Frailty and poor physical functioning as risk factors for driving cessation

Introduction

Frailty and low physical performance are modifiable factors and, therefore, targets for interventions aimed at delaying driving cessation (DC). The objective was to determine the impact of frailty and physical performance on DC.

Methods

Multisite prospective cohort of older drivers. The key inclusion criteria are as follows: active driver age 65-79 years, possessing a valid driver's license, without significant cognitive impairment, and driving a 1996 car or a newer model car. Of the 2,990 enrolled participants, 2,986 (99.9%) had at least one frailty or Short Physical Performance Battery (SPPB) measure and were included in this study. In total, 42% of participants were aged 65-69 years, 86% were non-Hispanic white, 53% were female, 63% were married, and 41% had a high degree of education. The Fried Frailty Phenotype and the Expanded Short Physical Performance Battery (SPPB) from the National Health and Aging Trends Study were utilized. At each annual visit, DC was assessed by the participant notifying the study team or self-reporting after no driving activity for at least 30 days, verified via GPS. Cox proportional hazard models, including time-varying covariates, were used to examine the impact of the SPPB and frailty scores on time to DC. This assessment included examining interactions by sex.

Results

Seventy-three participants (2.4%) stopped driving by the end of year 5. Among women with a fair SPPB score, the adjusted hazard ratio (HR) of DC was 0.26 (95% confidence interval (CI) 0.10-0.65) compared to those with a poor SPPB score. For those with a good SPPB score, the adjusted HR of DC had a p-value of <0.001. Among men with a fair SPPB score, the adjusted hazard ratio (HR) of DC was 0.45 (95% CI 0.25-0.81) compared to those with a poor SPPB score. For men with a good SPPB score, the adjusted HR of DC was 0.19 (95% CI 0.10-0.36). Sex was not an effect modifier between frailty and DC. For those who were categorized into pre-frail or frail, the adjusted ratio of HR to DC was 6.1 (95% CI 2.7-13.8) compared to those who were not frail.

Conclusion and relevance

Frailty and poor physical functioning are major risk factors for driving cessation. Staying physically active may help older adults to extend their driving life expectancy and mobility.

Association of Depression and Antidepressant Use With Driving Behaviors in Older Adults: A LongROAD Study

Older adults aged 70 and older who drive have higher crash death rates per mile driven compared to middle aged (35-54 years) adults who drive in the US. Prior studies have found that depression and or antidepressant medication use in older adults are associated with an increase in the vehicular crash rate. Using data from the prospective multi-site AAA Longitudinal Research on Aging Drivers Study, this analysis examined the independent and interdependent associations of self-reported depression and antidepressant use with driving behaviors that can increase motor vehicle crash risk such as hard braking, speeding, and night-time driving in adults over age 65. Of the 2951 participants, 6.4% reported having depression and 21.9% were on an antidepressant medication. Correcting for age, race, gender, and education level, participants on an antidepressant had increased hard braking events (1.22 [1.10-1.34]) but self-reported depression alone was not associated with changes in driving behaviors.

Migraine headaches are associated with motor vehicle crashes and driving habits among older drivers: Prospective cohort study

BACKGROUND

Migraine headache is common in older adults, often causing symptoms that may affect driving safety. This study examined associations of migraine with motor vehicle crashes (MVCs) and driving habits in older drivers and assessed modification of associations by medication use.

METHODS

In a multi-site, prospective cohort study of active drivers aged 65-79 (53% female), we assessed prevalent migraine (i.e., ever had migraine, reported at enrollment), incident migraine (diagnosis first reported at a follow-up visit), and medications typically used for migraine prophylaxis and treatment. During 2-year follow-up, we recorded self-reported MVCs and measured driving habits using in-vehicle GPS devices. Associations of prevalent migraine with driving outcomes were estimated in multivariable mixed models. Using a matched design, associations of incident migraine with MVCs in the subsequent year were estimated with conditional logistic regression. Interactions between migraine and medications were tested in all models.

RESULTS

Of 2589 drivers, 324 (12.5%) reported prevalent migraine and 34 (1.3%) incident migraine. Interactions between migraine and medications were not statistically significant in any models. Prevalent migraine was not associated with MVCs in the subsequent 2 years (adjusted OR [aOR] = 0.98; 95% CI: 0.72, 1.35), whereas incident migraine significantly increased the odds of having an MVC within 1 year (aOR = 3.27; 1.21, 8.82). Prevalent migraine was associated with small reductions in driving days and trips per month and increases in hard braking events in adjusted models.

CONCLUSION

Our results suggest substantially increased likelihood of MVCs in the year after newly diagnosed migraine, indicating a potential need for driving safety interventions in these patients. We found little evidence for MVC risk or substantial changes in driving habits associated with prevalent migraine. Future research should examine timing, frequency, and severity of migraine diagnosis and symptoms, and use of medications specifically prescribed for migraine, in relation to driving outcomes.

Impact of driving cessation on health-related quality of life trajectories

BACKGROUND

Trajectories of health-related quality of life (HRQoL) after driving cessation (DC) are thought to decline steeply, but for some, HRQoL may improve after DC. Our objective is to examine trajectories of HRQoL for individuals before and after DC. We hypothesize that for urban drivers, volunteers and those who access alternative transportation participants' health may remain unchanged or improve.

METHODS

This study uses data from the AAA Longitudinal Research on Aging Drivers (LongROAD) study, a prospective cohort of 2,990 older drivers (ages 65-79 at enrollment). The LongROAD study is a five-year multisite study and data collection ended October 31, 2022. Participants were recruited using a convenience sample from the health centers roster. The number of participants approached were 40,806 with 7.3% enrolling in the study. Sixty-one participants stopped driving permanently by year five and had data before and after DC. The PROMIS®-29 Adult Profile was utilized and includes: 1) Depression, 2) Anxiety, 3) Ability to Participate in Social Roles and Activities, 4) Physical Function, 5) Fatigue, 6) Pain Interference, 7) Sleep Disturbance, and 8) Numeric Pain Rating Scale. Adjusted (age, education and gender) individual growth models with 2989 participants with up to six observations from baseline to year 5 in the models (ranging from n = 15,041 to 15,300) were utilized.

RESULTS

Ability to participate in social roles and activities after DC improved overall. For those who volunteered, social roles and activities declined not supporting our hypothesis. For those who accessed alternative transportation, fatigue had an initial large increase immediately following DC thus not supporting our hypothesis. Urban residents had worse function and more symptoms after DC compared to rural residents (not supporting our hypothesis) except for social roles and activities that declined steeply (supporting our hypothesis).

CONCLUSIONS

Educating older adults that utilizing alternative transportation may cause initial fatigue after DC is recommended. Accessing alternative transportation to maintain social roles and activities is paramount for rural older adults after DC especially for older adults who like to volunteer.

Interaction between benzodiazepines and prescription opioids on incidence of hard braking events in older drivers

BACKGROUND

Polypharmacy use among older adults is of increasing concern for driving safety. This study assesses the individual and joint effects of benzodiazepines and prescription opioids on the incidence of hard braking events in older drivers.

METHODS

Data for this study came from the Longitudinal Research on Aging Drivers project-a multisite, prospective cohort study of 2990 drivers aged 65-79 years at enrollment (2015-2017). Adjusted incidence rate ratios (aIRRs) and 95% confidence intervals (CIs) of hard braking events (defined as maneuvers with deceleration rates ≥0.4 g and commonly known as near-crashes) were estimated through multivariable negative binominal modeling.

RESULTS

Of the 2929 drivers studied, 167 (5.7%) were taking benzodiazepines,  163 (5.6%) prescription opioids, and 23 (0.8%) both drugs at baseline. The incidence rates of hard braking events per 1000 miles driven were 1.14 (95% CI 1.10-1.18) for drivers using neither benzodiazepines nor prescription opioids, 1.25 (95% CI 1.07-1.43) for those using benzodiazepines only, 1.55 (95% CI 1.35-1.76) for those using prescription opioids only, and 1.63 (95% CI 1.11-2.16) for those using both medications. Multivariable modeling revealed that the use of prescription opioids was associated with a 19% increased risk of hard braking events (aIRR 1.19, 95% CI 1.03-1.36). There existed a positive interaction between the two drugs on the additive scale but not on the multiplicative scale.

CONCLUSION

Concurrent use of benzodiazepines and prescription opioids by older drivers appears to affect driving safety through increased incidence of hard braking events.

Improvements in dietary intake, behaviors, and psychosocial measures in a community-randomized cardiovascular disease risk reduction intervention: Strong Hearts, Healthy Communities 2.0

BACKGROUND

Cardiovascular disease (CVD) prevalence has disproportionately risen among midlife and older female adults of rural communities, partly due to poor diet and diet-related behaviors and psychosocial factors that impede healthy eating.

OBJECTIVES

This study aimed to evaluate the impact of Strong Hearts Healthy Communities 2.0 (SHHC-2.0) on secondary diet-related outcomes between intervention and control participants that align with the dietary goal and behavioral aims of the SHHC-2.0, a CVD risk reduction program.

