Search

Objectives: To prospectively validate and refine the 5-item "CRASH" screening tool for identifying older drivers needing a behind-the-wheel (BTW) test., Design: Prospective observational study., Setting: Geriatric and internal medicine primary care clinics affiliated with a tertiary care hospital and a local BTW program., Participants: Cognitively intact drivers aged 65 and older (N = 315)., Measurements: Participants completed baseline questionnaire (including CRASH tool) and assessments and BTW test (evaluator blinded to questionnaire results) and participated in 1-month telephone follow-up. Analysis included descriptive statistics and examination of predictive ability of the CRASH tool to discriminate normal (pass) from abnormal (conditional pass or fail) on the BTW test, with logistic regression and CART techniques for tool refinement., Results: Two hundred sixty-six participants (84%) had a BTW test; of these, 17% had a normal rating and 83% an abnormal rating. Forty-five percent of those with an abnormal score were advised to limit driving under particular conditions. Neither the CRASH tool nor its individual component variables were significantly associated with the summary BTW score; in refined models with other variables, the best-performing tool had approximately 67% sensitivity and specificity for an abnormal BTW score. Most participants found the BTW test useful and were willing to pay a median of $50. At 1-month follow-up, no participants had stopped driving., Conclusion: The CRASH screening tool cannot be recommended for use in clinical practice. Findings on older adults' perceived utility of the BTW test and the stability of driving patterns at 1-month follow-up could be useful for future research studies and for design of older driver programs., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objectives: To model the relative contributions of driver data and clinical judgments to clinical ratings of driver capability for a state licensing authority and to compare ratings with on-road test results., Design: Retrospective, logistic regression., Setting: Missouri Driver License Bureau., Participants: Adults aged 60 and older (N = 652; 52% male) evaluated by a physician of their choosing and a portion subsequently road tested (n = 286)., Measurements: Clinical data from an evidence-based physician statement (Form 1528). A three-level rating (likely capable, unclear, not capable) was collapsed into two outcomes (0 likely capable; 1 unclear, not capable) as the dependent variable. Independent variables (predictors) were age, sex, driving exposure, recent crash or police action, number of medical conditions, medication side effects, driver insight, and disease functional severity rating for driving., Results: Three variables in the model (Nagelkerke coefficient of determination = 0.64; P < .001) were significant in the expected direction: disease functional severity for driving (odds ratio (OR = 6.65), insight (OR = 2.35), and age (OR = 1.06). Proportionately more drivers rated likely capable (73%) passed the road test than those rated unclear or not capable (62%)., Conclusion: Judgments of disease severity, decrements in driver insight, and older age influenced clinician ratings of driving capability. Correspondence of physician ratings to on-road test outcomes was imperfect, highlighting the complexities in translation of clinical judgments to on-road performance. Both means of assessment have important and additive roles in driver licensing., (© 2016, Copyright the Authors Journal compilation © 2016, The American Geriatrics Society.)

