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Objectives: This study evaluates prevalence and trends in drugged driving in Canada based on multiple indicators collected from the Road Safety Monitor (RSM) and Canada's National Fatality Database maintained by the Traffic Injury Research Foundation (TIRF). The objective of this paper is to identify the state of drug-positive driving in Canada, as well as to make comparisons with data from previous years to determine whether changes have occurred., Methods: Available data from the RSM on self-reported drugged driving behaviours were collected and analyzed using multivariate techniques in various years spanning from 2002 to 2015. Data from TIRF's National Fatality Database from 2000 to 2012 were also analyzed to evaluate trends and prevalence of drugs in fatally injured drivers across Canada. Additionally, differences among drugged drivers with respect to gender and age were studied., Results: Analyses of the RSM data and of the National Fatality Database showed that, as a whole, the prevalence of drugged driving has remained relatively stable over the past decade, with some changes noticed in specific years for some drug types. Specifically from the RSM, there was a 62.5% increase from the 1.6% of drivers reporting driving within two hours of using marijuana in 2013 to 2.6% in 2015. The analyses of the fatality data revealed a 16.9% increase in the percentage of fatally injured drivers testing positive for drugs between 2000 and 2012 (from 33.56% to 39.24%). Cocaine-positive fatally injured drivers increased from 3.6% in 2000 to 6.2% in 2012. Similarly, marijuana-positive fatally injured drivers increased from 12.8% in 2000 to 19.7% in 2012. Results showed varying characteristics with respect to gender and age among self-reported and fatally injured drugged drivers., Conclusions: Drugged driving behaviours remain prevalent among Canadian drivers and drugs continue to be found in over one-third of tested fatally injured drivers. Although self-reported behaviours have neither decreased nor increased overall in the past decade according to RSM data, with the exception of driving within two hours of using marijuana, data from fatally injured drivers reveal that small, but significant increases in some behaviours have occurred., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: The goals of this study were to analyze possible trends of fatal and serious injuries related to vulnerable road users in Canada (pedestrians, cyclists and motorcyclists) from 1990 to 2012 and the role of alcohol and drugs in these cases. Drugs have rarely been documented with respect to vulnerable road users., Method: The Traffic Injury Research Foundation's National Fatality and Serious Injury Databases and the Public Health Agency of Canada's Canadian Hospitals Injury Reporting and Prevention Program databases were used. Numbers and rates of fatalities and serious injuries among vulnerable road users were analyzed and regression models were used to assess changes over time., Results: The analyses show that while the absolute number of fatalities and the rate per 100,000 population among vulnerable road users may be decreasing, no such trends are apparent when looking at the proportions of these road user fatalities out of all motor-vehicle fatalities. The trend for the proportion of motorcyclist fatalities is significantly increasing (coef.=0.16, p<0.001). The elderly (76years or older) are overrepresented among pedestrian fatalities, and serious injuries (they represent 18.5% of all pedestrian fatalities but only 5.8% of the population), while those 15years or younger are overrepresented among cyclists (they represent 23.3% of cyclist fatalities but 19.5% of the population), and those 16 to 25years old are overrepresented among motorcyclists (27.2% of motorcyclists fatalities and 13.6% of population). Alcohol and drug use among fatally injured vulnerable road users were significant problems, especially among pedestrians. Among fatally injured pedestrians tested for alcohol and drugs, 39.7% and 43.4% tested positive, respectively., Conclusions: With the promotion of walking and cycling as forms of exercise and the popularity of motorcycling, the safety of vulnerable road users is an important issue. The results corroborate previous research and extend our understanding about the influence of alcohol and drugs in vulnerable road user injuries., Practical Applications: These findings can help better inform prevention and mitigation initiatives for vulnerable road users., (Copyright © 2016 Elsevier Ltd and National Safety Council. All rights reserved.)