METHODS

A community-randomized controlled trial was conducted in rural, medically underserved communities. Participants were female adults ≥40 y who were classified as obese or both overweight and sedentary. Communities were randomized to SHHC-2.0 intervention (n = 5 communities; n = 87 participants) or control (with delayed intervention) (n = 6 communities; n = 95 participants). SHHC-2.0 consisted of 24 wk of twice-weekly experiential nutrition education and group-based physical activity classes led by local health educators. Changes between baseline and end point (24 wk) in dietary intake (24-h recalls), dietary behaviors (e.g., Rapid Eating Assessment for Participants-Short Version [REAP-S] scores) and diet-related psychosocial measures (e.g., Three Factor Eating questionnaire) between groups were analyzed using linear mixed-effects multilevel models.

RESULTS

At 24 wk, participants from the 5 intervention communities, compared with controls, consumed fewer calories (mean difference [MD]= -211 kcal, 95% CI: -412, -110, P = 0.039), improved overall dietary patterns measured by REAP-S scores (MD: 3.9; 95% CI: 2.26, 5.6; P < 0.001), and improved psychosocial measures (healthy eating attitudes, uncontrolled eating, cognitive restraint, and emotional eating).

CONCLUSIONS

SHHC-2.0 has strong potential to improve diet patterns and diet-related psychosocial wellbeing consistent with improved cardiovascular health. This trial was registered at www.

CLINICALTRIALS

gov as NCT03059472.

Motor Vehicle Crash Risk in Older Adult Drivers With Attention-Deficit/Hyperactivity Disorder

Importance

Symptoms of attention-deficit/hyperactivity disorder (ADHD), such as inattentiveness and impulsivity, could affect daily functioning and driving performance throughout the life span. Previous research on ADHD and driving safety is largely limited to adolescents and young adults.

Objective

To examine the prevalence of ADHD and the association between ADHD and crash risk among older adult drivers.

Design, Setting, and Participants

This prospective cohort study collected data from primary care clinics and residential communities in 5 US sites (Ann Arbor, Michigan; Baltimore, Maryland; Cooperstown, New York; Denver, Colorado; and San Diego, California) between July 6, 2015, and March 31, 2019. Participants were active drivers aged 65 to 79 years at baseline enrolled in the Longitudinal Research on Aging Drivers project who were studied for up to 44 months through in-vehicle data recording devices and annual assessments. The data analysis was performed between July 15, 2022, and August 14, 2023.

Exposure

Lifetime ADHD based on an affirmative response to the question of whether the participant had ever had ADHD or had ever been told by a physician or other health professional that he or she had ADHD.

Main Outcomes and Measures

The main outcomes were hard-braking events defined as maneuvers with deceleration rates of 0.4g or greater, self-reported traffic ticket events, and self-reported vehicular crashes. Multivariable negative binomial modeling was used to estimate adjusted incidence rate ratios (aIRRs) and 95% CIs of outcomes according to exposure status.

Results

Of the 2832 drivers studied, 1500 (53.0%) were women and 1332 (47.0%) were men with a mean (SD) age of 71 (4) years. The lifetime prevalence of ADHD in the study sample was 2.6%. Older adult drivers with ADHD had significantly higher incidence rates of hard-braking events per 1000 miles than those without ADHD (1.35 [95% CI, 1.30-1.41] vs 1.15 [95% CI, 1.14-1.16]), as well as self-reported traffic ticket events per 1 million miles (22.47 [95% CI, 16.06-31.45] vs 9.74 [95% CI, 8.99-10.55]) and self-reported vehicular crashes per 1 million miles (27.10 [95% CI, 19.95-36.80] vs 13.50 [95% CI, 12.61-14.46]). With adjustment for baseline characteristics, ADHD was associated with a significant 7% increased risk of hard-braking events (aIRR, 1.07; 95% CI, 1.02-1.12), a 102% increased risk of self-reported traffic ticket events (aIRR, 2.02; 95% CI, 1.42-2.88), and a 74% increased risk of self-reported vehicular crashes (aIRR, 1.74; 95% CI, 1.26-2.40).

Conclusions and Relevance

As observed in this prospective cohort study, older adult drivers with ADHD may be at a significantly elevated crash risk compared with their counterparts without ADHD. These findings suggest that effective interventions to improve the diagnosis and clinical management of ADHD among older adults are warranted to promote safe mobility and healthy aging.

Associations of cannabis use with motor vehicle crashes and traffic stops among older drivers: AAA LongROAD study

BACKGROUND

Acute cannabis use is associated with a higher risk of motor vehicle crashes (MVC). This study aimed to determine if self-reported past-year cannabis use is associated with MVC or traffic stops among older drivers.

METHODS

This cross-sectional analysis used data from a multi-center study enrolling active drivers aged 65-79 years. Data regarding cannabis use, MVC, and traffic stops (i.e., being pulled over by police, whether ticketed or not) within the previous 12 months were collected through participant interviews. Log-binomial regression models examined associations of past-year cannabis use with MVC and traffic stops, adjusting for site and sociodemographic and mental health characteristics.

RESULTS

Of 2,095 participating older drivers, 186 (8.88%) used cannabis in the past year but only 10 (<0.5%) within an hour before driving in the last 30 days; 11.41% reported an MVC and 9.45% reported a traffic stop. Past-year cannabis users had a higher prevalence of MVC (adjusted prevalence ratio [aPR] = 1.38; 95%CI: 0.96, 2.00; p = 0.086) and traffic stops (aPR = 1.58; 1.06, 2.35; p = 0.024).

CONCLUSIONS

Past-year cannabis use was associated with increased traffic stops, which are correlated modestly with increased MVC in past studies and may indicate impaired driving performance. We did not find a statistically significant association of past-year cannabis use with MVC, which may indicate limited sustained effects on driving performance from periodic use among older adults, who report rarely driving immediately after use.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs to Prevent Diabetes in People With Prediabetes

Individuals with an elevated fasting glucose level, elevated glucose level after glucose challenge, or elevated hemoglobin A1c level below the diagnostic threshold for diabetes (collectively termed prediabetes) are at increased risk for type 2 diabetes. More than one-third of U.S. adults have prediabetes but fewer than one in five are aware of the diagnosis. Rigorous scientific research has demonstrated the efficacy of both intensive lifestyle interventions and metformin in delaying or preventing progression from prediabetes to type 2 diabetes. The National Clinical Care Commission (NCCC) was a federal advisory committee charged with evaluating and making recommendations to improve federal programs related to the prevention of diabetes and its complications. In this article, we describe the recommendations of an NCCC subcommittee that focused primarily on prevention of type 2 diabetes in people with prediabetes. These recommendations aim to improve current federal diabetes prevention activities by 1) increasing awareness of and diagnosis of prediabetes on a population basis; 2) increasing the availability of, referral to, and insurance coverage for the National Diabetes Prevention Program and the Medicare Diabetes Prevention Program; 3) facilitating Food and Drug Administration review and approval of metformin for diabetes prevention; and 4) supporting research to enhance the effectiveness of diabetes prevention. Cognizant of the burden of type 1 diabetes, the recommendations also highlight the importance of research to advance our understanding of the etiology of and opportunities for prevention of type 1 diabetes.

The National Clinical Care Commission Report to Congress: Recommendations to Better Leverage Federal Policies and Programs to Prevent and Control Diabetes

The National Clinical Care Commission (NCCC) was established by Congress to make recommendations to leverage federal policies and programs to more effectively prevent and treat diabetes and its complications. The NCCC developed a guiding framework that incorporated elements of the Socioecological and Chronic Care Models. It surveyed federal agencies and conducted follow-up meetings with representatives from 10 health-related and 11 non-health-related federal agencies. It held 12 public meetings, solicited public comments, met with numerous interested parties and key informants, and performed comprehensive literature reviews. The final report, transmitted to Congress in January 2022, contained 39 specific recommendations, including 3 foundational recommendations that addressed the necessity of an all-of-government approach to diabetes, health equity, and access to health care. At the general population level, the NCCC recommended that the federal government adopt a health-in-all-policies approach so that the activities of non-health-related federal agencies that address agriculture, food, housing, transportation, commerce, and the environment be coordinated with those of health-related federal agencies to affirmatively address the social and environmental conditions that contribute to diabetes and its complications. For individuals at risk for type 2 diabetes, including those with prediabetes, the NCCC recommended that federal policies and programs be strengthened to increase awareness of prediabetes and the availability of, referral to, and insurance coverage for intensive lifestyle interventions for diabetes prevention and that data be assembled to seek approval of metformin for diabetes prevention. For people with diabetes and its complications, the NCCC recommended that barriers to proven effective treatments for diabetes and its complications be removed, the size and competence of the workforce to treat diabetes and its complications be increased, and new payment models be implemented to support access to lifesaving medications and proven effective treatments for diabetes and its complications. The NCCC also outlined an ambitious research agenda. The NCCC strongly encourages the public to support these recommendations and Congress to take swift action.

