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Background: Evaluating infection in home‐based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision‐making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision‐making by exploring the perspectives of clinicians in home‐based primary care. Methods: Clinicians from the Department of Veterans Affairs Home‐Based Primary Care Program were recruited. Semi‐structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes. Results: Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home‐based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow‐up) and those that inhibited prescribing (perceptions of antibiotic‐associated harms, willingness to trial non‐pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms). Conclusions: Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home‐based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: The Clock Drawing Test (CDT) is a widely used measure, which has been included as a recommended cognitive screen for driving evaluations. This study aimed to develop an optimized scoring method—the West Haven–Yale CDT (WHY‐CDT)—based on the scoring methods of Freund and Royall's CLOX, the latter of which is significantly associated with executive control functions. DESIGN: Retrospective cohort study. SETTING: Greater New Haven, Connecticut, area. PARTICIPANTS: A total of 237 adults, aged 70 years and older, who had a current driver's license and drove at least once a month. MEASUREMENTS: Clock drawings were independently scored using both scoring systems, as well as a qualitative‐based 5‐point gestalt score. Interrater reliability was calculated using Light's κ for dichotomous variables and intraclass correlations for continuous variables. A categorical principal component analysis was conducted to determine which items from the Freund and Royall scoring systems should be retained in the modified system, with the Kuder‐Richardson test used to assess internal consistency (reliability). RESULTS: The majority of the quantitative scoring items had moderate to almost perfect interrater reliability, with excellent interrater reliability for the qualitative gestalt score. The final scoring method retained seven items from the Freund and Royall versions, of which over 85% were from the latter. Internal consistency was fair to acceptable for the WHY‐CDT's two dichotomously scored subscales, but poor for both the Freund and Royall scoring methods. CONCLUSIONS: The WHY‐CDT is a simple scoring method that combines elements of the Freund and Royall methods, as well as an overall gestalt score, and has strong interrater reliability. Future directions for use of this modified system are discussed. J Am Geriatr Soc 67:2129–2133, 2019 [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: To determine the feasibility of conducting a cluster randomized controlled trial providing individualized feedback reports to increase advance care planning (ACP) engagement in the primary care setting. DESIGN: Pilot cluster randomized controlled trial. SETTING: Two primary care practices selected for geographic colocation. PARTICIPANTS: Adults aged 55 years and older. INTERVENTION: Brief assessment of readiness to engage in (stage of change for) three ACP behaviors (healthcare agent assignment, communication with agent about quality vs quantity of life, and living will completion) generating an individualized feedback report, plus a stage‐matched brochure. MEASURES: Patient recruitment and retention, intervention delivery, baseline characteristics, and stage of change movement. RESULTS: Recruitment rates differed by practice. Several baseline sociodemographic characteristics differed between the 38 intervention and 41 control participants, including employment status, education, and communication with healthcare agent. Feedback was successfully delivered to all intervention participants, and over 90% of participants completed a 2‐month follow‐up. More intervention participants demonstrated progression in readiness than did control participants, without testing for statistical significance. CONCLUSIONS: This pilot demonstrates opportunities and challenges of performing a clustered randomized controlled trial in primary care practices. Differences in the two practice populations highlight the challenges of matching sites. There was a signal for behavior change in the intervention group. J Am Geriatr Soc 67:1917–1921, 2019 [ABSTRACT FROM AUTHOR]

Objectives: To explore patient and caregiver experiences, preferences, and attitudes toward the provision and receipt of caregiving assistance with medical tasks. Design: Qualitative study consisting of in‐depth interviews with 20 patient–caregiver dyads. Setting: Community and academic‐affiliated primary care clinics. Participants: Individuals aged 65 or older with 2 or more health conditions and their family caregivers (n=20 patient–caregiver dyads). Measurements: Open‐ended questions were asked about the tasks that the patient and caregiver performed to manage the patient's health conditions; questions were designed to elicit participant reactions and attitudes toward the help they provided or received. Transcripts were analyzed using the constant comparative method. Results: Participant preferences and attitudes toward the receipt and provision of disease management tasks were highly personal. Participant responses clustered into 2 caregiving typologies: supportive caregiving relationships and conflicted caregiving relationships. Supportive relationships were characterized by patient–caregiver agreement about caregiver level of involvement, agreement about one another's competency to perform disease‐related tasks, mutual understanding, collaborative decision‐making and disease management, and use of family and formal caregiving. Conflicted relationships were characterized by disagreement about caregiver level of involvement, disagreement about one another's competency to perform disease management tasks, underappreciation of one another's experiences, disagreement over decision‐making and disease management, and use of formal caregiving. Conclusions: The views that patient–caregiver dyads expressed in this study illustrate the varied preferences and attitudes toward caregiving assistance with multiple health conditions. These findings support a dyadic approach to evaluating and addressing patient and caregiver needs and attitudes toward provision of assistance. [ABSTRACT FROM AUTHOR]