Objectives: To assess the clinical utility of the Trail-Making Tests (TMTs) as screens for impaired road-test performance., Design: Secondary analyses of three data sets from previously published studies of impaired driving in older adults using comparable road test designs and outcome measures., Setting: Two academic driving specialty clinics., Participants: Older drivers (N = 392; 303 with cognitive impairment, 89 controls) from Rhode Island and Missouri., Measurements: Standard operating characteristics were evaluated for the TMT Part A (TMT-A) and Part B (TMT-B), as well as optimal upper and lower test cut-points that could be useful in defining groups of drivers with indeterminate likelihood of impaired driving who would most benefit from further screening or on-road testing., Results: Discrimination remained high (>70%) when cut-points for the TMTs derived from Rhode Island data were applied to Missouri data, but calibration was poor (all P < .01). TMT-A provided the best utility for determining a range of scores (68-90 seconds) for which additional road testing would be indicated in general practice settings. A high frequency of cognitively impaired participants unable to perform the TMT-B test within the allotted time limited the utility of the test (>25%). Mere inability to complete the test in a reasonable time frame (e.g., TMT-A > 48 seconds or TMT-B > 108 seconds) may still be a useful tool in separating unsafe from safe or marginal drivers in such samples., Conclusion: The TMTs (particularly TMT-A) may be useful as screens for driving impairment in older drivers in general practice settings, where most people are still safe drivers, but more-precise screening measures need to be analyzed critically in a variety of clinical settings for testing cognitively impaired older drivers., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Objectives: To differentiate driving errors in persons with dementia who fail a performance- based road test from errors in persons who pass., Design: Cross-sectional., Setting: Community., Participants: Active drivers diagnosed with dementia (n = 60) and older adult controls (n = 32)., Measurement: All participants completed a standardized clinical and on-road driving assessment. The outcome variable was the number and types of driving errors according to the Record of Driving Errors (RODE), a standardized tool to record driving errors., Results: Sixty-two percent (n = 37) of individuals with dementia and 3% (n = 1) of controls failed the road test. Based on the RODE, individuals with dementia made twice as many driving errors as healthy controls. Within the dementia sample, individuals who failed the road test had more difficulties driving straight and making left and right turns than during lane changes. Dangerous actions occurred most often while driving straight and making left turns. Specific driving behaviors associated with road test failure in the sample with dementia included difficulties in lane positioning and usage, stopping the vehicle appropriately, attention, decision-making, and following rules of the road. Informants of participants with dementia who failed the road test reported more impairment with cognitive functioning on the Assessing Dementia 8 Screening Interview (AD8)., Conclusion: This report highlights the driving errors most common in people with dementia who fail a road test. The finding that most of the dangerous actions in the sample with dementia occurred while driving straight condition is novel. Driving on straight roads has not been considered a condition of "high challenge" in prior driving studies in individuals with dementia. This finding has potential implications for future interventions related to vehicle instrumentation and driving recommendations for people with dementia., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Objectives: To examine the sensitivity and specificity of the Assessment of Driving-Related Skills (ADReS), a clinical tool recommended by the American Medical Association for identifying potentially unsafe older drivers that includes tests of vision, motor function, and cognition., Design: Cross-sectional observation study., Setting: Memory assessment outpatient clinic of a university hospital., Participants: Drivers with normal cognition (n = 47) and cognitive impairment (n = 75)., Measurements: A neurologist completed the ADReS during an office visit. Additional cognitive tests of executive, visuospatial, and visuomotor function were also performed. On a separate day, participants completed a standardized on-road test, assessed by a professional driving instructor using a global safety rating and a quantitative driving score., Results: In this sample of currently active older drivers with and without cognitive impairment, measures of cognition-particularly the Trail-Making Test Part B-were more highly correlated with driving scores than other measures of function. Using recommended scoring procedures, the ADReS had a sensitivity of 0.81 for detecting impaired driving on the road test, with a specificity of 0.32 and an area under the receiver operating characteristic curve (AUC) of 0.57. A logistic regression model that incorporated computerized maze task and Mini-Mental State Examination scores improved overall classification accuracy, yielding a sensitivity of 0.61, a specificity of 0.84, and an AUC of 0.80., Conclusion: In its present form, the ADReS has limited utility as an office screen for individuals who should undergo formal driving assessment. Improved scoring methods and screening tests with greater diagnostic accuracy than the ADReS are needed for general office practice., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Objectives: To develop a screening battery for office-based clinicians that would assist with the prediction of impaired driving performance and deciding who should proceed to road testing in a sample of adults with cognitive or visual deficits., Design: Prospective observational study., Setting: Driving evaluation clinic at a Veterans Affairs Medical Center (VAMC) in St. Louis, Missouri., Participants: Seventy-seven individuals aged 23 to 91 with diagnoses of cognitive or visual impairment or both referred to an occupational therapy based driving clinic by VAMC providers because of concerns regarding driving safety., Measurements: Predictor variables included tests of visual and cognitive functioning and activities of daily living. The major outcome was pass or fail on a standardized performance-based on-road driving test., Results: Thirty percent of the referrals failed the road test. The best predictors of driving performance were the Trail-Making Test Part A and the Mazes Test from the Neuropsychological Assessment Battery., Conclusion: Measures of visual search, psychomotor speed, and executive functioning accurately predicted road test performance in a significant number of participants. These brief tests may assist clinicians in deciding who should proceed with a road test in a driver rehabilitation clinic or perhaps to whom it should be recommended to cease driving., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Objectives: To develop a cognitive and functional screening battery for the on-road performance of older drivers with dementia., Design: Prospective observational study., Setting: On-road driving evaluation clinic at an academic rehabilitation center., Participants: Ninety-nine older people with dementia (63% male, mean age 74.2 ± 9), referred by community physicians to an occupational therapy driving clinic., Measurements: The outcome variable was pass or fail on the modified Washington University Road Test. Predictor measures were tests of visual, motor, and cognitive functioning, selected for their empirical or conceptual relationship to the complex task of driving safely., Results: Sixty-five (65%) participants failed the on-road driving test. The best predictive model, with an overall accuracy of up to 85% when participants were blinded, included the Eight-item Informant Interview to Differentiate Aging and Dementia, Clock Drawing Test score, and time to complete the Snellgrove Maze Test or Trail Making Test Part A. Visual and motor functioning were not associated with road test failure., Conclusion: A screening battery that could be performed in less than 10 minutes predicted with good accuracy failure rate for the on-road driving test in this sample of older drivers with dementia. A probability of failure calculator is provided from a logistic regression model that may be useful for clinicians in their decision to refer impaired older adults for further testing. More studies are needed in larger community-based samples, along with discussions with patients, families, and clinicians, with regard to acceptable levels of test uncertainty., (© 2011, Copyright the Authors Journal compilation © 2011, The American Geriatrics Society.)

