognitive ability. Conclusion This study suggests that post-stroke drivers may be aware of their deficits and adjust their driving behavior. Furthermore, using self-performance measures alongside a driving simulator and cognitive assessments may provide complementary fitness-to-drive assessments, as well as rehabilitation tools during post-stroke recovery.

Return to Drive Counseling After Sports-Related Concussion: A Quality Improvement Project

Introduction

Concussion is a common injury in adolescent athletes, many of whom also drive. Counseling athletes and their families about driving risks post concussion is a potentially significant intervention. The aim of this quality improvement project was to increase driving recommendations for concussed athletes in a pediatric sports medicine clinic.

Methods

Patients in this quality improvement project were seen in the sports medicine concussion clinic between February 2014 and August 2015. We determined how often driving recommendations were documented through a retrospective chart review. Once the "return to drive" project was introduced to the sports medicine staff, multiple interventions were completed including handing out flyers to remind families about driving and creating changes to the electronic medical record.

Results

At baseline, 9.3% of visits had driving recommendations documented. After an intervention requiring clinical documentation in the electronic medical record, 97% of patients received driving recommendations.

Conclusions

The quality improvement effort was successful at increasing the frequency of delivery of appropriate driving recommendations provided to concussed athletes.

Development and Validity of Western University's On-Road Assessment

Although used across North America, many on-road studies do not explicitly document the content and metrics of on-road courses and accompanying assessments. This article discusses the development of the University of Western Ontario's on-road course, and elucidates the validity of its accompanying on-road assessment. We identified main components for developing an on-road course and used measurement theory to establish face, content, and initial construct validity. Five adult volunteer drivers and 30 drivers with multiple sclerosis participated in the study. The road course had face and content validity, representing 100% of roadway components determined through a content validity matrix and index. The known-groups method showed that debilitated drivers (vs. not debilitated), made more driving errors ( W = 463.50, p = .03), and failed the on-road course, indicating preliminary construct validity of the on-road assessment. This research guides and empirically supports a process for developing a road course and its assessment.

Occupational therapy and driving and community mobility for older adults

This special issue of the American Journal of Occupational Therapy includes summaries from a systematic evidence-based literature review of occupational therapy and driving and community mobility for older adults. Since the previous review on this topic in 2008, the cohort of 78 million baby boomers began turning 65 in January 2011. As a group, this cohort is more likely to have longer life expectancy, stay in the workforce longer, and age in place in the community. Is the occupational therapy profession ready for the potential demand for driving rehabilitation services from this generation of older drivers who grew up with the automobile and are dependent on it for access to and participation in their communities?

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

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

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

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

Decision tool for clients with medical issues: a framework for identifying driving risk and potential to return to driving

This paper offers occupational therapy generalists and specialists a new framework by which to consider clinical evaluation data and an older adult's driving risk and potential to resume this previously learned skill. Based on Michon's model describing the hierarchy of driving levels, clinical questions identify the factors that may affect a client's fitness to drive. The first part is intended to support clinical judgment of whether a client needs a driving evaluation by a driver rehabilitation specialist. The second part offers a framework to organize clinical data that are already known and determine what other evaluation information is justified and necessary to make a driving recommendation. Methods and rational for use are discussed.

Consensus statements on driving for persons with dementia

The presence of dementia can have a profound effect on a person's capacity for driving, and will lead to eventual cessation of driving and reliance on alternative transportation options. This paper offers evidence and discussion that affirm eight consensus statements related to drivers with dementia and the impact of dementia on the driving task. These statements offer guidance for occupational therapy practitioners when addressing driving and community mobility, a valued instrumental task of daily living.

Primary Care: A New Context for the Scholarship of Practice Model

Interest in the emerging role for occupational therapy in the primary care practice setting has increased due to implementation of the Patient Protection and Affordable Care Act (ACA), which intends to expand health care coverage to uninsured Americans while improving coordination of care, health outcomes, and cost savings. Expanding occupational therapy to encompass promotion of wellness and prevention in a primary care context provides an opportunity for occupational therapy. The purpose of this article is to describe the role of occupational therapy in primary care and how the Scholarship of Practice model can guide the development of occupation-based and evidence-based best practice in primary care.