Objectives A key objective of advance care planning ( ACP) is improving surrogates' knowledge of patients' treatment goals. Little is known about whether ACP outside of a trial accomplishes this. The objective was to examine patient and surrogate reports of ACP engagement and associations with surrogate knowledge of goals. Design Cohort study Setting Primary care in a Veterans Affairs Medical Center. Participants 350 community-dwelling veterans age ≥55 years and the individual they would choose to make medical decisions on their behalf, interviewed separately. Measurements Treatment goals were assessed by veterans' ratings of 3 health states: severe physical disability, cognitive disability, and pain, as an acceptable or unacceptable result of treatment for severe illness. Surrogates had knowledge if they correctly predicted all 3 responses. Veterans and surrogates were asked about living will and health care proxy completion and communication about life-sustaining treatment and quality versus quantity of life ( QOL). Results Over 40% of dyads agreed that the veteran had not completed a living will or health care proxy and that there was no QOL communication. For each activity, sizeable proportions (18-34%) disagreed about participation. In dyads who agreed QOL communication had occurred, 30% of surrogates had knowledge, compared to 21% in dyads who agreed communication had not occurred and 15% in dyads who disagreed ( P = .01). This relationship persisted in multivariable analysis. Agreement about other ACP activities was not associated with knowledge. Conclusion Disagreement about ACP participation was common. Agreement about communication regarding QOL was modestly associated with surrogate knowledge of treatment goals. Eliciting surrogates' perspectives is critical to ACP. Even dyads who agree about participation may need additional support for successful engagement. [ABSTRACT FROM AUTHOR]

Objectives To understand the perspectives of both patients and the person who would make medical decisions for them if they were unable (surrogates) on their participation in advance care planning ( ACP). Design Qualitative cross-sectional study. Setting Community. Participants Thirty-one veterans age 55 years and older and their surrogates. Measurements In interviews conducted with both the veteran and surrogate, they were asked to discuss their participation in four ACP activities: communication about life-sustaining treatment, communication about views on quality of life, completion of a living will, and appointment of a healthcare proxy. They were asked about barriers to and facilitators of ACP engagement. When they did not agree about engagement, they each provided their perspective on what they believed had or had not occurred. Results Many of the same barriers to and facilitators of engagement were discussed by both patients and surrogates. These included difficulty thinking about dying, differences in values, and experiences with others that demonstrated the ability of ACP to decrease burden or avoid conflict. Reasons for disagreements in perceptions about whether communication had occurred included surrogates' need for more detailed information, surrogates' lack of readiness to hear what the patient was saying, and surrogates' reliance on what they know about the patient. For some dyads, participation in the study prompted additional communication, resulting in a better shared understanding of ACP engagement. Conclusion Surrogates can both impede and facilitate engagement in ACP, and they can hold different perceptions from patients regarding this engagement. Efforts to promote ACP may be most successful if they assess and address both patients' and surrogates' attitudes and help to facilitate clear communication between them. [ABSTRACT FROM AUTHOR]

Background: Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning.Objective: To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings.Design: Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459).Setting: 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information.Participants: English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention.Intervention: Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months.Measurements: The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record-assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities.Results: Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race.Limitations: The study was done in a single region and excluded non-English speaking participants. No information was collected about nonparticipants.Conclusion: A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings.Primary Funding Source: National Institute of Nursing Research and National Institute of Aging. [ABSTRACT FROM AUTHOR]

The article describes the case of clinicians' experience and perspective with therapeutic decision making for older patients with multiple conditions. The study reveals that clinicians treat older patients on the basis of the patients' ability to adapt to the complex medical treatment plan, difference in belief regarding the advantages and disadvantages of using guidelines, difference in weighing pros and cons of treatment, patient-involvement in decision-making and blocks to clinicians preference.