Detecting mild cognitive impairment and dementia in older adults using naturalistic driving data and interaction-based classification from influence score

Several recent studies indicate that atypical changes in driving behaviors appear to be early signs of mild cognitive impairment (MCI) and dementia. These studies, however, are limited by small sample sizes and short follow-up duration. This study aims to develop an interaction-based classification method building on a statistic named Influence Score (i.e., I-score) for prediction of MCI and dementia using naturalistic driving data collected from the Longitudinal Research on Aging Drivers (LongROAD) project. Naturalistic driving trajectories were collected through in-vehicle recording devices for up to 44 months from 2977 participants who were cognitively intact at the time of enrollment. These data were further processed and aggregated to generate 31 time-series driving variables. Because of high dimensional time-series features for driving variables, we used I-score for variable selection. I-score is a measure to evaluate variables' ability to predict and is proven to be effective in differentiating between noisy and predictive variables in big data. It is introduced here to select influential variable modules or groups that account for compound interactions among explanatory variables. It is explainable regarding to what extent variables and their interactions contribute to the predictiveness of a classifier. In addition, I-score boosts the performance of classifiers over imbalanced datasets due to its association with the F1 score. Using predictive variables selected by I-score, interaction-based residual blocks are constructed over top I-score modules to generate predictors and ensemble learning aggregates these predictors to boost the prediction of the overall classifier. Experiments using naturalistic driving data show that our proposed classification method achieves the best accuracy (96%) for predicting MCI and dementia, followed by random forest (93%) and logistic regression (88%). In terms of F1 score and AUC, our proposed classifier achieves 98% and 87%, respectively, followed by random forest (with an F1 score of 96% and an AUC of 79%) and logistic regression (with an F1 score of 92% and an AUC of 77%). The results indicate that incorporating I-score into machine learning algorithms could considerably improve the model performance for predicting MCI and dementia in older drivers. We also performed the feature importance analysis and found that the right to left turn ratio and the number of hard braking events are the most important driving variables to predict MCI and dementia.

Changes in physical activity outcomes in the Strong Hearts, Healthy Communities (SHHC-2.0) community-based randomized trial

BACKGROUND

Physical inactivity is a risk factor for numerous adverse health conditions and outcomes, including all-cause mortality. Aging rural women are at particular risk for physical inactivity based on environmental, sociocultural, and psychosocial factors. This study reports on changes in physical activity and associated factors from a multicomponent community-engaged intervention trial.

METHODS

Strong Hearts, Healthy Communities 2.0 (SHHC-2.0) was a 24-week cluster (community) randomized controlled trial building on the results from the previous trial of SHHC-1.0. Rural women (n = 182) aged 40 and over living in 11 rural communities in upstate New York were recruited. The intervention consisted of twice-weekly experiential classes focused on exercise, nutrition, and civic engagement. Physical activity outcomes included accelerometry and self-report as well as related psychosocial measures at midpoint (12 weeks) and post-intervention (24 weeks). Data were analyzed using multilevel linear regression models with the community as the random effect.

RESULTS

Compared to participants from the control communities, participants in the intervention communities showed a significant increase in objectively measured moderate to vigorous intensity physical activity: at 12 weeks (increase of 8.1 min per day, P < 0.001) and at 24 weeks (increase of 6.4 min per day; P = 0.011). Self-reported total MET minutes per week also increased: at 12 weeks (increase of 725.8, P = 0.003) and 24 weeks (increase of 955.9, P = 0.002). Several of the psychosocial variables also showed significant positive changes.

CONCLUSIONS

The SHHC-2.0 intervention successfully increased physical activity level and related outcome measures. Modifications made based upon in-depth process evaluation from SHHC-1.0 appear to have been effective in increasing physical activity in this at-risk population.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT03059472. Registered 23 February 2017.

DIABETES MELLITUS AND HARD BRAKING EVENTS IN OLDER DRIVERS

There are an estimated 37 million people with diabetes mellitus (DM) in the United States, including 16 million older adults. DM can impair patients’ driving safety due to diabetic peripheral neuropathy, hypoglycemia, or hyperglycemia, and eye diseases. However, few studies have examined the association between DM and driving safety based on naturalistic driving data. Data for this study came from the Longitudinal Research on Aging Drivers (LongROAD) project, a multisite naturalistic driving study of 2990 drivers aged 65–79 years at baseline. Driving data for the study participants were recorded by in-vehicle recording devices for up to 44 months. We used multivariable negative binomial modeling to estimate the incidence rate ratios (IRRs) and 95% confidence intervals (CIs) of hard braking events (i.e., proxies for unsafe driving behavior defined as maneuvers with deceleration rates ≥ 0.4 g) associated with DM. Of the 2856 study participants eligible for this study, 482 (16.9%) reported having DM at baseline. The overall incidence rate of hard braking events was 1.16 per 1000 miles. Adjusted for age, race/ethnicity, marital status, education level, annual household income, urbanicity, history of stroke, and number of medications, drivers with DM had a 10% increased rate of hard braking events compared to drivers without DM (adjusted IRR 1.10; 95% CI: 1.08, 1.12). Results of this study indicates that DM is associated with a significantly increased rate of hard braking events in older drivers, suggesting less safe driving. Driving safety should be incorporated into DM management and care programs.

Association of falls and fear of falling with objectively-measured driving habits among older drivers: LongROAD study

OBJECTIVE

Falls in older adults are associated with increased motor vehicle crash risk, possibly mediated by driving behavior. We examined the relationship of falls and fear of falling (FOF) with subsequent objectively measured driving habits.

METHODS

This multi-site, prospective cohort study enrolled 2990 active drivers aged 65-79 (53% female). At enrollment, we assessed falls in the past year and FOF (Short Falls Efficacy Scale-International). Driving outcomes included exposure, avoidance of difficult conditions, and unsafe driving during one-year follow-up, using in-vehicle Global Positioning System devices.

RESULTS

Past-year falls were associated with more hard braking events (HBE). High FOF was associated with driving fewer days, miles, and trips, driving nearer home and more HBE. Differences were attenuated and not significant after accounting for health, function, medications and sociodemographics.

DISCUSSION

Differences in objectively measured driving habits according to past-year fall history and FOF were largely accounted for by differences in health and medications. Rather than directly affecting driving, falls and FOF may serve as markers for crash risk and reduced community mobility due to age-related changes and poor health.

Improvements and Maintenance of Clinical and Functional Measures Among Rural Women: Strong Hearts, Healthy Communities-2. 0 Cluster Randomized Trial

BACKGROUND

Cardiovascular disease is the leading cause of death in the United States; however, women and rural residents face notable health disparities compared with male and urban counterparts. Community-engaged programs hold promise to help address disparities through health behavior change and maintenance, the latter of which is critical to achieving clinical improvements and public health impact.

METHODS

A cluster-randomized controlled trial of Strong Hearts, Healthy Communities-2.0 conducted in medically underserved rural communities examined health outcomes and maintenance among women aged ≥40 years, who had a body mass index >30 or body mass index 25 to 30 and also sedentary. The multilevel intervention provided 24 weeks of twice-weekly classes with strength training, aerobic exercise, and skill-based nutrition education (individual and social levels), and civic engagement components related to healthy food and physical activity environments (community, environment, and policy levels). The primary outcome was change in weight; additional clinical and functional fitness measures were secondary outcomes. Mixed linear models were used to compare between-group changes at intervention end (24 weeks); subgroup analyses among women aged ≥60 years were also conducted. Following a 24-week no-contact period, data were collected among intervention participants only to evaluate maintenance.

RESULTS

Five communities were randomized to the intervention and 6 to the control (87 and 95 women, respectively). Significant improvements were observed for intervention versus controls in body weight (mean difference: -3.15 kg [95% CI, -4.98 to -1.32]; P=0.008) and several secondary clinical (eg, waist circumference: -3.02 cm [-5.31 to -0.73], P=0.010; systolic blood pressure: -6.64 mmHg [-12.67 to -0.62], P=0.031; percent body fat: -2.32% [-3.40 to -1.24]; P<0.001) and functional fitness outcomes; results were similar for women aged ≥60 years. The within-group analysis strongly suggests maintenance or further improvement in outcomes at 48 weeks.

CONCLUSIONS

This cardiovascular disease prevention intervention demonstrated significant, clinically meaningful improvements and maintenance among rural, at-risk older women.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03059472.

Implementation of Evidence-Based Disease Self-Management Programs in a Rural Region: Leveraging and Linking Community and Health Care System Assets

CONTEXT

Rural populations experience both a higher prevalence of and risk for premature death from chronic conditions than do their urban counterparts. Yet barriers to implement community-based chronic disease self-management programs persist.

PROGRAM

The Living Well program, a multi-sector collaboration between a rural health care system and a network of community-based organizations, has offered the 6-week evidence-based Chronic Disease Self-Management and Diabetes Self-Management workshops since 2017. The program was a response to a quality improvement initiative to improve hypertension and diabetes outcomes throughout the health care system.

IMPLEMENTATION

Using the rapid cycling quality improvement process, Living Well developed a self-management program recruitment, referral, and coordinating office for a six-county region. Through continuous capacity-building efforts with community partners, as well as leveraging key health care system assets such as the electronic health record and provider detailing, program reach and adoption was increased.

EVALUATION

The Reach, Effectiveness, Adoption, Implementation, and Maintenance framework was used for the process evaluation. During 3 years, more than 750 individuals engaged with the program, with nearly 600 completing a workshop. The region saw increased engagement by primary care clinicians to refer, and structural changes were embedded into the health care system to facilitate clinic-community partnerships.