Factors Influencing the Clinical Stratification of Suitability to Drive after Stroke: A Qualitative Study

While a clinical pre-selection screening process for a stroke patient's suitability for driving has been acknowledged, little is known about the factors or processes influencing this screening typically conducted by clinicians practicing at a generalist level. This study explored this clinical stratification process through the use of semi-structured interviews with senior occupational therapists (n = 17) and stroke physicians (n = 7) using qualitative description methodology. The findings revealed a trichotomy stratification of stroke patients for driving in the clinical setting; those who are fit to drive, unfit to drive, and a "maybe" group who need more detailed assessment and observation. Factors that had a major influence on this clinical-based stratification of driving suitability were client's levels of awareness, insight, and impulsivity. A period of prolonged contact with the client was preferential to guide the stratification decision in order for clinicians to build a comprehensive picture of the person. A mix of assessment approaches including standardized assessment but with increased emphasis on naturalistic observation of functional performance underpinned the clinical stratification process. This study uncovers some of the factors and processes influencing the early clinical-based stratification of driving suitability after stroke, and highlights the contribution of the generalist practitioner in the assessment of fitness to drive continuum.

The impact of driving cessation on older Kuwaiti adults: implications to occupational therapy

Older adults consider driving as a fundamental part of their identity and independence. In most western countries, driving cessation has been recognized as a major issue affecting their health and well-being. This study aimed to compare older Kuwaiti adults who were active drivers and those who had ceased driving, and to explore the impact of driving cessation on the psychological well-being and lifestyle of older ex-drivers. Participants included 114 community-dwelling older adults aged 55 years and older. A questionnaire based on the driving rehabilitation literature was administered along with the Geriatric Depression Scale (GDS). Results indicated that active drivers did not place greater importance on driving and spend more time in leisure pursuits. The overarching feelings following driving cessation were loss of control over one's life and an increased sense of dependency. Driving cessation also contributed to a reduced ability to perform family duties, and it was associated with giving up previously performed leisure activities. Our findings indicate that driving cessation adversely affects older adults' independence and role performance. Older ex-drivers may require assistance and intervention to facilitate their psychological well-being and community participation.

Driving rehabilitation programs for older drivers in the United States

The objective of this study was to describe the services, referral and reporting practices, and barriers to utilization of driver rehabilitation programs (DRPs) for older drivers. Identified through two national association databases, 204 DRPs completed an online survey. DRP availability varies, with a median of one program per 64,151 older adults (range: 1,006-676,981). The median cost for a complete evaluation was $400; 36% of DRPs reported no third-party reimbursement. Participants thought barriers to DRP use include cost/reimbursement, lack of program awareness, and issues with evaluator training. Models for insurance reimbursement, and increased awareness of program benefits by healthcare providers and older drivers, are needed.

Update on productive aging research in the American Journal of Occupational Therapy, 2013, and overview of research published 2009-2013

In light of the Centennial Vision charge of supporting practice through evidence, this article reviews productive aging research published in the American Journal of Occupational Therapy (AJOT) in 2013 and as a whole from 2009 to 2013. Thirteen such articles were published in 2013, consisting of 4 systematic reviews that identified effective occupational therapy interventions for older adults with low vision; 1 randomized controlled trial that examined changes in occupational therapists' mental health practices with DVD training; and 8 descriptive articles addressing instrument development, practitioner decision making, patient management of medications, and effects of task activities on pain and participation levels. From 2009 to 2013, the quantity and quality of AJOT articles on productive aging increased; 63 articles were published, including 24 effectiveness studies, 14 basic research studies, 15 articles on instrument development and testing, 1 article linking occupational engagement and health, 6 articles on professional education, and 3 articles addressing professional questions.

Understanding the needs of hand control users, driver rehabilitation specialists, and dealers/installers

Understanding unique perspectives from key stakeholder groups involved in the hand control (HC) industry, including driver rehabilitation specialists (DRSs) who train users how to use their HCs, dealers/installers, and users, may become increasingly important in the United States due to increases in elderly, diabetic, and wounded warrior amputee driving populations. In this exploratory study, phone interviews were conducted with 20 DRSs, 20 dealers/installers, and 20 users regarding their perspectives about HC training, maintenance and operation, and design improvements. Results revealed common views and differences in perspectives about whether HC users should receive training and for how long, when and how often users should receive maintenance on their HCs, and what DRSs, dealers/installers, and users would like to see in the future.