Objectives: To determine the prevalence of driving in older adults with mild to moderate physical frailty and to compare characteristics of current frail older adult drivers with those of former drivers in the sample., Design: Retrospective study of frail older adults enrolled in randomized trials of exercise and hormone replacement therapy., Setting: Urban, academic medical center., Participants: One hundred eighty-three sedentary community-dwelling men and women aged 75 and older with mild to moderate physical frailty, as defined by two of the following three criteria: modified Physical Performance Test (PPT) score between 18 and 32, peak oxygen uptake (VO2) between 10 and 18 mL/kg per minute, and self-report of difficulty or assistance with one activity of daily living (ADL) or two instrumental ADLs. Participants were classified as current or former drivers., Measurements: Demographic characteristics, medical diagnoses, medication use, modified PPT score, and psychometric tests., Results: The majority (85%) of the participants were drivers. Former drivers were more likely to be older, be female, reside in congregate independent living for the elderly, have a higher incidence of arthritis and congestive heart failure, take sedating medications, have lower total ADL scores, have lower VO2 peak scores, and have more impairment on tests of cognition and physical strength, although only age, type of residence, and grip strength were independent predictors of driving cessation in the regression analysis., Conclusion: Despite the presence of physical frailty, many older adults choose to continue to drive. Further studies are needed to better understand the driving behaviors of frail older adults and explore opportunities for optimizing driving abilities.

Older driver safety is a growing public health concern for which interventions are currently being sought. Statistics show that older drivers suffer a disproportionately high rate of motor vehicle fatalities compared with other adult drivers. This disproportion is due to two factors: an increased crash rate per vehicle mile driven and an increased risk of fatality in the event of a crash. Traditionally, traffic safety efforts for the older population have focused on methods to identify unsafe drivers to enforce driving cessation, but driving cessation deprives the majority of older Americans of their primary form of transportation and has been associated with an increase in depressive symptoms. In response to these concerns, the Older Drivers Project, created by the American Medical Association in partnership with the National Highway Traffic Safety Administration, describes and advocates a more acceptable approach to traffic safety. The primary objective of this approach involves helping older drivers stay on the road safely to preserve their mobility and independence. This can be accomplished through three methods: (1) optimizing the driver, (2) optimizing the driving environment, and (3) optimizing the vehicle. In this approach, driving cessation is recommended only after the safety of the driver cannot be secured through any other means.