DISCUSSION

A coordinated, multi-sector approach is necessary to develop solutions to complex, chronic health problems. A regional coordinating hub is an effective strategy for implementing community-based programs in rural areas. However, low health care system engagement and fragmented funding remain as barriers to optimal implementation.

Evaluating the Implementation of the Diabetes Self-Management Program in a Rural Population

The evidence-based Diabetes Self-Management Program (DSMP) has been shown to improve a variety of health-related outcomes, but the program has been challenging to implement in rural areas, and rural dissemination has been low. The purpose of this project was to evaluate the effect of implementing the DSMP on self-reported outcomes in a rural region. Through a collaboration with multiple partners, the Living Well program delivered 28 DSMP workshops from 2017 to 2019. Data were collected to determine whether there were post-intervention changes in patient-reported outcomes on measures of diabetes distress, self-management, and patient activation. In addition, secondary analysis of A1C was abstracted from the medical records of participants with type 2 diabetes who completed at least four sessions of a DSMP workshop between 2017 and 2019 and whose medical records had an A1C value in the year before the program and at least one A1C value >3 months after the program. Statistically significant improvements were seen for the Diabetes Distress Scale (P = 0.0017), the Diabetes Self-Management Questionnaire (P <0.0001) and the 10-item Patient Activation Measure (P <0.0001). There was no evidence of change in A1C over time in analyses of all participants (P = 0.5875), but a consistent though nonsignificant (P = 0.1087) decline in A1C was seen for a subset of participants with a baseline A1C ≥8%. This evaluation provides preliminary support for implementing the DSMP as part of a comprehensive treatment and self-management plan for people living with diabetes in rural areas.

Evaluation of a Peer Led Chronic Pain Self-Management Program in a Rural Population

BACKGROUND

The Chronic Pain Self-Management Program is an evidence-based intervention that has been shown to be efficacious in reducing symptoms of chronic pain. However, there is a paucity of research examining CPSMP in a predominantly rural population. The purpose was to evaluate patient-reported outcomes of in-person peer-led CPSMP workshops offered in a rural region in 2018 and 2019.

METHODS

Participants were surveyed at baseline and 6 months post-workshop. Descriptive statistics were used to describe characteristics of CPSMP completers. Paired t-tests were used to analyze change in depression score (PHQ-8), disability (modified Roland-Morris Disability Questionnaire), self-efficacy, and patient activation (PAM-10). Analysis of variance was used to detect differences over time by age group, education, insurance type, self-rated health, and comorbidities.

RESULTS

Among the 327 adults who enrolled in a workshop, 73.1% completed. Of completers, 74.9% were female, average age was 65. Significant improvements were observed in pain disability (P = .0008), patient activation (P = .0362), depression (P < .0001), and self-efficacy (P < .0001), at 6 weeks; and pain disability (P = .0030), depression (P = .0015), and self-efficacy (P = .0064) at 6 months post-program. Individuals who rated their health as fair/poor at baseline reported greater improvements in depression scores than individuals who rated their health as good or better (P < .0002). There were also distinct patterns of change in pain disability among the different age groups. No other differences between groups were noted.

CONCLUSIONS

The CPSMP appears to improve pain self-efficacy, disability, and depression regardless of age, gender, insurance status, education, or comorbidities. Healthcare and community organizations should consider investing in and offering chronic pain workshops in rural areas in order to promote health and wellness.

Rate of Social Isolation by Geographic Location Among Older Adults: AAA LongROAD Study

Introduction: Social isolation is a modifiable risk factor for negative health outcomes among older adults. This work assessed the relationship between geography (i.e., urban vs. non-urban residence) and social isolation in a cohort of older drivers.

Methods: The AAA LongROAD cohort with 2,989 older adult drivers from across the country were included. Social isolation was measured at baseline and at two subsequent annual follow-ups using PROMIS v2.0 Social Isolation 4a. The effect of geographic location with social isolation was assessed through with multivariable regression using a generalized estimating equation model.

Results: The rate of social isolation in urban areas was 21% lower (adjusted RR 0.79, 95% CI 0.46, 1.36) compared to non-urban areas after adjusting for covariates, though not significant.

Discussion: Social isolation is a predictor of poor health outcomes and geographic considerations have been lacking in the literature. The panel data in this analysis provides more evidence for causality though the under-representation of non-urban areas potentially reduces the power for the results.

Conclusions: It is important to understand the needs and risk of social isolation in various geographic settings to ensure resources and interventions are appropriately modified for a greater public health impact.

Physical activity and healthy eating behavior changes among rural women: an exploratory mediation analysis of a randomized multilevel intervention trial

Rural women experience disproportionately higher levels of obesity in comparison to their non-rural counterparts. The present exploratory mediation analysis sought to identify mechanisms that might have contributed to rural women's physical activity and diet changes after participating in a 6-month multilevel community-randomized trial: Strong Hearts, Healthy Communities (SHHC). SHHC was conducted in 16 rural towns in Montana and New York, between 2015 and 2016; 194 overweight, sedentary midlife, and older women (mean age 59; 26.8% overweight; 73.2% obese) participated. Participants in eight towns received the SHHC intervention (n = 101), which focused on healthy behavior change at the individual level as well as creating supportive social and built environments for physical activity and healthy eating. Participants in the other eight towns received an education-only control intervention (n = 93). We investigated the direct and indirect effects of the SHHC intervention through changes to self-efficacy, social support, and built environment perception, on changes in participants' physical activity and diet. Compared to the controls, SHHC intervention participants increased their social support from friends for physical activity (p = 0.009) and healthy eating (p = 0.032). Participants' improved social support from friends marginally mediated the intervention effects for walking metabolic equivalent minutes per week, explaining 40.5% of the total effect (indirect effect = +45.24, 95% CI: -1.51, +91.99; p = 0.059). Increasing social support from friends appears to be helpful in encouraging rural women to become more active. Further investigations are needed to better understand how multilevel interventions work in rural communities.

Adapted Stopping Elderly Accidents, Deaths, and Injuries Questions for Falls Risk Screening: Predictive Ability in Older Drivers

INTRODUCTION

Fall fatality rates among U.S. older adults increased 30% from 2007 to 2016. In response, the Centers for Disease Control and Prevention developed the Stopping Elderly Accidents, Deaths, and Injuries algorithm for fall risk screening, assessment, and intervention. The current Stopping Elderly Accidents, Deaths, and Injuries algorithm with 2 levels (at risk and not at risk) was adapted to an existing cohort of older adult drivers.

METHODS

A U.S. multisite prospective cohort (N=2,990) of drivers (aged 65-79 years), from 2015 to 2017, was used for these analyses completed in January 2020-October 2020. To measure the adapted Stopping Elderly Accidents, Deaths, and Injuries key questions for fall risk screening performance in predicting future falls, adjusted logistic regression determined the area of the receiver operating characteristic curve. An adjusted mixed logistic regression modeled the association between the adapted Stopping Elderly Accidents, Deaths, and Injuries key questions and future falls.

RESULTS

The adapted Stopping Elderly Accidents, Deaths, and Injuries key questions yielded an area under the curve of 0.65 in determining any fall over 2 years. The adjusted mixed logistic regression model suggests that those at risk for falls at baseline were associated with 2.37 times higher odds of any fall (95% CI=2.00, 2.80) and 3.60 times higher odds of multiple falls (95% CI=2.88, 4.51) over 2 years.

CONCLUSIONS

The adapted Stopping Elderly Accidents, Deaths, and Injuries key questions for fall risk screening yielded fair predictive ability for falls over 2 years and were strongly associated with future falls for older adult drivers. The adapted Stopping Elderly Accidents, Deaths, and Injuries key questions can be applied to existing data in nonclinical settings to strengthen fall screening and prevention at a population level.

Telomere shortening correlates with disease severity in hemoglobin H disease patients

Hemoglobin H (Hb H) disease is the most significant health problem of the α-thalassemia syndromes. The Hb disease patients are categorized based on their genotype to deletional and nondeletional, with the latter genotype presents the more severe clinical symptoms. Since telomere length is an indicator of biological aging and health, we hypothesized that telomere length could reflect Hb H disease's severity. In this study, we recruited 48 deletional and 47 nondeletional Hb H disease patients, along with 109 normal controls, for telomere length assessment. The leukocyte telomere length was assessed by monochromatic multiplex real-time PCR and reported as the telomere to single-copy gene (T/S) ratio. When telomere length was adjusted for age, the analysis of covariance between the control and the two Hb H disease groups revealed no significant difference. However, the telomere shortening rate was more rapid in the nondeletional Hb H disease group than those of the control and deletional Hb H disease groups. Gender analysis found that male patients have a significantly lower T/S ratio than females in the nondeletional group but not in the control and deletional groups. In the two disease groups, the T/S ratio was not influenced by ferritin level or transfusion burden but was positively correlated with the absolute reticulocyte count.