Driving with dementia: evaluation, referral, and resources

Driving is a highly valued instrumental activity of daily living, especially for the older adults who consider it part of their definition of independence and mobility. This paper discusses the issues associated with driving and older adults, including the difficulty of identifying when it is time to give up the keys. With a review of the latest research and need for specialized services for those with diminished capacity, the paper highlights how general practice occupational therapists must work in conjunction with driver rehabilitations specialists to meet the need of this growing population. A framework for referral and judgment is described and resources offered to practitioners to use.

Driving Assessment Tools Used by Driver Rehabilitation Specialists: Survey of Use and Implications for Practice

OBJECTIVE. This article describes the use of assessment tools by North American driver rehabilitation specialists (DRSs).

PARTICIPANTS. Participants were 227 self-identified DRSs from the combined databases of two national associations.

MEASURES. Information was solicited through a self-administered survey about the driving evaluation process, assessment tools, and process for making fitness-to-drive recommendations.

RESULTS. More than 80% of the DRSs reported testing visual acuity, range of motion, muscle strength, and fine motor coordination. The most consistently used cognitive–perceptual tests were the Trail Making Tests, Motor-Free Visual Perception Test–Revised, and short cognitive screening tests. A client’s behind-the-wheel performance was the main factor in making a fitness-to-drive recommendation. Few specialists are using computer-based tests or interactive driving simulators.

CONCLUSION. Although use of the Useful Field of View® has increased, there continues to be no consistency in cognitive assessments or guidelines for behind-the-wheel assessment. Implications for practice are discussed.

Meeting the occupational needs of a neurologically impaired client for driving: a case review

Driving as a means of community mobility is an activity highly valued by individuals. When a medical condition impacts a person's ability to drive, occupational therapy practitioners should address this instrumental task of daily living with the client in order for the client to know if and when return to driving might be possible. This case review illustrates how the task of driving motivated a neurologically impaired client in therapy as well as how driving evaluation and driving rehabilitation intervention should not be done in isolation, but with the communication that will optimally assist the client to return to functional performance.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Motor vehicle operation in the setting of multiple sclerosis with myelopathy: assessment, adaptive equipment, counseling, and cessation of driving

Many individuals with multiple sclerosis are safe drivers; others self-regulate their driving or cease driving altogether because of their own safety concerns. When patients are unsafe to drive and have poor insight into their condition, they may ignore a provider's repeated communication to stop driving. Addressing this issue when a person is initially diagnosed with multiple sclerosis and continuing the discussion over time when assessing other activities of daily living may ease the process of driving cessation. Referral for a driving evaluation may be appropriate, in conjunction with referrals to a social worker for mobility counseling and to a psychologist for grief and loss issues associated with driving cessation. When repeated recommendations to stop driving are ignored, notifying the appropriate government agencies should be considered.

Update on productive aging in the American Journal of Occupational Therapy 2011

A review of the productive aging articles published in the American Journal of Occupational Therapy during 2011 was conducted and discussed in light of meeting the Centennial Vision charge of supporting practice through evidence. Twelve articles that specifically addressed productive aging were published in AJOT in 2011. The review of these 12 articles found seven Level I studies. Six of the articles were systematic reviews identifying effective interventions for people with Alzheimer's disease and related dementias and their caregivers, and 1 was a randomized controlled trial of fall prevention in community-dwelling older adults. Five were basic research studies. Two of the 5 studies researched professional issues, and 3 addressed client-based issues. The quantity of productive aging research published in 2011 was consistent with the quantity reported in 2009 and 2010. More studies building the body of evidence about the effectiveness of occupational therapy with older adults are needed.

Physician knowledge, assessment, and reporting of older driver fitness

ABSTRACT Physicians have the potential to serve as an important portal for information gathering, assessment, counseling, and reporting older driver fitness, as almost all older adults require medical care and have a primary care physician. However, there are few studies that have evaluated physician knowledge about, attitudes toward, and performance of older driver fitness assessment. Two pilot studies were conducted to assess physician knowledge and attitudes and aid understanding of physician knowledge of legal reporting requirements regarding older driver medical fitness. Results suggest that although physicians believe that patients should be evaluated for safe driving, many physicians do not routinely assess fitness to drive and few feel qualified to do so. It also appears that physicians may not be adequately knowledgeable about laws about reporting unsafe drivers. Thus, occupational therapy practitioners have an opportunity to educate about driving as a complex instrumental activity of daily living.