Background: A new tool, the SIMARD-MD, has been proposed to help physicians identify cognitively impaired drivers who may be unfit to drive, but little empirical evidence is available to justify its use. We analyzed data from a cohort of older Canadian drivers who had undergone cognitive testing to: (1) correlate the SIMARD-MD with other tools that measure cognition (e.g., trail-making test), (2) identify how many drivers, using published cut-offs on the SIMARD-MD, would be recommended to lose their license, or be considered fit to drive, or be required to undergo further driving assessment, and (3) determine if the SIMARD-MD is biased by level of education as many cognitive tools are., Methods: Cross-sectional data from 841 drivers aged 70 and over from seven Canadian sites who are enrolled in a 5-year cohort study were used for the analyses. Scores on the SIMARD-MD were correlated with scores on the other cognitive measures. The recommendations that would be made based on the SIMARD-MD scores were based on published cut-off values suggested by the authors of the tool. The impact of education status was examined using linear regression controlling for age., Results: Correlations between the SIMARD-MD and other cognitive measures ranged from .15 to .86. Using published cut-off scores, 21 participants (2.5%) would have been recommended to relinquish their licenses, 428 (50.9%) would have been deemed fit to drive, and 392 (46.6%) would have been required to undergo further testing. We found a difference of 8.19 points (95% CI=4.99, 11.40, p<.001) in favor of drivers with post-secondary education versus those without, representing over 11% of the mean score., Discussion: The SIMARD-MD is unlikely to be valuable to clinicians because it lacks sufficient precision to provide clear recommendations about fitness-to-drive. Recommendations based solely on the SIMARD-MD may place many seniors at risk of losing their transportation mobility or incurring unnecessary stress and costs to prove they are safe to drive. Furthermore, the education bias may create an unwanted structural inequity. Hence, adoption of the SIMARD-MD as a tool to determine fitness-to-drive appears premature., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

The Candrive II/Ozcandrive study, a multicentre prospective cohort study examining the predictive validity of tools for assessing fitness to drive, aims to develop an in-office screening tool that will help clinicians identify older drivers who may be unsafe to drive. This paper describes the study protocol. We are following a cohort of drivers aged ≥70 years for up to 4 years. Starting in 2009, 928 participants have been recruited in seven cities in four Canadian provinces, as well as 302 participants in two sites in Melbourne, Australia and Wellington, New Zealand. Participants underwent a comprehensive assessment at baseline and repeat the assessment yearly thereafter, as well as a brief follow-up assessment at 4 and 8 months each year. A recording device is installed in participants' vehicles to assess driving patterns, and driving records are obtained from licensing authorities to determine the outcomes: at-fault crashes per kilometre driven and violations. To date, the protocol has been generally well adhered to, with 1230 participants, and barriers and challenges are being addressed, as necessary. The Candrive II/Ozcandrive study is unique owing to its size, duration, partnerships with Canadian, Australian and New Zealand stakeholders, and international research collaboration., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Although the vast majority of active, older drivers are safe drivers, health conditions and related functional declines associated with increasing age can affect driving ability. This is a concern for older drivers, their families, and the public, as well as government agencies. To address these issues, the Canadian Institutes of Health Research (CIHR) Team in Driving in Older Persons (Candrive II) Research Program was funded in 2008 to create a prospective cohort of older active drivers to be followed for several years. In 2009 an Australian collaboration (Ozcandrive) joined the project funded by an Australian Research Council (ARC) Linkage Grant. This special issue describes the preliminary findings of the Candrive/Ozcandrive prospective study of 1300 older drivers in Canada, Australia and New Zealand. The methodology for the study, description of the cohort and findings related to older driver health and effects on driving, as well as the utility of some existing older driver assessment tools used on this population, are described. Future findings from this ongoing study will lead to insights into older driver safety and tools that will ideally help keep older drivers safely on the road., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Multiple organizations and task forces have called for a reliable and valid method to identify older drivers who are medically unfit to drive. The development of a clinical decision rule for this type of screening requires data from a longitudinal