The Influence of Hearing Impairment on Driving Avoidance Among a Large Cohort of Older Drivers

As people age, some of the commonly experienced psychomotor, visual, and cognitive declines can interfere with the ability to safely drive, often leading to situational avoidance of challenging driving situations. The effect of hearing impairment on these avoidance behaviors has not been comprehensively studied. Data from the American Automobile Association (AAA) Longitudinal Research on Aging Drivers (LongROAD) study were used to assess the effect of hearing impairment on driving avoidance, using three measures of hearing. Results indicated that hearing loss plays a complex role in driving avoidance, and that an objective hearing measure was a stronger predictor than hearing aid use and self-rated hearing. Greater hearing impairment was related to less nighttime and freeway driving, more trips farther than 15 mi from home, and lower odds of avoiding peak driving times. The moderating influence of hearing on both vision and cognition is also discussed, along with study implications and future research.

Potentially Inappropriate Medication Use and Hard Braking Events in Older Drivers

Potentially inappropriate medications (PIMs) identified by the American Geriatrics Society should generally be avoided by older adults because of ineffectiveness or excess risk of adverse effects. Few studies have examined the effects of PIMs on driving safety measured by prospectively and objectively collected driving data. Data for this study came from the Longitudinal Research on Aging Drivers study, a multisite naturalistic driving study of older adults. Multivariable negative binominal modeling was used to estimate incidence rate ratios and 95% confidence intervals of hard braking events (proxies for unsafe driving behavior defined as events with a deceleration rate ≥0.4 g) associated with PIM use among older drivers. The study sample consisted of 2932 drivers aged 65-79 years at baseline, including 542 (18.5%) who used at least one PIM. These drivers were followed through an in-vehicle recording device for up to 44 months. The overall incidence of hard braking events was 1.16 per 1000 miles. Use of PIMs was associated with a 10% increased risk of hard braking events. Compared to drivers who were not using PIMs, the risk of hard braking events increased 6% for those using one PIM, and 24% for those using two or more PIMs. Use of PIMs by older adult drivers is associated in a dose-response fashion with elevated risks of hard braking events. Reducing PIM use in older adults might help improve driving safety as well as health outcomes.

Exploring How Hearing, Vision, and Cognition Affect Older Adults’ Driving Exposure Patterns

Better information is needed about how declines in sensory and cognitive function affect older drivers. This study assessed how hearing loss affects engagement in four challenging driving patterns. Data from the AAA Longitudinal Research on Aging Drivers study was used, including objectively-measured driving; three measures of hearing: reported hearing aid use, self-rated hearing, and the Whisper Test; visual acuity (Tumbling E); and cognition (Trail Making B). Failing the Whisper Test in both ears was related to significantly lower percentage of trips (%trips) at night, on freeways, and during rush hour, but a higher %trips >15 miles. Hearing aid use and self-rated hearing were not associated with any driving differences. Worse vision was related to a lower %trips >15 miles, while worse cognition was associated with a lower %trips at night, on freeways, and during rush hour. The Whisper Test interacted with cognition for rush hour trips.

Association of Physical Function With Driving Space and Crashes Among Older Adults

BACKGROUND AND OBJECTIVES

Balancing both driver mobility and safety is important for the well-being of older adults. However, research on the association of physical function with these 2 driving outcomes has yielded inconsistent findings. This study examined whether physical functioning of older drivers, as measured by the Short Physical Performance Battery (SPPB), is associated with either driving space or crash involvement.

METHODS

Using cross-sectional data of active drivers aged 65-79 years from the AAA Longitudinal Research on Aging Drivers (LongROAD) study (n = 2,990), we used multivariate log-binomial and logistic regressions to estimate the associations of the SPPB with either self-reported restricted driving space in the prior 3 months or any crashes in the past year. Interaction with gender was assessed using likelihood ratio tests.

RESULTS

After adjustment, older drivers with higher SPPB scores (higher physical functioning) had lower prevalence of restricted driving space (8-10 vs. 0-7, prevalence ratio [PR] = 0.88, 95% confidence interval [CI]: 0.78-0.99; 11-12 vs. 0-7, PR = 0.78, 95% CI: 0.61-0.99). Fair (8-10), but not good (11-12), scores were significantly associated with reduced crash involvement (8-10 vs. 0-7, odds ratio [OR] = 0.71, 95% CI: 0.60-0.84). Gender was not a significant effect modifier.

DISCUSSION AND IMPLICATIONS

This study provides evidence that higher physical functioning is associated with better driving mobility and safety and that the SPPB may be useful for identifying at-risk drivers. Further research is needed to understand physical functioning's longitudinal effects and the SPPB's role in older driver intervention programs.

Evaluating a Two-Level vs. Three-Level Fall Risk Screening Algorithm for Predicting Falls Among Older Adults

Background and Objectives: Falls account for the highest proportion of preventable injury among older adults. Thus, the United States' Centers for Disease Control and Prevention (CDC) developed the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm to screen for fall risk. We referred to our STEADI algorithm adaptation as “Quick-STEADI” and compared the predictive abilities of the three-level (low, moderate, and high risk) and two-level (at-risk and not at-risk) Quick-STEADI algorithms. We additionally assessed the qualitative implementation of the Quick-STEADI algorithm in clinical settings.

Research Design and Methods: We followed a prospective cohort (N = 200) of adults (65+ years) in the Bassett Healthcare Network (Cooperstown, NY) for 6 months in 2019. We conducted a generalized linear mixed model, adjusting for sociodemographic variables, to determine how baseline fall risk predicted subsequent daily falls. We plotted receiver operating characteristic (ROC) curves and measured the area under the curve (AUC) to determine the predictive ability of the Quick-STEADI algorithm. We identified a participant sample (N = 8) to gauge the experience of the screening process and a screener sample (N = 3) to evaluate the screening implementation.

Results: For the three-level Quick-STEADI algorithm, participants at low and moderate risk for falls had a reduced likelihood of daily falls compared to those at high risk (−1.09, p = 0.04; −0.99, p = 0.04). For the two-level Quick-STEADI algorithm, participants not at risk for falls were not associated with a reduced likelihood of daily falls compared to those at risk (−0.89, p = 0.13). The discriminatory ability of the three-level and two-level Quick-STEADI algorithm demonstrated similar predictability of daily falls, based on AUC (0.653; 0.6570). Furthermore, participants and screeners found the Quick-STEADI algorithm to be efficient and viable.

Discussion and Implications: The Quick-STEADI is a suitable, alternative fall risk screening algorithm. Qualitative assessments of the Quick-STEADI algorithm demonstrated feasibility in integrating a falls screening program in a clinical setting. Future research should address the validation and the implementation of the Quick-STEADI algorithm in community health settings to determine if falls screening and prevention can be streamlined in these settings. This may increase engagement in fall prevention programs and decrease overall fall risk among older adults.

Medication use and driving patterns in older drivers: preliminary findings from the LongROAD study

Background

The potential for impaired driving due to medication use can occur at any age, though older adults are more likely to take multiple prescribed medications and experience side effects that may affect driving ability. The purpose of this study was to characterize the relationship between medications and driving safety behaviors.

Methods

Data for this study came from the five-site Longitudinal Research on Aging Drivers (LongROAD) project. Participants were active drivers, age 65–79 years at enrollment, and patients at one of the 5 participating sites. Medication names and doses were obtained at baseline based on the “brown-bag review” method. Medications were coded using the American Hospital Formulary Service system. Driving data were collected by a GPS accelerometer installed in the study participants’ main vehicles.

Results

Medication data were available for 2949 (98.6%) of the 2990 participants, and 2898 (96.9% of all participants) had both medication data and at least 30 recorded days of driving. The median number of medications taken per study participant was seven, with a range of 0–51. Total number of medications was significantly associated with a higher rapid deceleration rate. Certain medication classes were significantly associated with other driving outcomes, including central nervous system agents (more speeding events), hormones and gastrointestinal medications (more rapid decelerations), electrolytes (fewer rapid decelerations), and antihistamines (greater right to left turn ratio).

Conclusions

Older adult drivers are taking large quantities of prescription and non-prescription medications that may affect their driving safety. Certain medication classes are associated with potentially adverse driving patterns, such as speeding and rapid decelerations, while others are associated with potentially protective maneuvers, such as right hand turning. Further research is warranted to identify and mitigate potential adverse effects of such medications on driving safety in older adults.

Ripple Effects of a Community-Based Randomized Trial for Rural Women: Strong Hearts, Healthy Communities

OBJECTIVE

This study aimed to examine (1) whether the Strong Hearts, Healthy Communities intervention (SHHC) improved social network members' (SNMs') weight, exercise, and diet and (2) whether SNMs' weight and behavioral changes were modified by their relationship closeness and/or spatial closeness with trial participants.

METHODS

Eight towns received the SHHC intervention, which focused on building individual healthy behaviors and creating supportive social and built environments for exercise and healthy eating. Eight towns received an education-only control intervention. SNMs (n = 487) were recruited to complete a questionnaire at baseline and at 6 months that asked about demographics, weight, height, exercise, and eating habits.

RESULTS

SHHC's effect on SNMs differed depending on their relationship closeness with trial participants. Among SNMs who had a very close relationship with trial participants, those associated with the intervention group lost more weight and decreased BMI more than those associated with the control group (weight [kilograms] between-group difference: Δ = -1.68; 95% CI: -3.10 to -0.25; P = 0.021; BMI between-group difference: Δ = -0.60; 95% CI: -1.16 to -0.04; P = 0.034). Spatial closeness did not modify any of SHHC's ripple effects.