OBJECTIVES: To explore whether models of health behavior change can help to inform interventions for advance care planning (ACP). DESIGN: Qualitative cross-sectional study. SETTING: Community. PARTICIPANTS: Sixty-three community-dwelling persons aged 65 and older and 30 caregivers with experience as surrogate decision-makers. MEASUREMENTS: In focus groups conducted separately with older persons and caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory. RESULTS: Four themes illustrated the potential of applying models of health behavior change to improve ACP. (1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. (2) Participants identified a wide range of benefits of and barriers to ACP. (3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. (4) Experience with healthcare decision-making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP. DISCUSSION: The variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness for participating in each component of ACP suggests the utility of customized, stage-specific interventions based on individualized assessments to improve ACP. [ABSTRACT FROM AUTHOR]

This letter comments on the letter by Buck et al. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which discusses a study about the use of health outcome prioritization as a tool for eliciting health outcome priorities among older people.

Objectives To develop and test the acceptability of personalized intervention materials to promote advance care planning (ACP) based on the Transtheoretical Model (TTM), in which readiness to change is a critical organizing construct. Design Development study creating an expert system delivering TTM-personalized feedback reports and stage-matched brochures with more-general information on ACP and modifications based on participant reviews. Setting Senior centers. Participants Community-living persons aged 65 and older (N = 77). Measurements Participant ratings of length, attractiveness, and trustworthiness of and reactions to reports and brochures. Results The expert system assessed participants' readiness to engage in each of four ACP behaviors: completion of a living will, naming a health care proxy, communication with loved ones about quality vs quantity of life, and communication with clinicians about quality vs quantity of life. The system also assessed pros and cons of engagement and values and beliefs that influence engagement. The system provided individualized feedback based on the assessment, with brochures providing additional general information. Initial participant review indicating unacceptable length led to revision of feedback reports from full-sentence paragraph format to bulleted format. After review, the majority of participants rated the materials as easy to read, trustworthy, providing new information, making them more comfortable reading about ACP, and increasing interest in participating in ACP. Conclusion Older adults found an expert system individualized feedback report and accompanying brochure to promote ACP engagement to highly acceptable and engaging. Additional research is necessary to examine the effects of these materials on behavior change. [ABSTRACT FROM AUTHOR]

Objectives To evaluate age-related differences in sleep-wake symptoms. Design Cross-sectional. Setting Technologist-attended, laboratory-based polysomnography ( PSG). Participants Community-dwelling adults aged 20 to 89 (N = 201): 52 aged 18 to 39, 72 aged 40 to 59, and 77 aged 60 and older. Measurements Medical burden (Charlson Comorbidity Index, medications, health status), PSG-defined sleep disorders (sleep-disordered breathing ( SDB), sleep-associated hypoxemia, periodic limb movements in sleep ( PLMS)), sleep-wake symptoms (Epworth Sleepiness Scale ( ESS), Insomnia Severity Index ( ISI), fatigue (Facit-F Scale)). Results Medical burden increased significantly with age (Charlson Comorbidity Index and number of medications, P < .001; health status, P = .005). Severity of sleep disorders also increased significantly with age ( SDB and hypoxemia, P < .001; PLMS, P = .008). Conversely, sleep-wake symptoms decreased with age (daytime drowsiness ( ESS ≥ 10), P = .02; insomnia ( ISI ≥ 8), P = .04; fatigue, P < .001). In adjusted models, a 1-year increase in age was significantly associated with a 4% decrease in the odds of having daytime drowsiness (odds ratio ( OR) = 0.96, 95% confidence interval ( CI) = 0.93-0.98). Similarly, but only in those with mild SDB, a 1-year increase in age was significantly associated with a 5% decrease in the odds of having insomnia ( OR = 0.95, 95% CI = 0.92-0.99). Conclusion Older age was characterized by less-severe sleep-wake symptoms (daytime drowsiness, insomnia, fatigue), despite an age-related increase in disease severity (medical burden, sleep disorders). Because the increase in disease severity included well-established risk factors for having sleep-wake symptoms, the age-related decrease in sleep-wake symptoms may reflect a decrease in symptom awareness. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the associations between sleep disturbances and driving practices, including driving cessation and trajectories of daily driving mileage (change over time), in older drivers. Design Longitudinal. Setting New Haven, Connecticut. Participants Four hundred thirty older drivers, mean age 78.5, recruited from clinic and community sites. Measurements Baseline measures included medical history, daily driving mileage, Insomnia Severity Index ( ISI), Epworth Sleepiness Scale ( ESS), and Sleep Apnea Clinical Score ( SACS). Longitudinal outcomes included at least one episode of driving cessation and trajectories of miles driven per day, as recorded every 6 months over 2 years. Results At baseline, participants drove an average of 22.2 miles per day; 26.0% (112/430) had insomnia ( ISI ≥ 8), 19.3% (83/430) had daytime drowsiness ( ESS ≥ 10), and 19.9% (84/422) had high sleep apnea risk ( SACS > 15). The sleep-based predictors of insomnia (risk ratio ( RR) = 1.20, 95% confidence interval ( CI) = 0.65-2.20), daytime drowsiness ( RR = 0.94, 95% CI = 0.46-1.95), and high sleep apnea risk ( RR = 0.62, 95% CI = 0.27-1.42) did not confer a significantly greater risk of driving cessation. Insomnia was the only sleep-based predictor that conferred a significant change in driving mileage, yielding an average decrease of 4.5 miles per day over 2 years ( P = .01). In the insomnia model, covariates that were associated with less driving mileage were polypharmacy (≥4 medications) and each year of additional age, yielding an average decrease of 8.3 ( P = .01) and 0.4 miles per day ( P = .02), respectively, over 2 years. Conclusion In a cohort of older drivers, insomnia and the covariates of polypharmacy and advancing age were longitudinally associated with less daily driving mileage. Because reductions in driving mileage in older persons often occur in response to reductions in driving capacity, these results support a clinical approach that considers insomnia-based cognitive-behavioral therapy and reduced polypharmacy as strategies for improving driving capacity in older persons. [ABSTRACT FROM AUTHOR]