prospective cohort of older drivers. The aim of this article is to identify potential design, sampling and data collection barriers to such studies based on an analysis of the Canadian Safe Driving Study-phase I pilot (Candrive I). A convenience sample of 100 active older drivers aged 70 years or more was recruited through the aid of a seniors' organization, 94 of whom completed the full study (retention rate 94%). Data were collected over the course of 1 year on various driving behaviours, as well as on cognitive, physical and mental functioning. Driving patterns were recorded using driving diaries, logs and electronic devices. Driving records from the Ministry of Transportation of Ontario (MTO) were obtained for the 3-year period preceding the study initiation and up to 1 year following study completion. An increased burden of illness was observed as the number of medical diagnoses and medication use increased over the study period. Study participants were involved in a total of five motor vehicle collisions identified through MTO records, which was comparable to the Ontario annual collision rate of 4.1% for drivers aged 75 years or older. In sum, many of the relevant logistical and practical barriers to studying a large sample of older drivers longitudinally have been shown to be addressable, supporting the feasibility of completing a large prospective cohort study of older drivers., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Previous research has found that only older drivers with low annual driving mileages had a heightened crash risk relative to other age groups. These drivers tend to drive mainly in urban areas, where the prevalence of complex traffic situations increases crash risk. However it might also be that some drivers may have reduced their driving due to perceived or actual declines in driving fitness. This paper uses Canadian and Australian data from the Candrive/Ozcandrive older driver study to investigate the association between annual driving distances and a set of driving-related factors, including fitness to drive. All drivers in the Candrive/Ozcandrive older driver cohort study were allocated to one of three groups according to their self-reported annual driving distances: <5001km; >5000 and <15,000km; and 15,000km or greater. Relationships between these driving-distance categories and: (a) self-reported crash data; (b) various Year 1 'fitness to drive' performance measures; and (c) self-perceptions of driving ability and of comfort while driving, were determined. Results confirmed the previously reported association between low mileage and heightened crash risk. Further, low mileage drivers performed relatively poorly on a wide range of performance measures, perceived their own driving ability as lower, and reported lower comfort levels when driving in challenging situations, compared to the higher mileage drivers. In most instances, these differences were statistically significant. The paper provides further evidence that the so-called 'older driver problem' is most pertinent to low mileage drivers, and that this is due in part to low mileage drivers tending to have reduced fitness to drive. This higher risk group represented a fairly small proportion of the sample in this study., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Chronic health conditions associated with ageing can lead to changes in driving ability. The Canadian Driving Research Initiative for Vehicular Safety in the Elderly (Candrive II) is a 5-year prospective study funded by the Canadian Institutes of Health Research aiming to develop an in-office screening tool that will help clinicians identify potentially at-risk older drivers. Currently, no tools exist to directly predict the risk of motor vehicle collision (MVC) in this population. The American Medical Association (AMA), in collaboration with the National Highway Traffic Safety Association, has designed an opinion-based guide for assessing medical fitness to drive in older adults and recommends that physicians use the Assessment of Driving Related Skills (ADReS) as a test battery to measure vision, cognition and motor/somatosensory functions related to driving. The ADReS consists of the Snellen visual acuity test, visual fields by confrontation test, Trail Making Test part B, clock drawing test, Rapid Pace Walk, and manual tests of range of motion and motor strength. We used baseline data from the Candrive/Ozcandrive common cohort of older drivers to evaluate the validity of the ADReS subtests. We hypothesized that participants who crashed in the 2 years before the baseline assessment would have poorer scores on the ADReS subtests than participants who had not crashed., Methods: In the Candrive/Ozcandrive study, 1230 participants aged 70 years or older were recruited from 7 Canadian cities, 1 Australian city and 1 New Zealand city, all of whom completed a comprehensive clinical assessment at study entry. The assessment included all tests selected as part of the ADReS. For this historical cohort study, data on all crashes (at-fault and non-at-fault) that occurred within 