CONCLUSIONS

Relationship closeness, rather than spatial closeness, played an important role in influencing a rural community-based intervention's ripple effects.

The Strong Hearts, Healthy Communities Program 2.0: An RCT Examining Effects on Simple 7

INTRODUCTION

Rural women have higher rates of cardiovascular disease than their nonrural counterparts, partially because of their social and environmental contexts. The study objective is to test a refined version of the multilevel Strong Hearts, Healthy Communities intervention, which used extensive process and outcome evaluation data from the original randomized trial to optimize effectiveness as measured by improved Simple 7 score, a composite measure of cardiovascular disease risk.

STUDY DESIGN

The intervention was implemented in a 6-month, delayed intervention, community-randomized trial; control participants received the program following 24-week outcome assessment. The study was conducted in 2017-2018; data analysis occurred in 2018-2019.

SETTING/PARTICIPANTS

The study was conducted in 11 rural, medically underserved towns in New York. Participants were women aged ≥40 years who were either (1) obese or (2) overweight and sedentary.

INTERVENTION

The intervention group received 24 weeks of hour-long, twice-weekly classes including strength training, aerobic exercise, and skill-based nutrition- and health-related education, as well as civic engagement activities focused on healthy food and physical activity environments.

MAIN OUTCOME MEASURES

Measures included weight and height; blood pressure; blood cholesterol; blood glucose; and self-reported smoking, diet, and physical activity behaviors. Individual Simple 7 components were examined, and mixed linear regression analyses were used to examine change in Simple 7 score.

RESULTS

A total of 182 participants were randomized. Compared with control participants, the intervention group had greater improvements in Simple 7 score (difference=1.03, 95% CI=0.44, 1.61, p<0.001) and 3 of the Simple 7 components (physical activity, healthy diet score, and BMI).

CONCLUSIONS

These findings highlight the importance of rigorously evaluating programs in real-world community settings and, when appropriate, revising and retesting interventions to optimize dissemination potential.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03059472.

The Relationship between in-Vehicle Technologies and Self-Regulation among Older Drivers

The study sought to understand the relationship between in-vehicle technologies (IVTs) and self-regulatory behaviors among older drivers. In a large multi-site study of 2990 older drivers, self-reported data on the presence of IVTs and avoidance of various driving behaviors (talking on a mobile phone while driving, driving at night, driving in bad weather, and making left turns when there is no left turn arrow) were recorded. Self-reports were used to identify whether avoidance was due to self-regulation. Hierarchical logistic regressions were used to determine whether the presence of a particular IVT predicted the likelihood of a given self-regulatory behavior after controlling for other factors. Results suggest that the presence of Integrated Bluetooth/Voice Control systems are related to a reduced likelihood of avoiding talking on a mobile phone while driving due to self-regulation (OR= 0.37, 95% CI= 0.29-0.47). The presence of a Navigation Assistance system was related to a reduced likelihood of avoiding talking on a mobile phone while driving (OR= 0.65, 95% CI= 0.50-0.84) and avoiding driving at night due to self-regulation (OR= 0.80, 95% CI = 0.64-1.00). Present findings suggest in-vehicle technologies may differently influence the self-regulatory behaviors of older drivers.

THE ASSOCIATION BETWEEN LOWER EXTREMITY FUNCTION, FRAILTY, AND LOW-MILEAGE DRIVER STATUS AMONG OLDER ADULTS

The crash rate per mile driven among older adults is higher than that of most age groups and comparable to that of the youngest, most inexperienced drivers. The low-mileage bias posits that the elevated rate among older adults results from an increased rate among those who accrue the fewest annual miles. This study evaluated whether low physical capacity among older drivers, measured by the National Health and Aging Trends Study (NHATS) Expanded Short Physical Performance Battery (SPPB) and Fried’s frailty phenotype, increases the risk of being low-mileage drivers. Data were collected for 2,990 older drivers via questionnaires and assessments in addition to 61,528 person-months of driving data. Multivariable log-binomial regression was used to estimate risk ratios. Those with fair and good function had 0.53 (95% CI: 0.40-0.69) and 0.60 (0.47-0.78) times the risk of driving fewer than 3,000 miles/year and 0.45 (0.26-0.77) and 0.48 (0.32-0.72) times the risk of driving fewer than 1,865 miles/year, respectively, compared to those with poor function. For an increase from not frail to pre-frail and from pre-frail to frail, the risk of driving fewer than 3,000 or 1,865 miles/year increased 1.36 (1.11-1.65) or 2.38 (1.63-3.46) times, respectively. Having low physical capacity is associated with an increased risk of low annual mileage. Given the known association between low-mileage driver status and increased crash rates and the modifiable nature of the risk factors examined in this study, interventions aimed at improving physical capabilities may lead to an improvement in safety among older drivers.

Social Support Moderates the Negative Association Between Reduced Driving and Life Satisfaction in Older Adults

When older adults reduce their driving, there can be subsequent decreases in life satisfaction. In this cross-sectional study, we used baseline data from the multi-site Longitudinal Research on Aging Drivers (LongROAD) study to examine whether social support moderates the negative association between reduced driving and life satisfaction. The outcome variable was life satisfaction, and the main predictor variable was past-year reduced driving (yes/no). Emotional, instrumental, and informational social support were measured using PROMIS v2.0 (Patient-Reported Outcomes Measurement Information System) items. We used generalized linear regression models to examine how social support moderated the association between reduced driving and life satisfaction. Statistical adjustment for social support attenuated the negative effect of reduced driving on life satisfaction by ~10% for all three types of social support.

Changes in diet and physical activity resulting from the Strong Hearts, Healthy Communities randomized cardiovascular disease risk reduction multilevel intervention trial

BACKGROUND

Women living in rural areas face unique challenges in achieving a heart-healthy lifestyle that are related to multiple levels of the social-ecological framework. The purpose of this study was to evaluate changes in diet and physical activity, which are secondary outcomes of a community-based, multilevel cardiovascular disease risk reduction intervention designed for women in rural communities.

METHODS

Strong Hearts, Healthy Communities was a six-month, community-randomized trial conducted in 16 rural towns in Montana and New York, USA. Sedentary women aged 40 and older with overweight and obesity were recruited. Intervention participants (eight towns) attended twice weekly exercise and nutrition classes for 24 weeks (48 total). Individual-level components included aerobic exercise, progressive strength training, and healthy eating practices; a civic engagement component was designed to address social and built environment factors to support healthy lifestyles. The control group (eight towns) attended didactic healthy lifestyle classes monthly (six total). Dietary and physical activity data were collected at baseline and post-intervention. Dietary data were collected using automated self-administered 24-h dietary recalls, and physical activity data were collected by accelerometry and self-report. Data were analyzed using multilevel linear regression models with town as a random effect.

RESULTS

At baseline, both groups fell short of meeting many recommendations for cardiovascular health. Compared to the control group, the intervention group realized significant improvements in intake of fruit and vegetables combined (difference: 0.6 cup equivalents per day, 95% CI 0.1 to 1.1, p = .026) and in vegetables alone (difference: 0.3 cup equivalents per day, 95% CI 0.1 to 0.6, p = .016). For physical activity, there were no statistically significant between-group differences based on accelerometry. By self-report, the intervention group experienced a greater increase in walking MET minutes per week (difference: 113.5 MET-minutes per week, 95% CI 12.8 to 214.2, p = .027).

CONCLUSIONS

Between-group differences in dietary and physical activity behaviors measured in this study were minimal. Future studies should consider how to bolster behavioral outcomes in rural settings and may also continue to explore the value of components designed to enact social and environmental change.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02499731. Registered 16 July 2015.

Prevalence of Potentially Inappropriate Medication use in older drivers

Background

Potentially Inappropriate Medication (PIM) use has been studied in a variety of older adult populations across the world. We sought to examine the prevalence and correlates of PIM use in older drivers.

Methods

We applied the American Geriatrics Society 2015 Beers Criteria to baseline data collected from the “brown-bag” review of medications for participants of the Longitudinal Research on Aging Drivers (LongROAD) study to examine the prevalence and correlates of PIM use in a geographically diverse, community-dwelling sample of older drivers (n = 2949). Proportions of participants who used one or more PIMs according to the American Geriatrics Society 2015 Beers Criteria, and estimated odds ratios (ORs) and 95% confidence intervals (CIs) of PIM use associated with participant characteristics were calculated.

Results

Overall, 18.5% of the older drivers studied used one or more PIM. The most commonly used therapeutic category of PIM was benzodiazepines (accounting for 16.6% of the total PIMs identified), followed by nonbenzodiazepine hypnotics (15.2%), antidepressants (15.2%), and first-generation antihistamines (10.5%). Compared to older drivers on four or fewer medications, the adjusted ORs of PIM use were 2.43 (95% CI 1.68–3.51) for those on 5–7 medications, 4.19 (95% CI 2.95–5.93) for those on 8–11 medications, and 8.01 (95% CI 5.71–11.23) for those on ≥12 medications. Older drivers who were female, white, or living in urban areas were at significantly heightened risk of PIM use.

Conclusion

About one in five older drivers uses PIMs. Commonly used PIMs are medications known to impair driving ability and increase crash risk. Implementation of evidence-based interventions to reduce PIM use in older drivers may confer both health and safety benefits.