Objectives To design a tool for nonvalvular atrial fibrillation ( NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication. Design Clustered randomized controlled trial. Setting Primary care clinics. Participants Individuals with NVAF (N = 135). Intervention Completion of tool before regularly scheduled visit. Measurements Primary outcomes included the 100-point informed and values clarity subscales of the decisional conflict scale (lower scores indicate individual is more informed and has greater clarity). Secondary outcomes included knowledge, patient-clinician communication, and change in treatment. Results Sixty-nine individuals were enrolled in the intervention group and 66 in the control group. After their visit, intervention participants had lower scores on the informed (mean difference = −11.9, 95% confidence interval ( CI) = −21.1 to −2.7) and values clarity subscales (mean difference = −14.6, 95% CI = −22.6 to −6.6). Greater proportions of intervention participants knew medications for reducing stroke risk (61% vs 31%, P < .001) and side effects (49% vs 37%, P = .07). Stroke (71% vs 12%) and bleeding risk (69% vs 20%) were discussed more frequently in the intervention than control group ( P < .001). Five intervention participants expressed a preference for medication that was not concordant with their current treatment plan. There was no change in treatment plan in either group. Conclusion The tool was effective in improving perceived and actual knowledge and values clarity and in increasing physician-patient communication but did not change treatment. [ABSTRACT FROM AUTHOR]

Objective: To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM. Methods: Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age≥65 years. Results: Items for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76–.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks’λ =.555–.809, η 2 =.068–.178, p ≤.001 for all models. Conclusion: Core constructs of the TTM as applied to ACP can be measured with high reliability and validity. Practice implications: Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons’ engagement in ACP. [Copyright &y& Elsevier]

To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP). Observational cohort study. Community. Persons aged 65 and older and the individual they identified as most likely to make treatment decisions on their behalf. Older persons were asked about participation in four activities: completion of living will, completion of healthcare proxy, communication regarding views about life-sustaining treatment, and communication regarding views about quality versus quantity of life. Surrogates were asked whether they believed the older person had completed these activities. Of 216 pairs, 81% agreed about whether a living will had been completed (κ=0.61, 95% confidence interval (CI) 0.51-0.72). Only 68% of pairs agreed about whether a healthcare proxy had been completed (κ=0.39, 95% CI 0.29-0.50), 64% agreed about whether they had communicated regarding life-sustaining treatment (κ=0.22, 95% CI 0.09-0.35), and 62% agreed about whether they had communicated regarding quality versus quantity of life (κ=0.23, 95% CI 0.11-0.35). Although agreement between older persons and their surrogates regarding living will completion was good, agreement about participation in other aspects of ACP was fair to poor. Additional study is necessary to determine who is providing the most accurate report of objective ACP components and whether agreement regarding participation in ACP is associated with greater shared understanding of patient preferences. [ABSTRACT FROM AUTHOR]

The article discusses research on the willingness of older people to take medication for primary cardiovascular disease prevention according to benefits and harms. A total of 356 community-living older persons were interviewed about taking drugs for primary prevention of myocardial infarction (MI) with varying benefits and harms. It was found that the willingness of older people to take medication is not influenced by its benefits, but highly sensitive to its adverse effects.