2 years preceding the baseline assessment were obtained from the respective licensing jurisdictions. Those who crashed were compared to those who had not crashed on their ADReS subtest scores using Pearson's chi-squared test and Student's t-test., Results: Sixty-three of the 1230 participants (5.1%) were involved in an MVC within the 2 years preceding the baseline assessment. Contrary to our hypothesis, there were no statistically significant associations between abnormal performance on the tests constituting the ADReS and history of crash in the previous 2 years (p>0.01)., Discussion: We found that a history of crash in the previous 2 years was not associated with abnormalities on the subtests comprising the ADReS. This suggests the need for prospective analyses of risk factors over time to establish sensitive, valid predictors of crash that can be incorporated in clinical practice guidelines., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Numerous medical conditions can affect one's ability to operate a motor vehicle. The likelihood of having multiple medical conditions increases with advancing age; however, the interplay of the associated impairments has not been previously addressed in the literature., Objective: To identify the incremental risks for the effects of multiple chronic medical conditions on driving ability and crash risk., Methods: A comprehensive English-language literature search using the keywords driving, motor vehicle crashes, accidents, multiple medical conditions, and chronic medical conditions was completed. To be included, the article had to address the effects of the combination of multiple chronic medical conditions on driving and include a relevant outcome, such as crashes, driving violations, on-road driving assessment, driving simulator assessment, or driving cessation/avoidance patterns., Results: The overall trend was for increasing number of chronic medical conditions to be associated with higher crash risk and higher likelihood of driving cessation. Although there is some evidence that impaired functional abilities are associated with poorer driving outcome, most of the studies do not support this. No studies were identified that evaluated compensation techniques for drivers with multiple chronic medical conditions with the exception of driving avoidance or self-restriction., Conclusions: The evidence supports the view that drivers with more chronic medical conditions tend to cease driving or engage in driving avoidance. The myriad combinations of diseases and disease severity present a level of complexity that complicates making informed decisions about driving with multiple chronic medical conditions.

Introduction: Older drivers have one of the highest motor vehicle crash (MVC) rates per kilometer driven, largely due to the functional effects of the accumulation, and progression of age-associated medical conditions that eventually impact on fitness-to-drive. Consequently, physicians in many jurisdictions are legally mandated to report to licensing authorities patients who are judged to be medically at risk for MVCs. Unfortunately, physicians lack evidence-based tools to assess the fitness-to-drive of their older patients. This paper reports on a pilot study that examines the acceptability and association with MVC of components of a comprehensive clinical assessment battery., Objectives: To evaluate the acceptability to participants of components of a comprehensive assessment battery, and to explore potential predictors of MVC that can be employed in front-line clinical settings., Methods: Case-control study of 10 older drivers presenting to a tertiary care hospital emergency department after involvement in an MVC and 20 age-matched controls., Results: The measures tested were generally found to be acceptable to participants. Positive associations (p

Objectives: To determine whether persons with dementia are at greater driving risk and, if so, to estimate the magnitude of this risk and determine whether there are efficacious methods to compensate for or accommodate it., Design: Systematic review of the literature., Setting: Case-control studies., Participants: Drivers with a diagnosis of dementia., Measurements: Most studies used state and caregiver reported crash rates, performance-based road tests, and driving simulator evaluations as their outcome measures., Results: Twenty-three studies were included. Drivers with dementia universally exhibited poorer performance on road tests and simulator evaluations, although only one study using an objective measure of motor vehicle crashes was able to show that drivers with dementia were involved in more crashes than control subjects. No studies were found that examined the efficacy of methods to compensate for or accommodate their worse driving performance., Conclusion: Drivers with dementia are poorer drivers than cognitively normal drivers, but studies have not consistently demonstrated higher crash rates. Clinicians and policy makers must take these findings into account when addressing issues pertinent to drivers with a diagnosis of dementia.