Trial registration

Not applicable.

Relationship Between Physical Activity and Motor Vehicle Crashes Among Older Adult Drivers

Background: There are approximately 42 million licensed drivers aged 65 years or older in the United States, who face unique age-related risks while driving. While physical activity affects several chronic conditions thought to be associated with motor vehicle crashes (MVCs), it is unclear if increased physical activity leads to fewer MVCs. This study explores whether self-reported vigorous and moderate physical activity is associated with MVCs in the previous year. Methods: Using cross-sectional data from the LongROAD study, a large multisite prospective cohort study of 2990 older adult drivers, we examined variables related to physical activity and performed a multivariate regression analysis to examine the association of physical activity health behaviors with self-reported MVCs. Results: Overall, 41.2% of participants reported vigorous and 69.6% of participants reported moderate exercise at least once per week. Eleven percent of participants reported at least 1 MVC in the previous year. Neither vigorous nor moderate physical activity was significantly associated with self-reported MVCs in the previous year. Select variables that were significantly associated with self-reported MVC included self-reported unsafe driving practices (odds ratio [OR] 1.55, confidence interval [CI] 1.05-2.29), and fall in the past 12 months (OR 1.46, CI 1.14-1.85). Conclusions: We were unable to detect a significant association between self-reported physical activity and MVCs in the past year among this group of older drivers. Use of objective measures of activity may better clarify this relationship.

Strong Hearts for New York: A multilevel community-based randomized cardiovascular disease risk reduction intervention for rural women

BACKGROUND

Rural midlife and older women have high rates of cardiovascular disease (CVD) risk factors and lower access to healthy living resources. The Strong Hearts, Healthy Communities (SHHC) intervention, tailored to the needs of rural women, demonstrated effectiveness on many outcomes. The purpose of the Strong Hearts for New York (SHNY) study is to evaluate the efficacy of an enhanced version of the curriculum (SHHC-2.0).

METHODS

SHNY is a randomized controlled efficacy intervention, comparing participants receiving the SHHC-2.0 curriculum with a delayed intervention control group. SHHC, informed by formative research, includes core elements from three evidence-based programs. Changes based on extensive outcome and process evaluation data were made to create SHHC-2.0. Classes will meet twice weekly for 24 weeks and include individual, social, and environmental components. Overweight women age 40 and over will be recruited from 11 rural, medically underserved communities in New York; data will be collected at baseline and 12, 24, 36, and 48 weeks across individual, social, and environmental levels. Primary outcome is body weight. Secondary outcomes include Simple 7 (composite CVD risk score), anthropometric, physiologic, biochemical, physical activity, and dietary intake measures; healthy eating and exercise self-efficacy and attitudes; and self-efficacy of the social network of participants.

DISCUSSION

The aims of this study are to evaluate the efficacy of the enhanced SHHC-2.0 program for participants, changes among participants' social networks, and the difference in outcomes when participants are and are not provided with technological tools (Fitbit and body composition scale).

Patterns of Self-Reported Driving While Intoxicated Among Older Adults

Objective: This study examines the prevalence of self-reported driving while intoxicated (DWI) among drivers aged 65 and older. Method: This cross-sectional study was based on baseline data from the AAA Longitudinal Research on Aging Drivers (LongROAD) study, a multisite prospective cohort study of 2,990 older adult drivers. Alcohol-related variables from the baseline questionnaire were examined in relation to demographics, health status, and driving behaviors. A logistic regression model assessed variables associated with DWI. Results: Of the 2,990 participants, 72.7% reported consuming alcohol, 15.0% reported high-risk drinking, and 3.3% reported DWI. High-risk drinking (OR = 12.01) and risky driving behaviors (OR = 13.34) were significantly associated with at least occasional DWI. Avoidance of hazardous driving conditions (OR = 0.71) and higher level of comfort during challenging driving scenarios (OR = 0.65) were less likely to be associated with DWI. Conclusion: A large number of older adults engage in high-risk drinking and DWI. Public health education and DWI-related interventions should include older adults.

Cost-effectiveness of a community-based cardiovascular disease prevention intervention in medically underserved rural areas

Background

Rural women experience health disparities in terms of cardiovascular disease (CVD) risk compared to urban women. Cost-effective CVD-prevention programs are needed for this population. The objective of this study was to conduct cost analysis and cost-effectiveness analyses (CEAs) of the Strong Hearts, Healthy Communities (SHHC) program compared to a control program in terms of change in CVD risk factors, including body weight and quality-adjusted life years (QALYs).

Methods

Sixteen medically underserved rural towns in Montana and New York were randomly assigned to SHHC, a six-month twice-weekly experiential learning lifestyle program focused predominantly on diet and physical activity behaviors (n = 101), or a monthly healthy lifestyle education-only control program (n = 93). Females who were sedentary, overweight or obese, and aged 40 years or older were enrolled. The cost analysis calculated the total and per participant resource costs as well as participants’ costs for the SHHC and control programs. In the intermediate health outcomes CEAs, the incremental costs were compared to the incremental changes in the outcomes. The QALY CEA compares the incremental costs and effectiveness of a national SHHC intervention for a hypothetical cohort of 2.2 million women compared to the status quo alternative.

Results

The resource cost of SHHC was $775 per participant. The incremental cost-effectiveness ratios from the payer’s perspective was $360 per kg of weight loss. Over a 10-year time horizon, to avert per QALY lost SHHC is estimated to cost $238,271 from the societal perspective, but only $62,646 from the healthcare sector perspective. Probabilistic sensitivity analyses show considerable uncertainty in the estimated incremental cost-effectiveness ratios.

Conclusions

A national SHHC intervention is likely to be cost-effective at willingness-to-pay thresholds based on guidelines for federal regulatory impact analysis, but may not be at commonly used lower threshold values. However, it is possible that program costs in rural areas are higher than previously studied programs in more urban areas, due to a lack of staff and physical activity resources as well as  availability for partnerships with existing organizations.

Trial registration

ClinicalTrials.gov identifier NCT02499731, registered on July 16, 2015.

Importance of Driving and Potential Impact of Driving Cessation for Rural and Urban Older Adults

PURPOSE

Analyses compared older drivers from urban, suburban, and rural areas on perceived importance of continuing to drive and potential impact that driving cessation would have on what they want and need to do.

METHODS

The AAA LongROAD Study is a prospective study of driving behaviors, patterns, and outcomes of older adults. A cohort of 2,990 women and men 65-79 years of age was recruited during 2015-2017 from health systems or primary care practices near 5 study sites in different parts of the United States. Participants were classified as living in urban, surburban, or rural areas and were asked to rate the importance of driving and potential impact of driving cessation. Logistic regression models adjusted for sociodemographic and driving-related characteristics.

FINDINGS

The percentages of older drivers rating driving as "completely important" were 76.9%, 79.0%, and 83.8% for urban, suburban, and rural drivers, respectively (P = .009). The rural drivers were also most likely to indicate driving cessation would have a high impact on what they want or need to do (P < .001). After adjustment for sociodemographic and driving-related characteristics, there was a 2-fold difference for rural versus urban older drivers in odds that driving cessation would have a high impact on what they need to do (OR = 2.03; 95% CI: 1.60-2.58).

CONCLUSIONS

Older drivers from rural areas were more likely to rate driving as highly important and the prospect of driving cessation as very impactful. Strategies to enhance both the ability to drive safely and the accessibility of alternative sources of transportation may be especially important for older rural adults.

Effects of the Strong Hearts, Healthy Communities Intervention on Functional Fitness of Rural Women

PURPOSE

The purposes of these analyses were to determine whether Strong Hearts, Healthy Communities (SHHC), a multilevel, cardiovascular disease risk reduction program for overweight, sedentary rural women aged 40 or older, led to improved functional fitness, and if changes in fitness accounted for weight loss associated with program participation.

METHODS

Sixteen rural communities were randomized to receive the SHHC intervention or a control program. Both programs involved groups of 12-16 participants. The SHHC program met 1 hour twice a week for 24 weeks where participants engaged in aerobic exercise and progressive strength training. Program content addressed diet and social and environmental influences on heart-healthy behavior. The control group met 1 hour each month for 6 months, covering current dietary and physical activity recommendations. Objective measures of functional fitness included the 30-second arm curl, 30-second chair stand, and 2-minute step test. Self-reported functional fitness was measured by the Physical Functioning Subscale of the MOS Short Form-36 (SF-36 PF).

FINDINGS

The SHHC program was associated with increased strength and endurance, as represented by greater improvement in the chair stand and step test; and with increased physical function, as represented by the SF-36 PF. Adjustment for change in aerobic endurance, as measured by the step test, accounted for two-thirds of the intervention effect on weight loss at the end of the intervention.

CONCLUSIONS

SHHC participants experienced improved performance on objective measures of functional fitness and self-reported measures of physical function, and changes in weight were partially accounted for by changes in aerobic fitness.