Objective: To develop and test a simple tool to elicit the preferences of older persons based on prioritization of universal health outcomes. Methods: Persons age ≥65 participating in a larger study were asked to rank 4 outcomes on a visual analogue scale: (1) maintaining independence, (2) staying alive, (3) reducing/eliminating pain, (4) reducing/eliminating other symptoms. Results: Interviewers rated 73% of the 81 participants as having good to excellent understanding, and cognitive interviews demonstrated the tool captured how participants thought about trade-offs. Test-retest reliability was fair to poor for ranking most of the outcomes as either most or least important (kappa .28–1.0). Patient characteristics associated with ranking “keeping you alive” as most important have been shown to be associated with a preference for life-sustaining treatment, a related construct. There was substantial variability in the outcome ranked as most important. Conclusions: The task of ranking 4 universal health outcomes was well understood, captured what was important when considering trade-offs, and demonstrated content validity. However, test-retest reliability was fair to poor. [Copyright &y& Elsevier]

To develop stages-of-change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP. Observational cohort study. Community. Persons aged 65 and older recruited from physician offices and a senior center. Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues. Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life-sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life. Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP. [ABSTRACT FROM AUTHOR]

Background. This study was designed to determine whether an education program consisting of classroom and on-road training could enhance driving performance. Methods. This randomized controlled trial with blinded endpoint assessment enrolled 126 community-living drivers 70 years old or older who were recruited from clinic and community sources. Treatment assignment was concealed until eligibility was established. Participants randomized to intervention underwent two 4-hour classroom and two 1-hour on-road sessions focused on common problem areas of older drivers. Controls received modules directed at vehicle, home, and environmental safety. A knowledge test and driving performance were assessed at baseline and 8 weeks. On-road driving performance was assessed by an experienced evaluator in a dual-brake-equipped vehicle in urban, residential, and highway traffic. Driving performance was rated on a 36-item scale with potential scores from 0 to 72 (higher score better). The knowledge test included 20 road knowledge and eight road sign questions, scored from 0 to 28 correct. Results. The least squares mean change in road test score relative to baseline was 2.87 points higher in the intervention than in the control group (p = .001). The least squares mean change in knowledge test scores relative to baseline was 3.45 points higher in the intervention than in the control group (p < .001). Conclusions. An education program consisting of classroom and on-road training targeted to common errors of older drivers enhanced performance on knowledge and on-road tests. Such interventions offer older drivers the potential to continue driving safely longer and to maintain their out-of-home mobility. [ABSTRACT FROM AUTHOR]

Background: As the number of older drivers increases, concern has been raised about the potential safety implications. Flexibility, coordination, and speed of movement have been associated with older drivers' on road performance.Objective: To determine whether a multicomponent physical conditioning program targeted to axial and extremity flexibility, coordination, and speed of movement could improve driving performance among older drivers.Design: Randomized controlled trial with blinded assignment and end point assessment. Participants randomized to intervention underwent graduated exercises; controls received home, environment safety modules.Participants: Drivers, 178, age > or = 70 years with physical, but without substantial visual (acuity 20/40 or better) or cognitive (Mini Mental State Examination score > or =24) impairments were recruited from clinics and community sources.Measurements: On-road driving performance assessed by experienced evaluators in dual-brake equipped vehicle in urban, residential, and highway traffic. Performance rated three ways: (1) 36-item scale evaluating driving maneuvers and traffic situations; (2) evaluator's overall rating; and (3) critical errors committed. Driving performance reassessed at 3 months by evaluator blinded to treatment group.Results: Least squares mean change in road test scores at 3 months compared to baseline was 2.43 points higher in intervention than control participants (P = .03). Intervention drivers committed 37% fewer critical errors (P = .08); there were no significant differences in evaluator's overall ratings (P = .29). No injuries were reported, and complaints of pain were rare.Conclusions: This safe, well-tolerated intervention maintained driving performance, while controls declined during the study period. Having interventions that can maintain or enhance driving performance may allow clinician-patient discussions about driving to adopt a more positive tone, rather than focusing on driving limitation or cessation. [ABSTRACT FROM AUTHOR]