Problem: The safety of older drivers is of growing concern as fatal crashes in this group increase annually. The objective was to systematically and critically appraise the evidence on effectiveness of older driver retraining., Method: Articles were grouped according to the intervention studied: physical retraining, visual perception, or education. Randomized trials were appraised using the Physiotherapy Evidence Database (PEDro) Scale and interpreted following Foley's quality assessment. Each intervention was then rated for effectiveness based on Sackett's levels of evidence., Results: Six RCTs, one pre-post-study design, and one descriptive study met the inclusion criteria, one investigating physical retraining, one a visual perception intervention, five using an educational intervention, and one examining a combination of all three, in addition to traffic engineering improvements. There is limited evidence that physical retraining (Level 2a) and visual perception retraining (Level 2a) improve driving related skills in older drivers. There is moderate evidence that educational interventions improve driving awareness and driving behavior (Level 1a), but do not reduce crashes (Level 1b) in older drivers., Summary: The current evidence on the effectiveness of retraining aimed at older drivers is limited but sufficiently encouraging to merit further research., Impact on Industry: Given the potential cost savings to the insurance and health care industries, as well as the safety impact to the general population, the research agenda in this area requires much greater attention.

Objectives: To perform a systematic review of evidence available regarding in-office cognitive tests that differentiate safe from unsafe drivers with dementia., Design: A comprehensive literature search of multiple databases including Medline, CINAHL, PsychInfo, AARP Ageline, and Sociofile from 1984 to 2005 was performed. This was supplemented by a search of Current Contents and a review of the bibliographies of all relevant articles., Setting: English prospective cohort, retrospective cohort, and case-control studies that used accepted diagnostic criteria for dementia or Alzheimer's disease and that employed one of the primary outcomes of crash, simulator assessment, or on-road assessment were included., Participants: Two reviewers., Measurements: The reviewers independently assessed study design, main outcome of interest, cognitive tests, and population details and assigned a Newcastle-Ottawa quality assessment rating., Results: Sixteen articles met the inclusion criteria. Tests recommended by guidelines (e.g., the American Medical Association (AMA) and Canadian Medical Association guidelines) for the assessment of fitness to drive did not demonstrate robustly positive findings (e.g., Mini-Mental State Examination, Trails B) or were not evaluated in any of the included studies (e.g., Clock Drawing). Fifteen studies did not report any cutoff scores., Conclusion: Without validated cutoff scores, it is impossible to employ tests in a standardized fashion in front-line clinical settings. This study identified a research gap that will prevent the development of evidence-based guidelines. Recommendations to address this gap are that driving researchers routinely perform cutoff score analyses and that stakeholder organizations (e.g., AMA, American Geriatrics Society) sponsor consensus fora to review driving research methodologies.

Study Objectives: To determine whether drivers with sleep apnea are at increased risk of motor vehicle crash; whether disease severity, daytime sleepiness, or both disease severity and daytime sleepiness affect this risk, and whether treatment of sleep apnea reduces crash risk., Design: Systematic review of published literature., Setting: N/A., Patients/participants: Patients with sleep apnea., Interventions: N/A., Measurements and Results: Forty pertinent studies were identified. For studies investigating whether noncommercial drivers with sleep apnea have increased crash rates, the majority (23 of 27 studies and 18 of 19 studies with control groups) found a statistically significant increased risk, with many of the studies finding a 2 to 3 times increased risk. Methodologic quality of the studies did not influence this relationship (p = .22). For commercial drivers, only 1 of 3 studies found an increased crash rate, with this association being weak (odds ratio of 1.3). The evidence was mixed regarding whether the risk of crash involvement is proportional to the severity of the sleep apnea, with about half of the studies finding a statistically significant increased risk with increased severity. Correlation with subjective daytime sleepiness and crash risk was also found in only half of the studies reviewed. Treatment of sleep apnea consistently improved driver performance (including crashes) across all studies., Conclusions: Noncommercial drivers with sleep apnea are at a statistically significant increased risk of involvement in motor vehicle crashes. Studies did not consistently find that daytime sleepiness and the severity of sleep apnea were correlated with crash risk. Successful treatment of sleep apnea improves driver performance. Clinicians should educate their patients with sleep apnea about the importance of treatment adherence for driving safety.