Examining the Associations between Walk Score, Perceived Built Environment, and Physical Activity Behaviors among Women Participating in a Community-Randomized Lifestyle Change Intervention Trial: Strong Hearts, Healthy Communities

Little is known about the relationship between perceived and objective measures of the built environment and physical activity behavior among rural populations. Within the context of a lifestyle-change intervention trial for rural women, Strong Hearts, Healthy Communities (SHHC), we examined: (1) if Walk Score (WS), an objective built environment measure, was associated with perceived built environment (PBE); (2) if WS and PBE were associated with moderate-to-vigorous physical activity (MVPA); and (3) if MVPA changes were modified by WS and/or PBE. Accelerometers and questionnaires were used to collect MVPA and PBE. Bivariate analyses and linear mixed models were used for statistical analyses. We found that WS was positively associated with perceived proximity to destinations (p < 0.001) and street shoulder availability (p = 0.001). MVPA was generally not associated with WS or PBE. Compared to controls, intervention group participants increased MVPA if they lived in communities with the lowest WS (WS = 0), fewer perceived walkable destinations, or extremely safe perceived traffic (all p < 0.05). Findings suggest that WS appears to be a relevant indicator of walkable amenities in rural towns; results also suggest that the SHHC intervention likely helped rural women with the greatest dearth of built environment assets to improve MVPA.

Improving Safe Mobility: An Assessment of Vehicles and Technologies among a Large Cohort of Older Drivers

Evidence suggests that older driver safety may be improved by good vehicle maintenance, in-vehicle advanced technologies, and proper vehicle adaptations. This study explored the prevalence of several measures of vehicle maintenance and damage among older drivers through inspection of their vehicles. We also investigated the prevalence of in-vehicle technologies and aftermarket adaptations. Vehicle inspections were conducted by trained research staff using an objective, standardized procedure. This procedure, developed by a multidisciplinary team of researchers, was based on a review of inspection checklists used by automobile dealerships and the project team's expertise. The study used baseline data from vehicles of 2988 participants in the multi-site Longitudinal Research on Aging Drivers (LongROAD) study. Among this cohort, vehicles were well maintained, had little damage, and contained a range of advanced technologies but few aftermarket adaptations. Implications of study findings for occupational therapy practice are discussed.

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.

Strong Hearts, Healthy Communities: A Community-Based Randomized Trial for Rural Women

OBJECTIVE

The aim of this study was to evaluate a multilevel cardiovascular disease (CVD) prevention program for rural women.

METHODS

This 6-month, community-based, randomized trial enrolled 194 sedentary rural women aged 40 or older with BMI ≥ 25 kg/m2 . Intervention participants attended 6 months of twice-weekly exercise, nutrition, and heart health classes (48 total) that included individual-, social-, and environment-level components. An education-only control program included didactic healthy lifestyle classes once a month (six total). The primary outcome measures were change in BMI and weight.

RESULTS

Within-group and between-group multivariate analyses revealed that only intervention participants decreased BMI (-0.85 units; 95% CI: -1.32 to -0.39; P = 0.001) and weight (-2.24 kg; 95% CI: -3.49 to -0.99; P = 0.002). Compared with controls, intervention participants decreased BMI (difference: -0.71 units; 95% CI: -1.35 to -0.08; P = 0.03) and weight (1.85 kg; 95% CI: -3.55 to -0.16; P = 0.03) and improved C-reactive protein (difference: -1.15 mg/L; 95% CI: -2.16 to -0.15; P = 0.03) and Simple 7, a composite CVD risk score (difference: 0.67; 95% CI: 0.14 to 1.21; P = 0.01). Cholesterol decreased among controls but increased in the intervention group (-7.85 vs. 3.92 mg/dL; difference: 11.77; 95% CI: 0.57 to 22.96; P = 0.04).

CONCLUSIONS

The multilevel intervention demonstrated modest but superior and meaningful improvements in BMI and other CVD risk factors compared with the control program.

The effects of demographics, functioning, and perceptions on the relationship between self-reported and objective measures of driving exposure and patterns among older adults

The exploratory study reported here was intended to examine: how strongly subjectively reported driving avoidance behaviors (commonly referred to as self-regulation) and exposure were related to their objectively measured counterparts and whether it depended on the specific behavior; the extent to which gender and age play a role in the association between subjectively reported driving avoidance behaviors and exposure and their objectively measured counterparts; and the extent to which demographics, health and functioning, driving-related perceptions, and cognition influence the association between subjective and objective driving avoidance behaviors overall. The study used data from the Longitudinal Research on Aging Drivers (LongROAD) study, a multisite, prospective cohort study designed to generate empirical data for understanding the role of medical, behavioral, environmental, and technological factors in driving safety during the process of aging. Objective driving measures were derived from GPS/datalogger data from 2131 LongROAD participants' vehicles. The corresponding subjective measures came from a comprehensive questionnaire administered to participants at baseline that asked them to report on their driving exposure, patterns, and other aspects of driving. Several other variables used in the analyses came from the comprehensive questionnaire and an inperson clinical assessment administered to participants at baseline. A series of simple linear and logistic models were fitted to examine the relationship between the subjective and objective driving measures of interest, and a multivariable analysis was conducted to examine the potential role of selected factors in the relationship between objective and subjective driving avoidance behaviors. Results of the models are presented and overall findings are discussed within the context of the existing research literature.

Prevalence, attitudes, and knowledge of in-vehicle technologies and vehicle adaptations among older drivers

The purpose of the present study was to gain a better understanding of the types of in-vehicle technologies being used by older drivers as well as older drivers' use, learning, and perceptions of safety related to these technologies among a large cohort of older drivers at multiple sites in the United States. A secondary purpose was to explore the prevalence of aftermarket vehicle adaptations and how older adults go about making adaptations and how they learn to use them. The study utilized baseline questionnaire data from 2990 participants from the Longitudinal Research on Aging Drivers (LongROAD) study. Fifteen in-vehicle technologies and 12 aftermarket vehicle adaptations were investigated. Overall, 57.2% of participants had at least one advanced technology in their primary vehicle. The number of technologies in a vehicle was significantly related to being male, having a higher income, and having a higher education level. The majority of respondents learned to use these technologies on their own, with "figured-it-out-myself" being reported by 25%-75% of respondents across the technologies. Overall, technologies were always used about 43% of the time, with wide variability among the technologies. Across all technologies, nearly 70% of respondents who had these technologies believed that they made them a safer driver. With regard to vehicle adaptations, less than 9% of respondents had at least one vehicle adaptation present, with the number of adaptations per vehicle ranging from 0 to 4. A large majority did not work with a professional to make or learn about the aftermarket vehicle adaptation.

Longitudinal Research on Aging Drivers (LongROAD): study design and methods

BACKGROUND

As an important indicator of mobility, driving confers a host of social and health benefits to older adults. Despite the importance of safe mobility as the population ages, longitudinal data are lacking about the natural history and determinants of driving safety in older adults.

METHODS

The Longitudinal Research on Aging Drivers (LongROAD) project is a multisite prospective cohort study designed to generate empirical data for understanding the role of medical, behavioral, environmental and technological factors in driving safety during the process of aging.

RESULTS

A total of 2990 active drivers aged 65-79 years at baseline have been recruited through primary care clinics or health care systems in five study sites located in California, Colorado, Maryland, Michigan, and New York. Consented participants were assessed at baseline with standardized research protocols and instruments, including vehicle inspection, functional performance tests, and "brown-bag review" of medications. The primary vehicle of each participant was instrumented with a small data collection device that records detailed driving data whenever the vehicle is operating and detects when a participant is driving. Annual follow-up is being conducted for up to three years with a telephone questionnaire at 12 and 36 months and in-person assessment at 24 months. Medical records are reviewed annually to collect information on clinical diagnoses and healthcare utilization. Driving records, including crashes and violations, are collected annually from state motor vehicle departments. Pilot testing was conducted on 56 volunteers during March-May 2015. Recruitment and enrollment were completed between July 2015 and March 2017.

CONCLUSIONS

Results of the LongROAD project will generate much-needed evidence for formulating public policy and developing intervention programs to maintain safe mobility while ensuring well-being for older adults.

Epidemiology of Infective Endocarditis in Rural Upstate New York, 2011 - 2016

Background

The epidemiology of infective endocarditis (IE) depends on a number of host factors whose prevalence can vary globally. The usual patient population affected by IE is sicker and older, often with many comorbid conditions. The risk is growing in younger populations due to the emerging epidemic of intravenous (IV) drug use. We have performed a temporal trend analysis of various factors of IE in the rural counties covering a major part of central Upstate New York.

Methods

We performed a retrospective analysis of electronic medical records of patients who were admitted in a tertiary care hospital in rural Upstate New York and diagnosed with IE from January 1, 2011 to December 31, 2016. Forty-five patients were identified with definite IE and nine with possible IE.

Results

Total incidence of IE was 3.5 cases per 100,000 person years in the total population and 4.4 if we consider total population ≥ 18 years in the denominator. A significant (P = 0.022) increase in incidence of IE from 2011 to 2016 was seen by univariate analysis. Incidence was higher in males (P = 0.029) and for those aged 65 or older (P = 0.0003). IV drug use among cases is noted to be more prevalent in 2015 and 2016 compared to previous years.

Conclusion

In this study of patients in a rural region of New York, an increase in the incidence of IE was seen over the study period with changes in patient characteristics and etiology over this time. We speculate that an increase in IV drug use could be a leading factor in the recent and future increased incidence of IE in the area.