Objectives: To longitudinally assess on-road driving performance in healthy older adults and those with early-stage dementia of the Alzheimer type (DAT)., Design: A prospective longitudinal study., Setting: Large urban medical center and surrounding area., Participants: A sample of 58 healthy controls, 21 participants with very mild DAT, and 29 participants with mild DAT participated. DAT was diagnosed using validated clinical diagnostic criteria and staged according to the Clinical Dementia Rating (CDR) Scale., Measurements: Healthy controls and individuals with very mild DAT and mild DAT were administered a standardized on-road driving assessment over repeated times of testing., Results: Subjects in the CDR=1 group (mild DAT) had a faster rate of receiving a rating of not safe on the driving test than subjects in the CDR=0 group (healthy controls; log rank test, P=.006), and the survival function of the CDR=0.5 group (very mild DAT) fell between those of the CDR=0 and CDR=1 groups. A Cox proportional hazards model indicated a significant difference in survival functions between the CDR=0 and CDR=1 groups after baseline age was controlled for (P<.001). Cox regression analysis also indicated that baseline age was a significant risk factor for a rating of "not safe" (P=.002)., Conclusion: This study provides longitudinal evidence for a decline in driving performance over time, primarily in early-stage DAT, and supports the need not only for driving assessments, but also for reevaluation of individuals with very mild and mild DAT.

Objective: To determine whether there is a difference in crash rates and characteristics between drivers with dementia of the Alzheimer type (DAT) and nondemented older persons who were controls., Design: A pilot study using a 5-year retrospective analysis of state-recorded crash data and crash characteristics followed by patient enrollment into a study on road test skills., Setting: Alzheimer's Disease Research Center at Washington University in St. Louis, Missouri. Subjects were enrolled as volunteers in a longitudinal study of aging and DAT., Participants: One hundred twenty-one subjects (58 nondemented, older drivers and 63 drivers with DAT) with a mean age of 77 years met the inclusion criteria for this study. DAT was diagnosed using validated clinical diagnostic criteria and was staged by the Clinical Dementia Rating (CDR) Scale. All subjects with DAT were in the very mild (CDR = 0.5) or mild (CDR = 1) stages., Main Outcome Measure: State-recorded traffic crashes. Also, a daily driving diary was completed by each subject and used to estimate miles traveled per year., Results: Subjects diagnosed with mild DAT (CDR = 1) reported less roadway exposure (average number of miles driven per year) than did drivers with very mild DAT (CDR = 0.5) or controls. Crashes in both groups were infrequent, with 0.07 state-recorded crashes per driver per year in the nondemented group (CDR = 0), 0.06 in the very mild DAT group (CDR = 0.5), and 0.04 in the mild DAT group (CDR = 1). There was no statistical difference in the crash frequency between groups, even when adjusting for exposure. Drivers with DAT had trends toward more at-fault crashes, crashes with injuries, and crashes in which the officer on the scene cited failure to yield., Conclusions: In our sample, individuals with very mild or mild DAT who continued to drive seemed to have crash rates similar to those of the controls. There may be significant differences between the causes and the consequences of crashes involving drivers with DAT when compared with cognitively intact age-matched controls, but none were found in this pilot study. Further research on crash characteristics is needed in larger samples of community-based drivers with DAT across wider ranges of dementia severity to address issues such as driving competency and public safety.

Objective: To compare ratings of patients referred for geriatric evaluation and their proxies with respect to patients' ability to perform activities of daily living., Design: Retrospective chart audit., Setting: University-based Outpatient Geriatric Clinic., Patients: Elderly medicine patients referred to a university-based outpatient geriatrics clinic for the first time., Main Outcome Measures: Modified Katz Physical Activities of Daily Living (PADL) and Instrumental Activities of Daily Living (IADL)., Results: With regard to PADLs, patients were generally rated as independent by both patients (91%) and proxies (87%); for IADLs, ratings of independence by both patients (68%) and proxies (51%) were significantly lower. Concordance between patient and proxy ratings was significantly (P less than 0.001) greater for PADLs (92%) than for IADLs (82%). When disagreement occurred, patients consistently rated themselves as more independent than their proxies, especially for IADLs. Moreover, concordance between patients and proxies regarding IADLs was significantly (P less than 0.001) worse for patients who had scores below 24 on the Folstein Mini-Mental State Examination (72%) compared with those scoring 24 or higher (95%)., Conclusions: Patient and proxy ratings were concordant when rating patients' ability to perform PADLs. Moreover, concordance was extremely high on IADLs when patients' Folstein scores were 24 or higher. Concordance with respect to IADLs was relatively poor only among patients with Folstein scores below 24. In that case, patients had a more optimistic view of their independence, compared with their proxies.